John Campbell

Africa in Transition

Campbell tracks political and security developments across sub-Saharan Africa.

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Guest Post: Making the Cut: HIV/AIDS and Male Circumcision in South Africa

by Guest Blogger for John Campbell
August 2, 2012

Fathers surround a boy as a doctor performs surgery during an Islamic group's circumcision session for boys in Khartoum April 7, 2012. (Stringer/Courtesy Reuters) Fathers surround a boy as a doctor performs surgery during an Islamic group's circumcision session for boys in Khartoum April 7, 2012. (Stringer/Courtesy Reuters)

Laura Dimon is the Africa Studies intern at the Council on Foreign Relations.  Previously, she worked for the Clinton Health Access Initiative in Pretoria, South Africa.  She has entered the Columbia University School of Journalism.

At the 19th International AIDS Conference, Secretary Clinton announced that the U.S. will give forty million dollars to South Africa to support a voluntary medical male circumcision program for almost half a million boys and men in the coming year. Why South Africa, and why circumcision?

South Africa has the highest prevalence of HIV/AIDS in the world. There are 34 million people in the world living with HIV/AIDS and 5.38 million of them are in South Africa; 16.6% of people ages 15-49 in South Africa are HIV-positive. Many South Africans are unaware of these staggering statistics.

Further, South Africa’s general public is unlikely to be familiar with circumcision’s role in the prevention of transmission of the disease. But in the words of Dr. Anthony Fauci, circumcision is “stunningly successful” in preventing female-to-male transmission. His views are supported by various studies in Africa which have shown that circumcision cuts transmission risk by about 60%.

Why is this? According to the CDC, the inner mucosa of the foreskin—compared to the dry external skin surface—has a higher density of target cells for HIV infection and higher likelihood of abrasion during intercourse, providing entry points for the virus. Further, the microenvironment of the space created by the unretracted foreskin may be conducive to virus survival. Finally, the higher rates of STDs observed in uncircumcised men may also increase susceptibility to HIV.

Beyond the science, beliefs about circumcision are deeply rooted in cultural practice and tradition and vary greatly between regions and ethnic groups in Africa—and elsewhere (a German court recently banned circumcision of minors.) In South Africa, the Zulu have historically not favored circumcision, but the Xhosa and Sotho view it as a rite of passage into manhood and perform it traditionally, not medically.

As the correlation between circumcision and prevention of the transmission of HIV/AIDS becomes better known, the number of procedures in South Africa is likely to increase, especially where it does not clash with deep-seated religious or ethnic values.

 

Post a Comment 6 Comments

  • Posted by Jack

    “elation between circumcision and prevention of the transmission of HIV/AIDS ”

    In the real world, cutting off parts of a man’s penis has not cut the risk of female-to-male transmission of HIV. It has actually increased the spread of HIV/AIDS.

    In Zimbabwe, after a circumcision campaign (as per the WHO), the cut men have higher rates of HIV than those not It does NOT WORK for HIV prevention as HIV prevention via penis parts cutting is not observed in the real world. The mutilation practice has no purpose except to remove thousands of nerves, shut down part of the human sensory system and give men ED at a young age.

    Let us also not ignore the fact that In 2009 a circ pushing team (Wawer/Gra-y) reported that the Ugandan men they cut were 50% MORE likely to infect their female partners.

    The numbers show, particularly in Swaziland, that HIV transmission was more prevalent among the circumcised. HIV transmission was found to be more prevalent in at least 6 African countries. Cameroon (4.1% v 1.1%), Ghana (1.6% v 1.4%), Lesotho (22.8% v 15.2%), Malawi (13.2% v 9.5%), Rwanda (3.5% v 2.1%), and, Swaziland (21.8% v 19.5%). IN Kenya they just did a study of a group and circumcision status was not associated with HIV or HSV-2 seroprevalence or current genital ulceration. The US sponsored DHS Comparative Reports No. 22 showed that in Africa there appears no clear pattern of association between male circumcision and HIV prevalence. In 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries HIV prevalence is higher among circumcised men.

    Stop pushing this mutilation practice. It does not slow the spread of HIV and it does harm the men cut.

  • Posted by Ronald Goldman, Ph.D.

    Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. They have various flaws. The absolute rate of HIV transmission reduction is only 1.3%, not the claimed 60%. Authorities that cite the studies have other agendas including political and financial. Research shows that circumcision causes physical, sexual, and psychological harm. This harm is ignored by circumcision advocates. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Please see http://www.circumcision.org/hiv.htm for more information and links to literature.

  • Posted by Chris Jennings

    The pivotal studies purportedly demonstrating the efficacy of circumcision in preventing HIV transmission (or, actually, contraction of HIV infection by circumcised males) are invalid. Ryan McAllister, PhD, Biophysicist succinctly describes the methodological fault of these studies. Go to 29 minutes and 9 seconds into the youtube presentation:https://www.youtube.com/watch?v=Ceht-3xu84I&feature=related

    Moreover, the purported 17% seroprevalence rate among South Africans is entirely implausible. This computer-generated calculation based on one-off sero-surveys of antenatal clinics are simply beyond any plausible level of sexual activity.

    Literally, the heterosexual males of South Africa would require 100 to 400 different sexual partners every six months, and the heterosexual South African females would require 110 – 1320 different sexual partners every 6 months — just to equal the prevalence of AIDS in New York City.

    These calculations based on:

    (1) an average of 20 different sexual partners every 6 months for highly active gay males in NYC at the outset of the AIDS epidemic

    (2) a 1 in 100 rate of HIV transmission rate to the receptive partner during unprotected anal intercourse

    (3) a 5 – 20 times lower efficacy of HIV transmission (male-to-female) during unprotected vaginal intercourse, this risk being to the receptive partner

    (4) a 1.1 – 3.3 times lower efficacy of HIV transmission (female-to-male) during unprotected vaginal intercourse to the insertive , this 1.3 – 3.3. lower efficacy in comparison male-to-female transmission under the same circumstances

    Altogether, these calculations, if the same relative proportions of gay males in NYC and heterosexual males + females engaged in such sexual activity, then the prevalence rates of New York City and South Africa would be comparable.

    (5) if we take the cumulative total of AIDS cases in the NYC Metropolitan Statistical Area (which includes NYC, Long Island, and Newark NJ, the latter being a foci of IV drug AIDS cases), i.e., if we add up the cumulative total of AIDS cases in the the NYC Metropolitan Statistical Area from the beginning of the AIDS epidemic (1981) until 1981, then we have a cumulative AIDS prevalence rate of 1.1%. And in South Africa, we are supposed to have a heterosexually based HIV infection rate of 17% — males and females equal

    What’s wrong with this picture?

  • Posted by Hugh Intactive

    The “60% reduction” is one of those statistics that comes after “lies and damn lies”. It is based on 74 circumcised men who did not get HIV (when 64 did) less than two years after 5,400 men were circumcised in three prematurely curtailed, non-double-blinded, non-placebo-controlled trials on paid volunteers for circumcision, held by circumcision advocates. Thus the way was wide open for experimenter and experimentee bias.

    Drop-out rates were several times higher than infection rates, so it is entirely possible there was no protection at all. Contacts were not traced, so there is no guarantee that the men were even infected (hetero)sexually.

    The “protection only applies to men, and women are already at greater risk. A trial in Uganda started to show that circumcising men INcreases the risk to women, but it was cut short for no good reason before that could be confirmed.

    Circumcised men will think they are immune and disempower women from demanding condoms. At the AIDS 2012 Conference itself, a poster-boy for circumcision, Angelo Kaggwe from Uganda, said ” Now I have no worries if I have an opportunity and I have forgotten to bring along a condom.” and none of the top circumcision honchos, Daniel Halperin, Bertran Auvert or Robert Bailey, who were listening, corrrected him.

  • Posted by Curt

    This New Zealand study addesses the failings of that one.
    Jounal of Paediatrics
    March, 2008
    Circumcision and risk of sexually transmitted infections in a birth cohort

    Dickson NP, van Roode T, Herbison P, Paul C.
    Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
    OBJECTIVE: To determine the impact of early childhood circumcision on sexually transmitted infection (STI) acquisition to age 32 years.
    STUDY DESIGN: The circumcision status of a cohort of children born in 1972 and 1973 in Dunedin, New Zealand was sought at age 3 years. Information about STIs was obtained at ages 21, 26, and 32 years. The incidence rates of STI acquisition were calculated, taking into account timing of first sex, and comparisons were made between the circumcised men and uncircumcised men. Adjustments were made for potential socioeconomic and sexual behavior confounding factors where appropriate.
    RESULTS: Of the 499 men studied, 201 (40.3%) had been circumcised by age 3 years. The circumcised and uncircumcised groups differed little in socioeconomic characteristics and sexual behavior. Overall, up to age 32 years, the incidence rates for all STIs were not statistically significantly different – 23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively. This was not affected by adjusting for any of the socioeconomic or sexual behavior characteristics.
    Although our results are consistent with the lack of a protective effect, they are at variance with the recently published report by Fergusson et al, who, using data from another New Zealand cohort, found that circumcision reduced by more than one-half the risk of any STI up to age 25 years. Because both studies have particular strengths for examining this question, it is important to consider reasons for the discrepant findings. A lower proportion of the Christchurch sample (30.2%) was circumcised than the proportion of our Dunedin sample (40.2%; who were born 5 years earlier). This difference is in keeping with trends in circumcision in New Zealand at the time. This might have introduced a difference in characteristics between the circumcised men and uncircumcised men in the Christchurch compared with the Dunedin cohort, so residual confounding is more likely in the Christchurch analysis. But because adjustment for confounding increased the protective effect found in that study, this is an unlikely explanation. Another difference was that in the Christchurch study only 8.5% of men reported an STI between ages 18 and 25 years, which was less than half the 19.9% reported in our Dunedin study up to age 26 years. The reasons for this are not clear, but possibly the computer-presented questions in the latter study promoted disclosure. Finally, as noted, the Christchurch study was a relatively small sample; thus their estimate of the protective effect of circumcision lacks precision, with wide confidence intervals, and is compatible with only a small increase in risk.
    CONCLUSIONS: These findings are consistent with recent population-based cross-sectional studies in developed countries, which found that early childhood circumcision does not markedly reduce the risk of the common STIs in the general population in such countries. [In this case, not even "markedly" - does not reduce it at all, and could increase it.]

  • Posted by Brian Earp

    This post at the University of Oxford’s Practical Ethics website breaks down the much-cited “60%” figure quoted in this article … http://blog.practicalethics.ox.ac.uk/2012/05/when-bad-science-kills-or-how-to-spread-aids/ … The statistic is wildly misleading, and the data from which it is derived are problematic in a number of ways discussed in the Oxford post.

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