Experts recommend circumcision to combat male HIV infections in Africa
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39171.431736.DB (Published 05 April 2007) Cite this as: BMJ 2007;334:712All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Adult and Child Circumcision
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
Competing interests: No competing interests