Guest guest Posted February 10, 2006 Report Share Posted February 10, 2006 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@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2006 Report Share Posted February 14, 2006 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@... Quote Link to comment Share on other sites More sharing options...
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