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Goal to Circumsise Men in Countries Hit Hard by HIV Hits Hygiene Roadblock

By L.K. Regan

The controversy over advocating mass circumcisions to prevent HIV transmission in developing areas hardest hit by HIV/AIDS continues. Recently, RealJock reported findings presented at the International AIDS conference suggesting that circumcision be more broadly adopted in Africa as an HIV transmission prevention tool. Now, a new study sponsored by the World Health Organization (WHO) has complicated that picture by warning that, while HIV transmission is definitely substantially reduced by circumcision, a lack of training and infrastructure in performing the procedure can counteract those benefits. Ouch. The WHO has therefore called for caution in the implementation of circumcision programs.

The current emphasis on circumcision as a tool for HIV prevention has been based on a series of randomized, controlled trials conducted in Africa. As the WHO puts it, "Over 35 observational studies and three randomized controlled trials from sub-Saharan Africa have shown that male circumcision reduces the risk of HIV incidence by approximately 60%." This statistic is not in doubt—but the same researchers who discovered this effect, and who spoke of the need for broader circumcision programs in the developing world at the International AIDS conference last month, have found problems with performing the procedure. Dr. Robert Bailey, a leading researcher on the seminal studies in circumcision's efficacy against HIV transmission, is first author on the WHO's current study. He reports that, "A serious concern, however, is whether male circumcision can be provided to large numbers of adult males safely. While the beneficial effects of male circumcision are now widely recognized, those benefits must be weighed against the potential harms. Male circumcision is a relatively simple, quick, and safe procedure when performed in a clinical setting under aseptic conditions by a trained practitioner with proper instrumentation. However such conditions do not always prevail." The original clinical trials had enforced ideal medical conditions, leading to a minimum of complications from the circumcisions performed. To judge the state of circumcision programs without those research conditions, Dr. Bailey and his co-researchers followed 1,007 recently circumcised young men in the Bungoma district of Kenya. Their conclusion, and that of the WHO, is that the kind of ideal conditions found in earlier clinical trials are not typically found—and without them, complications abound.

In Africa, circumcision has been a traditional ritual in some communities for generations. Recent HIV prevention programs have introduced medical circumcisions to the same communities. The subjects followed in the WHO study chose which method to use. And, as anticipated, ritual circumcision came with a much higher rate of infection, scarring, and other complications. But, researchers were disappointed to find, medical circumcision was only somewhat better. As the study reports, "Those circumcised traditionally were 2.53 times more likely to report an adverse event than those circumcised medically. The proportion of males circumcised traditionally and reporting adverse events was a shocking 35.2%. The adverse-event rate among those circumcised medically was significantly lower (17.7%) but nevertheless very high compared with rates observed in developed countries and in clinical settings in Kenya and Nigeria."

The outcome of a botched circumcision was not pretty. As the researchers report, "The most common complications reported were excessive bleeding, infections, and excessive pain, with bleeding the most common. Other common adverse events reported were pain upon urination, incomplete circumcision requiring recircumcision, and lacerations of the glans, the scrotum and the thighs…. In 24% of the traditional cases and 19% of the medical cases, the wound had still not healed when participants were observed at 60 days after the operation."

Much of this problem is structural, and could, according to the study's authors, be corrected by both better training and the injection of medical and financial resources: "Even the best trained and most experienced clinician will have difficulty in keeping adverse events to a minimum if they do not have the correct surgical instruments or expendable supplies at hand. Many of the adverse events we observed were attributable to lack of instruments in good working order or to use of the wrong suture material." If clinics were better outfitted, they might be able to make greater improvements over ritual circumcision.

Circumcision prevents HIV transmission, the WHO study reports, by reducing the number of "HIV target cells (e.g. Langerhans' cells, CD+ T-cells and macrophages), which are plentiful on the inner, mucosal surface of the foreskin and through formation of a thick layer of squamous epithelial cells that form a barrier to HIV uptake in the underlying target cells." It has been studies for effectiveness in preventing female-to-male transmission of the virus; but its effects on male-to-male transmission are woefully understudied.