The 'SNIP': Male circumcision and HIV prevention

Male circumcision is on the cards following the clear link between lower rates of infection from women to circumcised men, shown in three randomised controlled trials conducted in Kenya, Uganda and South Africa. Geofrey Setswe suggests how male circumcision could form part of comprehensive prevention plan.

At the time of the adoption of the new HIV & AIDS and STI National Strategic Plan for South Africa 2007-2011 (NSP) in May 2007, male circumcision was identified as an ‘emerging' HIV prevention measure. On the basis of the conclusive evidence of the partial efficacy of male circumcision provided by these trials, male circumcision has been recommended as an HIV prevention measure by UNAIDS and the World Health Organisation (WHO).

In particular, the NSP ‘recommended that the Department of Health consider the effectiveness of male circumcision as an HIV prevention intervention and develop appropriate policies.'

According to the WHO, ‘the three randomised controlled trials showed that circumcision performed by well-trained medical professionals was safe and reduced the risk of acquiring HIV infection by approximately 60%. Circumcision should now be recognised as an efficacious intervention for HIV prevention and promoting circumcision should be recognised as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.'

The overwhelming scientific evidence of the efficacy of circumcision for HIV prevention and the urgent need to confront the AIDS epidemic devastating some sections of the South African community, several ethical analyses have concluded that it is unethical not to offer heterosexual men at risk of exposure to HIV infection access to safe, voluntary circumcision services.

On the strength of the UNAIDS and WHO recommendations that circumcision becomes a part of national HIV prevention strategies, implementation began with several sub-Saharan African countries in 2008, introducing circumcision as an HIV prevention intervention, for example, in Botswana, Uganda and Zambia.

The NSP ‘recommended that the Department of Health consider the effectiveness of male circumcision as an HIV prevention intervention and develop appropriate policies.'

As more and more people in South Africa become needlessly infected with HIV, the time has come to move beyond debating the merits of this evidence and to start implementing safe, voluntary male circumcision as part of a comprehensive HIV prevention programme in South Africa.

Adult male circumcision is already a part of South Africa's cultural landscape. Knowledge of the outcomes of the circumcision trials is now well known, although often linked to misunderstanding. Many men are getting circumcised and there is a need for a policy to regulate the practice of circumcision in both clinical and traditional settings.

Challenges

The WHO states that ‘it is important to ensure that circumcised men do not develop a false sense of security that could cause them to engage in higher-risk behaviour.' Male circumcision does not provide 100% effective protection for anyone, but rather that it reduces the risk of transmission from women to men significantly.

As with any partially protective intervention, circumcision programmes must be appropriately conceptualised, explained and implemented so as to minimise risks. Some of the risks include:

  • men who don't allow their body to fully heal for 6-8 weeks immediately following circumcision;
  • newly circumcised men who might believe that circumcision permits unsafe and risky sexual behaviour;
  • women who might think that unprotected sex with circumcised men is safe (or safer);
  • those who elect to undergo circumcision in traditional settings and who don't ensure that it is conducted in a hygienic or sterile environment.

Interest groups in the HIV sector are respectful of the important roles played by traditional and religious practices regarding circumcision. For many South Africans, circumcision is an integral part of the culture and the initiation of boys into manhood. There is a need for ongoing dialogue with traditional leaders, traditional healers and faith-based sectors about what circumcision means to them and for improving the traditional practices related to circumcision as well as for the evolution of custom. Better communication with traditional health practitioners and for including and consulting them in the efforts to get men to take responsibility for their sexual health - will go a long way in obtaining their cooperation in implementing a circumcision policy.

The WHO states that ‘it is important to ensure that circumcised men do not develop a false sense of security that could cause them to engage in higher-risk behaviour.'

It is therefore important that before circumcision policy is introduced, there should be consultations and communication with all stakeholders. However, whilst recognising the challenges of reaching everyone during consultations and communication sessions, the country cannot ignore or delay acting upon the scientific consensus about the benefits of circumcision.

A comprehensive programme

The national department of health, with support from the SA National AIDS Council (SANAC), is currently developing a policy on circumcision. However, a policy on male circumcision should expressly recognise that this is not a stand-alone intervention but forms part of a comprehensive HIV prevention programme that, among other things, does the following:

  • promotes delaying the onset of sexual relations, with a particular focus on delaying vaginal and/or anal sex;
  • promotes the correct and consistent use of male and female condoms; consistently promotes sexual and gender equality; ensures access to appropriate HIV testing and counselling services;
  • encourages everyone to know their HIV status;
  • promotes safer sex practices (including reducing the number of concurrent sexual partners); and
  • encourages the prompt treatment of sexually transmitted infections (STIs), including the treatment of partner(s).

When all HIV prevention measures are integrated as one comprehensive strategy the chances of being infected by HIV or of infecting others are dramatically reduced. As circumcision only offers partial protection against HIV infection for heterosexual men and boys, it must be combined with appropriate messaging and risk counselling to ensure that people who are circumcised understand the need to continue practising safer sex.

Circumcision should be voluntary

A policy on circumcision should be completely voluntary. Boys who elect to be circumcised before the age of traditional initiation should not be discriminated against and, if possible, discussion should take place to adapt cultural practices to accommodate this. Boys who are circumcised as part of initiation practices should also be counselled about sexual health, sexual responsibility and HIV prevention. Where boys and men undergo circumcision in clinical rather than traditional settings they should not be prejudiced, stigmatised or discriminated against, whether or not their culture has such a tradition. Messaging should be developed to guard against this and where necessary cultural practices should be adapted.

When all HIV prevention measures are integrated as one comprehensive strategy the chances of being infected by HIV or of infecting others are dramatically reduced.

Finally, in keeping with existing policy and law, circumcision conducted in traditional settings should be made safer. Three provincial departments of health (DoH) have already introduced legislation in their respective provinces that addresses concerns relating to safety, hygiene and informed consent. The DoH is working with traditional leaders to identify and close illegal and unregistered conductors of traditional male circumcision.

Professor Geoffrey Setswe is a research director in the programme on Social Aspects of HIV/AIDS and Health, and the co-convener of the Research, Monitoring and Evaluation Technical Task Team of South African National AIDS Council (SANAC).