Inter Press Service - October 3, 2003
Wilson Johwa

At the centre of the hypothesis that male circumcision does provide a measure of protection against HIV-AIDS are puzzling discrepancies in HIV prevalence between different countries and regions, despite the presence of what seem to be similar risk factors.

For example, rates of HIV infection continue to be much lower in the Philippines (0.06 percent of the adult population) and Bangladesh (0.03 percent) than in Thailand (2.2 percent) and Cambodia (2.4 percent).

Infection rates are also much lower in Nigeria (4.12 percent) and Ghana (2.38 percent) than in Namibia (19.94 percent) and Zimbabwe (25.84 percent).

It is this startling disparity between West and Southern Africa that has led some researchers into concluding that the missing link is because unlike in Southern Africa, in much of West Africa circumcision is an ingrained cultural and traditional practice that has worked to keep HIV at bay.

There is no disagreement on the fact that HIV-AIDS is predominantly spread through heterosexual contact. The argument centres around protection men reportedly derive from the removal of the foreskin, to the extent that circumcision arguably reduces infection by up to 50 percent.

Dr Shannon Hader, the director of the Centre for Disease Control and Prevention in Zimbabwe, says the preliminary data suggesting that male circumcision may reduce "although not ameliorate" an individual's risk of contracting HIV/AIDS, is intriguing.

"But it is far from being definitive in giving us the evidence we need to say that this is something that works." She says clinical trials in Kenya and Uganda will hopefully shed light on whether male circumcision does reduce HIV infection.

"Until we have more definitive data as to whether or not circumcision does in fact prevent HIV infection we will not support statements, policies or recommendations to pursue this at this time," she says. "We await the data and we think it's an important topic."

Some researchers argue that the skin on the inside of the male foreskin is 'mucosal', similar to the skin found on the inside of the mouth or nose. This mucosal skin reportedly has a high number of langerhan cells, which are HIV target cells rich in white blood cells or doorway cells for HIV.

Dr Jimmy Gazi, who is acting-president of the Zimbabwe Red Cross Society and also chairman of a Southern Africa Development Community (SADC) AIDS Scaling Committee, says due to the "moist, mucosal surface" on his penis, "the uncircumcised male has a much higher chance of having a micro alceration in the glands and inside the foreskin than the circumcised male". This exposes him to a greater risk of getting sexually transmitted diseases and HIV.

Gazi, however, says although circumcision is a good practice for those who subscribe to it, "I would not put it as a major in the transmission of HIV/AIDS."

It is now over 10 years since the first study on the increased risk of HIV infection among uncircumcised men was published. Since then, countless scientific inquiries have been performed to examine the link between HIV and circumcision.

One of the earlier investigations on the issue is a comparative study of four African cities conducted in 1999. Two West African cities, Cotonou in Benin, and Yaounde, the capital of Cameroon, were found to have low HIV infection rates of three percent and four percent, respectively, among men aged 15-49. The other two sites, Kisumu, Kenya, and Ndola in Zambia, had infection rates of 20 percent and 23 percent, respectively, for the same population group.

In Cotonou and Yaounde, nearly all the men in the study reported being circumcised. Only 10 percent of the men in Ndola and less than 30 percent of the men in Kisumu, meanwhile, had undergone the procedure. Furthermore, the study found, "HIV prevalence was below eight percent in men circumcised before their sexual debut and 25 percent in uncircumcised men".

Despite studies like this, the medical body is still divided on the preventative benefits male circumcision might have.

Potentially, however, a pro-circumcision verdict within the medical community would allow for a relatively cost-effective mass circumcision campaign in much of resource-strapped Southern Africa where, according to the Red Cross and Red Crescent Societies, "a gradual slide into destitution is underway which triggers further spread of HIV and ever-greater vulnerability to common disease and disaster."

The Red Cross adds that "the situation is slowly overwhelming Southern Africa and the longer-term projections are startling." Such a grim prognosis on prospects for the region suggests that any new weapon in fighting HIV/AIDS would be more than welcome.

The Gaborone-based Botswana Harvard AIDS Institute for HIV Research and Education says if supported by clinical trials, male circumcision might be an acceptable method of preventing HIV transmission among adults and adolescents.

The institute has gone on to assess the acceptability of circumcision among adults and children through a cross sectional survey at nine geographically representative locations in Botswana. Results have shown widespread acceptance of the practice if it was performed free of charge in a hospital setting.

Among those who believe the virtues of male circumcision must be recognized is Dr Mariam Esat, an infectious diseases specialist based in Zimbabwe. However, she says part of the reason why there is a dearth of publicity on the perceived benefits of male circumcision is that "medical insurance (in Zimbabwe) doesn't pay for it, certainly not adult circumcisions and not as a prophylactic against HIV."

The Dean of the College of Health Sciences at the University of Zimbabwe, Ahmed Latif, says scientific evidence does prove that circumcision in children allows the skin to keratinize (harden) like the back of the hand, thereby affording a great deal of protection against infections.

On the other hand, he says, the inner surface of the foreskin is made of mucosal membrane which gives it a very large surface area of contact because it is folded into itself.

"We are very aware of the association between HIV and circumcision but we are waiting for further confirmatory data," Latif says. "We might be convinced but we need to see more long-term studies.

"Just like we know that there is a link between alcohol and the spread of HIV, we should also be tackling this but everything takes place slowly," says Latif.

Much like many aspects of the HIV-AIDS, the link between the virus and male circumcision is still inconclusive. The fact that the World Health Organisation (WHO) has not yet given a cue in this area means it could be light years before Southern Africans know if circumcising their baby boys is tantamount to inoculating them against HIV-AIDS.(END/IPS/AF/SA/EA/WA/HE/SD/WJ/MN/03)

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