To cut or not to cut
Living with AIDS # 269
KHOPOTSO: Exactly a month ago, the Data and Safety Monitoring Board of the National Institute of Allergy and Infectious Diseases (NIAID), part of the United States’ Department of Health and Human Services met to review the interim data from two clinical studies of adult male circumcision to prevent HIV infection. The trials, sponsored by NIAID, are being conducted in the east African countries of Kenya and Uganda. The outcome, contained in a skimpy press release, was simple:
EXCERPT FROM PRESS RELEASE: We recommend an additional interim analysis within the next year. At this time, there are not enough efficacy data to justify an early end to either trial.
KHOPOTSO: If either trial could have shown findings similar to those from a study conducted in the area of Orange Farm, south of Johannesburg, one or both could have been stopped because the objective of proving the protectiveness of male circumcision against HIV infection would have been achieved. The South African study concluded that circumcision can have a 60% protective effect against HIV. So exciting was the result, say researchers, that it was stopped several months before completion. This was on the basis that 20 of the more than 1500 men who got circumcised during the trial got HIV, compared to 49 of the same number of men who did not get circumcised during the study.
DIRK TALJAARD:A protective effect of 60% is enormous. It could really make a huge difference.
KHOPOTSO: That’s Dirk Taljaard, of research and consultancy firm, Progressus, which monitored the study participants over a 21-month period. Daniel Halperin, regional HIV/AIDS programme advisor for the United States’ AIDS agency in Mbabane, Swaziland, concurs, but points out that the research must be informed by the knowledge and beliefs of the communities where it’s being conducted.
DANIEL HALPERIN: I just think it’s important to listen to the men themselves – and the women – in the communities and see what they think about these things. I was doing research on this topic about 10 years ago and then again, about five years ago in the Soweto area, in North West province and in KwaZulu-Natal. And so many men believe that circumcision is a good thing to do. Many of them believe they have less chance of getting STDs and they believe it’s cleaner and many of them believe that sex is better and quite a few believe it’s easier to use a condom if you’re circumcised’¦ We have to listen to that folk knowledge as well as the scientific knowledge.
KHOPOTSO: In township lingo Soweto men refer to the foreskin as a hoover, meaning that if you’re uncircumcised you suck up all the dirt that you can find from sex. That is folk knowledge backed up by some medical and hygienic plausibility. But if scientific knowledge were to say that removing the foreskin is a weapon against HIV infection that could potentially spell danger.
Many, me included, are concerned that in a society such as ours where in some cultures male circumcision is viewed as what constitutes a man and where women will not sleep with an uncircumcised man because such a man is viewed as being less of a man, promoting general male circumcision in the name of reducing HIV risk could have some serious repercussions. Men and women alike could find it easier to have unprotected sex for an additional reason ‘ circumcision could be construed as some form of immunity from HIV infection. Promoting general circumcision could pose a threat to the ABC principle of HIV prevention. The scientists must be clear about one thing. They must be clear that the C, which stands for ‘Condomise’, in the ABC strategy must not under any circumstance be replaced with a new word, ‘Circumcise’. It’s heartening to note that the researchers are well aware of the danger. Dirk Taljaard again.
DIRK TALJAARD: Each person needs to remember that for him or her to be safe they still have to practice abstinence, condom use, be faithful. All those things are still important because it’s not 100% effective’¦ I think what we need to be realistic about is that male circumcision is not a magic bullet. Male circumcision is not going to wipe out HIV in South Africa in a short space of time.
KHOPOTSO: Results from the two study sites in Kenya and Uganda are expected in July and September next year, respectively. If they confirm the results of the Orange Farm study, no doubt male circumcision will be on high demand even in countries where the practice is not so prevalent, such as in the southern Africa region. What scientists and medical researchers should give our populations is a clear, unambiguous message that to cut or not to cut is a choice and does not guarantee protection against contracting HIV.
That is common sense.
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