Africa: Male circumcision: cutting into the debate

I have always been skeptical about male circumcision (MC) as a preventative measure for HIV/AIDS, pondering just how effective it is for not only men, but also their female partners. A new study - carried out in Rakai district, Uganda - gives a glimpse into the answer. Sadly, it is not what activists in gender and HIV hoped to hear. It seems that male circumcision may actually increase women’s transmission risk from their HIV positive circumcised male partner.

When in 2007, the World Health Organization (WHO) and UNAIDS recommended MC as an effective HIV prevention measure, I worried about all the praise that the practice was receiving for its efficacy. My fears centred around two points.

The first was that once a man had an MC operation done, he might begin to believe that all the risk of contracting HIV had lain within a flap of skin removed from his genitals. With that hotspot for HIV finally snipped off, he could think that he was now immune to the virus and engage in risky sexual activities – all to the detriment of himself, and his partners.

Secondly, I wondered what a 60% reduction in risk of heterosexually acquired HIV infection for men (as three MC trials in South Africa, Uganda and Kenya collectively approximated) really meant without a way to estimate similar harm reduction for women.

Many questions arose. What did MC really mean for male-to-female HIV transmission? Could it also protect women? Scientists and researchers also pondered these questions, which led to the recently released study in Uganda, involving 922 men living with HIV and 163 of their HIV-negative female.

The findings suggest that male circumcision may have actually increased HIV risk to some of the women in the intervention group. After six months, women whose partners ignored advice to abstain from sex for at least six weeks after the circumcision procedure had an HIV acquisition rate of 27.8%, compared to 9.5% among women whose male partners delayed sex until healing was complete, and 7.9% among women with uncircumcised partners.

Out of 92 couples in a group of circumcised men (used as the experiment group), 18% of the women became infected during the study period, compared to 12% of women in the uncircumcised control group.

Alarm within circles that have embraced the call to scale up resources towards universal access to MC would be justified. After all, governments and organisations have already invested great quantities of human, technical and financial resources into the area.

The health ministries of Botswana and Zambia have already put in place ambitious targets for national MC coverage, while several other sub-Saharan nations – where HIV still has its most fertile breeding ground – are in the process of conducting situational analyses and crafting policies around the practice.

However, before we kill MC off the HIV agenda, it is still worth looking into the factors that might have led to the negative results yielded by this most recent study. For a start, complacency kills.

Immediately after MC surgery, a couple may become more cautious about their sexual practices. Wounds from MC can take at least six weeks to heal, meaning no sexual activity for that whole period. However, initial diligence about hygiene and abstinence may not last this long.

Some men say they would never consider MC because they just would not be able to live without sex for six whole weeks. I wonder just how many of those who get circumcised might be re-engaging in sexual contact too soon after their operations – when open wounds around the penis give free access for the HI virus to pass on to a female partner during intercourse.

And yes, there can be complacency about condoms too. If you read the fine print closely enough, you will notice that MC always comes with a “disclaimer” – the practice should be carried out in tandem with continuing condom use for sex. MC is not a vaccine for HIV. It just reduces risks of transmission. Condoms, regular HIV testing and faithfulness are all still prerequisites in the effort to avoid infection and re-infection.

The second factor about MC relates to faithfulness. HIV negative men use MC to avoid initial infection, while men who are already HIV positive circumcise to avoid re-infection, as well as onward transmission of the virus. There is much to be lost for both groups if they begin believing that MC affords them some sort of exemption from HIV. Contrary to what many might think, MC is not a passport to risk-free sex.

These are the reasons for my skepticism about MC. Perhaps these new study findings are the jolt needed to realise that there is more work needed to correctly communicate the benefits and limitations of MC.

Certainly, it is an important component of a holistic approach to HIV reduction, but it must be linked to other critical services such as HIV counselling and testing, partner reduction and monogamy. On the other hand, when coupled with complacency and recklessness, MC becomes more of a bain than boon in our efforts towards eliminating HIV.

* Fungai Machirori is a writer from Zimbabwe. This article is part of the Gender Links Opinion and Commentary Service that provides fresh views on everyday news.