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Rapid Responses: Rapid Responses published:
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Are we going round in circles?
- Nonyelum N Agomo (10 April 2007)
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Re: Are we going round in circles?
- Onisillos Sekkides (10 April 2007)
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HIV epidemic, &nature in West Bengal State;India,: Role of male Circumcision Possible amongst Hindus as additional preventive measure?Will state government start thinking of It?
- Professor Pranab Bhattacharya, Bhattacharya Rupak, Bhattacharya Ritwik,- Purbapalli, Sodepur 24 Parganas(north) Kolkata110, Bhattacharya Palash MD(Post Graduate Trainee),Roy Arnab Medical Officer HIV clinic Dept of Medicine IPGME&R 244A AJC Bose Road Kolkata-20, West Bengal, India (10 April 2007)
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Adult and Child Circumcision
- Michael G. O'Toole, Trinity College Dublin 2 (13 April 2007)
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Nonyelum N Agomo, SHO (MBBS, DRCOG) UCH, London NW1 2BU
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I had no excuse for not reading my Easter edition of the BMJ this weekend as courtesy of Jesus, I had 4 continuous days off (not taken from my precious annual leave allocation) and so I read more of the articles in greater detail than usual. It was thus with great interest that I read the articles on Pg 712 - 713 which were titled "WHO recommends circumcision to combat HIV infections in men in Africa" and another "Drugs are as good as PCI in stable coronary disease" which showed that drugs and healthy living were just as good as PCI This set me thinking "Are we going round in circles or what?" What is today being hailed as good evidence is not as surprisingly new as one might think. No one buys a new car or complex gadget without referring to the manufacturers instructions for maintenance and operation. So also those who read the Creator's manual for life or the bible would know that circumcision was already instructed (Genesis 17: 10-27) and has been of benefit to many generations, as are the instructions for healthy living in all its forms, strong family units, team working, avoiding stress and burnout etc (1 Corinthians 6:19, 1Peter 5:7, Exodus 20:10) Even the politicians are now advocating these forgotten truths as a way out of 21st century societal ills and they too are referring to it as good evidence. Selah (Pause and Consider) N.Agomo Competing interests: NonyeLum Agomo is a christian |
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Onisillos Sekkides, Medical Editor NW1 7BY
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I'd just like to point out that the type of circumcision practised in biblical times was very minimal. The circumcision that may offer some benefit with regard to HIV is much more extensive. This type of circumcision was not adopted for religious reasons, but to stop circumcised athletes during the ancient Olympic games from hiding the fact they were circumcised. Competing interests: None declared |
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Professor Pranab Bhattacharya, Professor of Pathology, Incharge of Histopathology;cytogenetics, Blood Bank &VCTC, Malari Clinic Institute of Post Graduate Medical Education& Research;244A AJC Bose Road, KOlkatta-20, W.B, India, Bhattacharya Rupak, Bhattacharya Ritwik,- Purbapalli, Sodepur 24 Parganas(north) Kolkata110, Bhattacharya Palash MD(Post Graduate Trainee),Roy Arnab Medical Officer HIV clinic Dept of Medicine IPGME&R 244A AJC Bose Road Kolkata-20, West Bengal, India
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HIV epidemic is focused on identification of individual risk behavior and prevention of new infection through modification of this behavior. These individual behaviors need to be considered within its social and cultural context. India has now the world's largest numbers of HIV infected people, surpassing South Africa. The Indian HIV epidemic is very complex and challenging one and mainly through heterosexual route (85%). Homosexual route of transmission is negligible, if at all present not reported. Current UNIAIDS estimation of adult HIV prevalence in India (0.5-1.5%). Indian National Behavioural surveillances (NBSS) reported extramarital sexual contact raised within the previous years by 8.6% of men & 1.7% of married educated middle aged women(1)Further a randomized community based study of adults in 28 chennai slums found that 2.9% of men and less then 1% of women reported extramarital sexual contact on regular basis with 1% and 0.2% of HIV infected respectively(2) 1% increase in AIDS prevalence in adults results in an additional five(5) million people infected with the virus. There are abundant evidences that male Circumcision reduces the risk of HIV transmission. Halperin et al(3) showed increased risk for HIV (ranging 2-8 fold) amongst uncircumcised men. The proposed mechanism for this protective effect is that foreskin of Penis is lined by Langerhan cells which contain CD4+ & CCR5 receptors and that it may be more prone to trauma during active intercourse than the rest of penis(4). But circumcision requires surgery and raises cultural and personal issues. Moreover at present meta analysis data are insufficient and no international recommendation exist to promote Circumcision for purpose of prevention of HIV infection. However estimates by WHO & joint united Nations programme on HIV/AIDS shows that HIV prevalence is low in Middle East & North Africa region, Egypt, Jordan, Palestine, Iraqi, Syria, Saudi Arabia and in Pakistan. It has been hypothesized that low prevalence of HIV in these countries specially in Middle east & north African Region is some how linked to ISLAM and its influence on behaviors that effect HIV transmission. It is possible that some practices amongst Muslim population contribute to decreasing the risk of transmission. One is very low alcohol use, and other is male circumcision(5). Two trials funded by US NIH were carried out in Kisimu, Kenya, among men aged 18-24 years and in Rakai, Uganda, among men aged 15-49 years. The trials which completed enrollment of Patients in 2005 were stoPped by NIH data safety and monitoring board (DSMB) evaluating the results of interim analysis. The role of DSMB was to assess prognosis of the trial and recommendation whether to continue, modify or terminate the trial. NIH studies were stopped because they revealed approximate halving of risk of HIV infection in men who were circumscribed. Another trial named as South Africa Orange Farm Intervention Trial funded by French Agency National de Researchers Sur le SIDA(ANRS) and published in late 2005 demonstrated 60% reduction of HIV infection among men who were circumscribed(6) In one study from India, by Reynolds et al showed most circumscribed men in India are Muslim (62.1%) and most uncircumcised men were identified as Hindu (85%). > Uncircumcised men were likely to have genital ulcer at base line (30.6% vs. 22%). Their study showed that after adjustment for socio demographic and behavioral risk factors in proportional model circumcision though had no significant protective effect on incidence of HSV2, syphilis or gonococcus urethrities, circumcision was strongly protective against HIV1 acquisition with 6.7 fold reduction in risk of HIV 1 infection(7) The question beforE the authors are although these results demonstrated that male circumcision reduces the risk of men becoming infected with HIV, can it provide complete protection against HIV infection in India and in West Bengal? Circumscribed men can still become infected with virus and if they become infected as HIV positive, they can infect their sexual partners. Male circumcision should therefore never replace other known effective prevention methods and should therefore considered as an additional comprehensive package for prevention along with correct and consistent use of male and female condoms, practice of safe sex, delays in onset of sexual relations HIV testing and Counseling. another question before the presenting authors is that will the interest of male circumcision be promoted from government level in the government hospitals, non government institutions amongst the Hindus in West Bengal at free of cost? The question stands with cultural, political, Human Rights considerations associated with promoting circumcisions. However Circumcision at mass scale is not without Human Risk of complications from surgical procedure like Hemorrhages, Shock, Penile edema, Sepsis based on rural and unhygienic settingswhen performed in the rural set up. References 1) National AIDS control organization, Government of India, National baseline general population behavioral surveillances survey 2001 htpp:// www naco online. Org/ publication htm.] 2) Srikrisnan AK, Sivram .S et al " The HIV epidemic in chennai 9 southern India remains concentrated in high risk groups. Xv International AIDS conference, Bangkok, Thailand, july11-16, 2004 MopeC3469 3) Halperen.D.T, Bailey. R.C” Male circumcision & HIV infection 10 years and control- The Lancet 354(3192);1813-15;1999 4)Szabo.R, ShortRV How does male Circumcision protects against HIV Infection BMJ 320(7249) ;1592-94;2000 5) Carle Makhhoulf Obermeyer “ HIV in Middle East” BMJ 333;21st Octebar;851-54;2006 6) Statement of Kenyan and Ugandan Trial findings regarding male circumcision &HIV; Statement by WHO, UNFPA,UNICEF,World Bank,and UNIAIDS- 13th December -2006 File:/>/172.16.137.3/hmis_ph2/doc/WHO%2020Statement%20on%20 Kenyan%20 page-1 Accessed on 14.12.2006 7) Steven. J Reynolds, Mary E shepherd & Aru. R Risbud " Male circumcision & risk of HIV1 & other sexually transmitted infection in India - The Lancet vol 363 March 27 P 1039-40; 2004 Acknowledgement= To Mrs Dahlia Mukherjee, Debasis Mukherjee of South Habra North 24 Parganas Professor KK Haldar, professor of Microbiology IPGMER DR Sougata Sanyal Asst.professor of Microbiology IPGMER, KOlkata Competing interests: The first author is also in charge of VCTC center of IPGME&R /SSKM Hospital Kolkata, India |
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Michael G. O'Toole, Tutor Centre for Global Health, Trinity College Dublin 2
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In the recent debate on male circumcision and HIV transmission the age of circumcision does not seem to be considered. Circumcision as a child would allow the exposed penis to develop a keratinised (less HIV permeable) layer of skin before the start of sexual activity. Adult circumcision may in fact expose the skin of the penis which may be more permeable to HIV until the keratinisation process is complete. This may account for the variation seen in the studies carried out in this regard. It may be necessary to study the permeability of the penis at various times after the operation to determine how long is required before adults should resume sexual activity. It may not only be the removal of the permeable foreskin that is involved and studies should be carried out to determine this. Competing interests: None declared |
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