Note:
The HIV prevention project in central Kenya is supported by Swedish Agency for Research Cooperation with Developing Countries (SAREC).
Poland R, The Question of Routine Infant Circumcision. NE Jour Med, Vol 3 No 18, May 3, 1990. pp. 1312-1314
An excerpt:
It has been proposed that circumcision may protect men from infection with the human immunodeficiency virus (HIV). Two recent reports concluded that uncircumcised men exposed to HIV during heterosexual intercounres appeared to be more susceptible to infection. The presence of a penile ulcer was found to be as important, or more important, as a risk factor, for seroconversion. The data were collected in a clinic for venereal disease in Kenya, where the heterosexual trasmission of HIV appears to be more prevalent than in North America. In these studies, the uncircumcised mencame from areas of the country un whih HIV was endemic, and the circumcised men came from areas of lower risk. Whichi is cause and which is effect remains unknown. Many of the studies' conclusions depended on retrospective data, and again, important sources of bias may have obscured the true contribution to the risk of the transmission of HIV.
WE MUST REMEMBER THAT CIRCUMCISION IS NOT PERFORMED RANDOMLY; (Emphasis added) it is more common in certain socioeconomic, ethnic and religious groups. Jews and Muslims are circumcised for religious reasons. In the United States, neonatal circumcision is less common among the poor and among Hispanic Americans. In Japan and Sweden, neonatal circumcision is not performed routinely. These demographic factors may in turn be associated with sexual practices and exposures that have a significant effect on the incidence of HIv infection. Nevertheless, the studies cited do suggest that HIV may be more infectious during heterosexual intercoures if the male partner is uncircumcised and has a mucosal or cutaneous ulcer. In preventing the transmission of HIV, however, circumcision is unlikely to be as effective as limiting the number of sexual contacts or using condoms properly.
de Vincenzi I, Mertens T., Male Circumcision: a role in HIV prevention?, AIDS Vol 8 No 2, February 1994, pp.153-160
Conclusion: The potential public-health benefits of male circumcision have been greatly discussed in the past 50 years, often in a passionate and emotional manner. However, relatively few studies have been carried out and those that have, present conflicting results. The major criticism of most of the studies performed to date is the lack of confounding factors, which could be related to both circumcision status and risk of sexually transmitted infections, such as sexual behaviour or different hygienic practices or differential use of health facilites. As Poland noted, 'We must remember that circumcision is not performed randomly.'
Therefore, further efforts are still required to quantify the relative risk associated with the lack of male circumcision. Some of this can be achieved by using observational designs which better address the limitations discussed above. Laboratory and primate research might continue to provide useful information.
As the safety, expected benefits, feasibility and acceptablity of mass circumcision are all questionable, neither public-health interventions nor intervention studies appear to be defensible options before there is stornger evidence from observational studies in differnet settings that show lack of male circumcision may be a genuinely independent risk factor for the transmission of HIV.
Krantz I, Ahlberg BM. Circumcision and HIV Letter, Lancet Vol 345, March 18, 1995, p. 730
Sir-According to several workers,1,2 absence of male circumcision increases the probability of transmission of HIV. The quantification of the potential prevention benefit from male circumcision is highly problematic.3 The strength of the association, when present, varies greatly between studies. Despite inconsistency, published finding seem to have resulted in some consensus that male circumcision should be promoted as an HIV preventative intervention, especially in African countries.4 What seems to be of little concern to advocates of circumcision is the meaning and practices associated with it. The studies so far, which mainly used case control designs, have not made preper allowances for possbile extraeous factors such that may have effceted the relation examined. Nobody is circumcised at random. The researchers cannot refer to high correlation coefficients and rely on regression models as controls for possible confounding factors; first they have to be cultura lly competent to understand which factors determine whether you are circumcised or not as a young boy.
Among the Kikuyu in Kenya, before the colonial and Christian missionary interventions at the turn of the century, all boys and girls went though the ritual of circumcision and clitoridectomy, respectively. Circumcision was associated with acquirement of social status for the initates and their parents.5 Just before the operation, the parents of the would be male initiate identifed a person who was responsible and knowledgeable to act as mutiri
. The mutiri was supposed to advise and prepare the boy for initiation, take him through the operation by physically supproting him, take care of the wound, and guide him afterwards. Part of the education was hawe to relate to women and how to maintain discipline in sexual matters.
According to our experince from central Kenya, almost all boys aged 12-15 years undergo circumcision in clinics before they start secondary school. Apart from the academic qualification, there is eveidently a demand for social adulthood defined through circumcision. However although the operation marks entry into adulthood as it was known traditionally, its form and organisation have changed. Unlike in the past almost no ceromonial preparations are made and the adults and the community in general are not involved in the associated education. Parents no longer have the important role of identifying the mutiri. The link between youth and adults no longer exists. At the age and season for initiation the youths turn to their peers and usually choose somone to be mutiri who went though the initiation in the previous season. In the youth subculture the only part of the educational message is that, as proof of manhood, sexual intercourse must take follow soon after circumcision.
If this takes place in the commercial sex market the implications for acquiring sexually transmitted diseases, HIV included are far reaching.
The idea that circumcision should be promoted, similiarly to condoms, as a preventative measure against HIV colud thus be counterproductive. The link between circumcision and protection against HIV might very well be biologically plausible, but the onus remains to produce adequate evidence of safety before a supposedly protective measureis implemented anywhere.
Note:
*Ingela Krantz, Beth Maina Ahlberg
*Unit of International Health Care Research (IHAR), Department of International and Social Medicine. Department of International Health and Social Medicine, Karolinska Institutet,`s-171 77 Stockholm, Sweden; Nordic School of Public Health, Goteberg; and Department of Sociology, Uppsala University, Upsulla
Grosskurth H, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS Vol 9 No 8 Augst 1995 pp. 927-934
Some excerpts:
Among men, HIV prevalence was significantly higher among those who had been circumcised.
On univariate analysis, circumcised men were at significantly higer risk than uncircumcised men of the same age and living in the same community (OR, 154; P=0.03)… The reasons for the apparent lack of a protective effect of circumcision in this population are not clear. It may be that circumcised men in Mwanza Region live a more modern lifestyle, and are at increased risk due to behavioural factors that were not measured in this survey. Circumcision is known to be more common in uban areas, and among certain ethnic groups originating from other areas who therefore tend to travel more often. Further research is being conducted to answer this question.
The Circumcision Information and Resource Pages are a not-for-profit educational resource and library. IntactiWiki hosts this website but is not responsible for the content of this site. CIRP makes documents available without charge, for informational purposes only. The contents of this site are not intended to replace the professional medical or legal advice of a licensed practitioner.
© CIRP.org 1996-2024 | Filetree | Please visit our sponsor and host: 
IntactiWiki.