Tackling taboos--male circumcision in the Indian context

[Guest guest]

Dear FORUM,

If there was a vaccine that could reduce HIV incidence by 60 per cent,

should it be provided to all who would want it? Should discussion on the

merits and demerits of this vaccine be debated at the country level? Should

the population at risk for this epidemic be made aware of this vaccine?

If the answer to any of the above questions is “yes” then there is a need

for debate on what is emerging to be a highly successful HIV prevention

intervention—male circumcision. Recent scientific evaluations have provided

evidence for the large protective effect of male circumcision in the

transmission of HIV. Specific to the Indian context, a prospective study of

2298 HIV-uninfected men attending sexually transmitted infection clinics in

India found circumcision was strongly protective against HIV-1 infection.A

meta-analysis of 38 studies concluded that uncircumcised men were more than

twice as likely to have HIV than circumcised men. A longitudinal study of

male sexual partners of HIV-positive women in Rakai, Uganda, found that

40-137 uncircumcised men and 0-50 circumcised men acquired HIV. Ecological

evidence demonstrates an increasingly close geographic association between

lower male circumcision and higher HIV prevalence rates. A major UNAIDS

multi-country comparison of high and low prevalence African cities concluded

that male circumcision was the major predictor of disparities in HIV levels.

No Asian country with widespread male circumcision, such as Bangladesh or

Pakistan, has a significant sexual HIV epidemic. In addition, in mid-2005, a

randomized controlled male circumcision trial of 3,035 men in Orange Farm,

South Africa was halted when an interim analysis demonstrated a protective

effect so large that it would have been unethical to continue the trial. The

analysis showed that male circumcision reduced HIV incidence by 60 per cent,

from 2.2 per cent to 0.77 per cent. Two similar ongoing studies in Kenya and

Uganda are also possibly going to be stopped earlier due to finding of

similar protective effects of circumcision.

There are plausible biological explanations for the relationship between

male circumcision and HIV infection. Circumcision removes the inner foreskin

and the frenulum, which are the prime sites of entry for HIV into the penis.

The intact foreskin has far more Langerhans target cells than other genital

tissue. Circumcision results in keratinisation, or toughening of the glans.

An intact foreskin provides a warm, moist environment for infectious agents

including HIV. Male circumcision has also been shown to protect men from

human papilloma virus infection, and their wives from cervical carcinoma.

Male circumcision is not without its risks. Potential complications from

male circumcision range from excessive bleeding and infection to penile

damage, erectile dysfunction, and in rare cases even death. While the risks

should not be trivialized, the recent study of male circumcision in Orange

Farm, South Africa show less than a 4 per cent incidence for any kind of

complications and a less than 1 per cent incidence of severe complications

(with no deaths reported). These risks are similar to those for vaccines and

can be greatly reduced through safe medical interventions.

The evidence on male circumcision is especially relevant for the Indian

context. With 5.1 million HIV infections, the disease is mostly spread

through heterosexual contact. Male circumcision, along with prevailing

interventions of condom promotion and behavior change programs, could play

an important role in potentially reducing the spread of this epidemic among

high risk groups. However, the debate on male circumcision is also a tricky

one due to the numerous religious and cultural sensibilities it involves.

This could perhaps explain the lack of rhetoric-free discussion on this

topic in this and other AIDS forums. There is a reluctance to grapple this

topic by AIDS program implementation agencies for fear of offending local

sensibilities. Therefore, “locals” need to exert their agency and discuss

this topic in a critical and culturally sensitive manner.

With the growing body of evidence showing the protective effects of

circumcision, it is important to carve out a safe sphere where scientific

evidence can be methodically evaluated, cultural sensitivities can be

navigated, and at risk populations can be made aware of this “60 per cent

effective vaccine”. Circumcision does not offer total protection, and at

most could be one of an array of HIV preventive interventions discussed with

high risk groups. AIDS is changing the landscape of our country, and this

necessitates a rational discourse on previously taboo topics. Religious

choices should be allowed to be re-examined if our next generation is to be

protected. If this intervention is not comprehensively assessed for its

feasibility in the Indian context, as AIDS activists we are doing our

constituents the greatest disservice—we are guilty of the sin of omission.

Best,

Aakanksha Pande

aaka_pande@...

[Guest guest]

Dear FORUM,

This posting ref; message from Aakanksha Pande, " Tackling taboos--male

circumcision in the Indian context- Is it wise to recommend it as vaccination? "

Congratulations for such a nice letter. I will like to add that it may be

possible to have some protective effect due to thickened and

keratinised glans in those who have been circumcised in early childhood or

infancy, but same will not be true of those who get circumcised a fresh and

therefore using or recommending this practice as vaccine is not likely to be

effective. More so such a recommendation may give an edge to some religious

leaders to propagate their religion too and to instigate conversion.

Is it possible for me to get the detailed report of study done in orange farm in

South Africa, though you say that this study was abandoned but you are giving

ref. to it?

I did Paediatric Surgery from KEM hospital in Bombay way back in 1980 and now

settled in UK. Circumcision Vs non-circumcision was my thesis topic and because

of immediate and long term complications, I always believed and never

recommended circumcision unless essential and that too if required it should be

done by a qualified person in hospital atmosphere only. Though I have known

before, but while working in Iran and Saudi Arabia in eighties, my colleagues in

Gynaecology presented such horrendous cases of injuries in

females due to violent sexual intercourse, that my views against

circumcision were reinforced. You may be aware that due to lack of

sensations with keratinised glans, there are more incidences of violent sex

leading to very serious injuries in females in such population with immediate

dangers and long term complications as compared to non-circumcised population

and communities.

However in spite of my reservations, I shall have an open mind and shall try to

look into this evidence through our facilities at Gwalior in India details on

www.helpchildrenofindia.org

Can you please guide me for any possibility for a research grant to pursue this

study from your university or otherwise.

Thanks, with regards and best wishes,

Dr.B.K.Sharma,

Gwalior Childrens Hospital Charity,

14,Magdalene Road, Walsall,West Midlands. WS1 3TA(U.K.)

Tel. +44(0)1922 629842 Fax. 01922 632942

Mobile. 07729929982

Email: gwalior.hospital@...