Effectiveness of Male Circumcision in Reducing HIV Transmission

The HIV virus spreads silently before wreaking devastation that consequently creates a legacy of both social and economic instability. AIDS, which is the first successive wave of HIV transmission, decimates economies, public institutions and families indiscriminately. In the absence of any mitigating measures, HIV presents a portent of disaster in the offing. It is for this reason that HIV/AIDS has finally reached the top of health sector’s agenda. Stakeholders in the health sector have been pre-occupied in designing measures to control and manage the HIV menace. Of these measures, male circumcision has gained has gained prominence as one of the effective tools in the armory of fighting HIV transmission. This paper thus sets out to assess the impact of male circumcision in reducing HIV transmission.

Studies have shown the biological plausibility in the association between male circumcision and reduced risk for HIV transmission. Basically, the foreskin in an uncircumcised penis contains high concentration of superficial Langerhans cells, CD₄⁺ T-cells and microphages that are all target cells for HIV infection.  In addition to these cells, the Preputial sac in uncircumcised penis may serve as a reservoir for HIV-containing secretions resulting in prolonged contact time after exposure to the secretions.  In an uncircumcised penis therefore, the foreskin may present less of a physical barrier to HIV entry as compared to the heavily keratinized skin of the penile shaft in a circumcised penis (Kawamura, Kurtz, Blauvell and Shimada, 2005). Moreover, Weiss, Quicley and Hayeslack (2006) have argued that the absence of male circumcision is associated with increased risk of genital ulcers which are associated with increased risk of HIV transmission.

During the last decade, male circumcision has moved to the forefront of international HIV discussions and presentation research.  As early as the late 1980’s, observational and ecological studies in the developing world suggested that higher rates of male circumcision were associated with lower rates of HIV transmission. In Sub-Saharan Africa for instance, estimates of HIV prevalence are significantly associated with estimated prevalence of male circumcision. Based on research findings by Auvert et al. (2005), the median prevalence rate of HIV is 17% in countries where fewer than 30% of men are circumcised. On the contrary, the median prevalence rate of HIV is 2.9% where 90% of men are circumcised. Based on this observational data, epidemiologists and other researchers have designed experimental trials with the goal of establishing a causal link between male circumcision and HIV transmission.

Notable of these experimental trials are the randomized controlled clinical trials that were carried out in the Orange farm of South Africa, the Kisumu region of Kenya and the Rakai region of Uganda. Typically, these regions have low prevalence of male circumcision while recording high prevalence rates for HIV/AIDS. After the conclusion of these studies, analyzed data from the South African randomized trials indicated that there were 20 new HIV infections among the circumcised and 49 new infections among the uncircumcised.  It was concluded that circumcision reduced the risk of HIV infection by 60%. Moreover, male circumcision was found to reduce sexual transmission of HIV from women to male by 60%. The researchers therefore concluded that male circumcision provides an intervention of proven efficacy for reducing the spread of HIV (Auvert et al., 2005).

Based on findings from the Kenyan trials as provided by Bailey, Moses and Parker (2007), there were 47 new HIV infections among the uncircumcised men compared to 22 among the circumcised. Additionally, the 2-year HIV incidence rate was at 2.1% in the controlled group and 4.2% in the uncontrolled group while the relative risk of HIV infection in the circumcised men was 0.47 representing a 53% reduction in HIV infection risk.  From these findings, the researchers in the Kenyan study concluded that male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. From the Ugandan study, Gray, Kigozi and Serwadda (2207), found out that there were 43 new infections among the uncircumcised men compared to 22 new cases among the circumcised men. These findings indicated an estimated efficacy of male circumcision to be 51%. Researchers for the Ugandan trials concluded that male circumcision reduces HIV incidence in men without behavioral inhibition and circumcision can be recommended for HIV prevention in men.

Research has indeed shown that the risk of HIV acquisition is higher in the uncircumcised as compared to their circumcised counterparts.  However, the bottom line is that people should be cautious about indulging in unsafe and reckless sexual behaviors regardless of whether they are circumcised or not. Appropriate, voluntary, safe and affordable circumcision services should be integrated with other HIV preventive interventions. Even though sexual intercourse may not be as casual as a handshake or as violent as a rugby match, it causes lacerations and nicks to the body. It is these lacerations and nicks arising from the sexual act that provides a medium through which the HIV virus permeates blood cells whether circumcised or not. To that end, the ABC principle underlying information, education and communication remains the only viable strategy (in the absence of a cure) against the HIV/AIDS scourge.

References
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