The Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organisation (WHO) have endorsed male circumcision for the prevention of HIV.
According to scientific trials, male circumcision can reduce a man’s risk of becoming infected with HIV during heterosexual intercourse by up to 60 per cent.
Relying on these studies, WHO and UNAIDS have recommended male circumcision as an important new element of HIV prevention. Since the recommendation, the demand for circumcision has been on the rise.
In Nigeria, male circumcision involves removing the foreskin, a loose fold of skin that covers the head of the penis. The procedure can be carried out at any stage- during infancy, childhood, adolescence or adulthood.
At the World AIDS conference in Washington DC, United States, Director-General of the National Agency for the Control of AIDS (NACA) Prof John Idoko explained how medical male circumcision can prevent HIV transmission.
“HIV is a virus that suppresses the immune system of an infected person. It targets and destroys particular white blood cells (CD4 cells, a type of T cell) that the immune system must have to fight disease. The virus is transmitted from person to person through contact with HIV-infected blood or other infected bodily fluids such as semen.
“HIV can remain in the body for over 10 years without causing outward signs of illness. However, as HIV-related immune destruction progresses, symptoms may include enlarged lymph glands, depression, fatigue, fever, yeast infections of the mouth and vagina, night sweats, diarrhoea, loss of appetite, loss of memory, and weight loss. The HIV-infected person is also more susceptible to illnesses that usually do not affect healthy people. These are called opportunistic infections, meaning that they take advantage of a weakened immune system.
“Several characteristic opportunistic infections are PCP (Pneumocystis carinii- pneumonia), yeast infections of the esophagus, tuberculosis, Kaposi’s sarcoma, and cytomegalovirus. An HIV-infected person is considered to have AIDS when his or her CD4 cell count falls below 200/mL. AIDS is also characterised by the appearance of opportunistic infections. In the majority of cases, the absence of treatment once AIDS is acquired leads to death.
“Compared with the dry external skin surface, the inner mucosa of the foreskin has less keratinisation (deposition of fibrous protein), a higher density of target cells for HIV infection (Langerhans cells), and is more susceptible to HIV infection than other penile tissue in laboratory studies. The foreskin may also have greater susceptibility to traumatic epithelial disruptions (tears) during intercourse, providing a portal of entry for pathogens, including HIV. In addition, the micro environment in the preputial sac between the unretracted foreskin and the gland penis may be conducive to viral survival. Finally, the higher rates of sexually transmitted genital ulcerative disease, such as syphilis, observed in uncircumcised men may also increase susceptibility to HIV infection”.
How does circumcision prevent HIV?
Describing how medical male circumcision can prevent HIV, Idoko said: “There are several ways in which the foreskin acts as HIV’s main ‘entry point’ during penetrative sex between an uninfected man and an HIV-infected person. The inner surface of the foreskin contains a higher proportion of the cells that HIV targets, such as T-cells. Conversely, the inner foreskin has less keratin, a protein found in the skin, which has a protective effect. A study of Zambian men before and after circumcision concluded that observed decreases in anaerobic bacteria may play a role in reducing the risk of HIV acquisition. Circumcision can reduce the likelihood of genital ulcers, which increase HIV-risk. In addition, any small tears in the foreskin that occur during sex make it much easier for the virus to enter the body.”
Chief Mumena of the Kaonde people of Zambia, from the Bill and Melinda Gates Foundation, described how his people benefited from medical male circumcision to reduce HIV.
“It is not in the culture of Provinces in Zambia to circumcise at infancy. Male circumcision is more of passage of right. My-19-year-old son came home from school one day and demanded to be circumcised. I dug into the reason by asking questions and reading literatures on the subject. I discovered the enormous benefits. It was not an easy task trying to change cultural norms. I had several towns’ meetings and today many men in Kaonde are voluntarily asking for medical male circumcision.”
He added that from the medical records of his people, male circumcision can be protective against HIV transmission through sexual intercourse. “Over 400 men came out for medical circumcision. Kaonde men have recorded over 71 per cent HIV reduction. Circumcision significantly reduces a man’s risk of contracting HIV from an HIV-positive woman during penile-vaginal sex, as shown by several types of research.
“A review of 28 studies of male circumcision, as it is related to heterosexual transmission of HIV in Africa, showed that the relative risk for becoming infected with HIV was 44 per cent lower in circumcised men. In addition, male circumcision has been associated with protection against other sexually transmitted infections such as syphilis and chancroid.
“Not only that, it was discovered as well that it helped in the reduction of cervical cancer in women because the virus used to hide in the foreskin of men that are not circumcised. What is the essence of culture when life is not protected, but rather maimed.”
Mumena said: “Biologically, there are several possible reasons circumcised men are less likely to contract HIV. One, the foreskin is moist and helps the virus survive and reproduce. When the foreskin is removed, this moist environment is eliminated as well; two, the foreskin is not keratinised and thus may have greater susceptibility to tears during intercourse, providing a portal of entry for pathogens, including HIV; and three, the foreskin has a high concentration of target cells to which the virus can attach and cause infection. Accordingly, male circumcision, together with other prevention interventions, could play an important role in HIV prevention.”
Voluntary male medical circumcision (VMMC) reduces the risk of men contracting HIV, the Human Papilloma Virus (HPV) and other sexually transmitted infections from an infected female. However, male circumcision confers only partial protection and should be considered as only one of several other prevention measures. Despite the effectiveness of VMMC, it is essential that circumcised men be encouraged to continue using condoms during sexual intercourse.