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| Government turns to circumcision to fight HIV/AIDS |
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The government is in the advanced stages of developing a policy that will see men and young boys circumcised as part of the HIV prevention strategy to help them stave-off the virus.
Key areas of the policy, which has been under development since April, are being fine tuned to make it as elaborate as possible. An advisor from the United States government is helping in the drafting of the policy. If adopted, Kenya is going to become one of the first countries in Africa to officially embrace circumcision as a weapon against HIV infection. Circumcision involves removal of the foreskin. Studies have shown the skin’s inner mucosal surface to be the breeding ground for the virus because it has more immune cells vulnerable to HIV infection than the external surface. The age at which males are to be circumcised, standardization of the operation, and the required qualification of the medical care provider, are some of the highlights of the proposed policy. Already, the government is exploring the possibility of offering circumcision as part of a package of immunization and other jabs given to every child when still young. Architects of the policy believe if circumcision is done at a very early age there is likely to be minimal resistance from parents, the child, or family members. Local anesthesia to numb the pain, which makes many men shiver at thought of being circumcised, is also going to be used as a standard procedure to make it acceptable to men. Officials at the National Aids Control Council (NACC), who are gearing up for the new policy and practice, say circumcision is going to improve the arsenal of preventive strategies against HIV. “Using circumcision as a protective mechanism is not going to be used in isolation, but as package of preventive strategies the country is currently implementing,” says Prof Alloys Orago, NACC’s Director. He argues that not single preventive method can stop the spread of HIV, hence a range of options are needed. Once completed, Prof Orago says the policy is to be deliberated upon by all stakeholders, fine tuned, and then presented to the cabinet for approval. “This is a cultural and emotional issue and the process we are taking is designed to increase acceptance of the policy before implementation,” adds Orago. Circumcision advocates say the underlying principle should be to engage all stakeholders in the discussion of how to go forward, including those who disagree with male circumcision. “Collaboration rather than confrontation and entrenchment is key to effective and speedy implementation,” say the researchers who conducted the study. In Kenya, three communities, Teso, Luo, and Turkana, and few people in Coast province, do not circumcise males as part of their culture. Convincing them to embrace circumcision poses one of the major challenges the government has to confront. Even in communities where male circumcision is acceptable, debate will focus on the age at which circumcision would be required. In some of these communities, circumcision is a rite of passage that must be performed at a particular time and age. If this is proposed, the policy may not be in tune with every tradition. However, in communities that do not circumcise men, the government plans to use elders to help surmount some of these challenges and ease the implementation process. The policy will also spell out who should provide this surgical operation, the method and equipment to be used, and the conditions under which is to be executed. Those institutions or individuals to carry out the operation are to be licensed. “One of the approaches we are going to advocate for is training of medical students on circumcision as part of the many other surgical operations they are expected to learn,” says Prof Orago. Researchers have shown that adult male circumcision performed by trained medical personnel, with appropriate post-surgical follow-up is safe and acceptable to many people. Besides using elders and trained personnel, NACC also plans to provide the public with information and education on the proposed HIV prevention method, emphasizing why they need to embrace it as a complement to other preventive strategies currently in operation. The operation is likely to be voluntary to avoid conflicting with communal and individual human rights. Prof Orago however cautions that circumcised men will have to practice safe sex by using condoms, to significantly lower chances of acquiring the virus. Others are advised to abstain from sex or remain faithful to their partners. There is fear that circumcision may offer some men a false sense of security from HIV infection, making them engage into risky sexual behaviours such as having multiple sexual partners. A couple of months ago, the World Health Organization and UNAIDS issued recommendations calling for increasing male circumcision rates in countries where the HIV infections are high. Kim Dickson, coordinator of the joint WHO/UNAIDS working group that came up with the recommendations, is quoted in March 2007 New Scientists magazine saying, “We reviewed all the evidence, and the evidence is compelling." In the South Africa study, circumcision was found to reduce HIV infection rates by more than 60 percent in a group of 3,000 HIV negative men. Of the 1,546 who were circumcised, 20 men became infected with HIV, while 49 of the 1,582 uncircumcised men became infected. Funded by the French Agence Nationale de Recherches sur le Sida (ANRS), the study sent a strong message in 2005 on the effectiveness of circumcision in HIV prevention. Buoyed by these results, South African scientists see large-scale implementation of male circumcision, as a possible strategy for preventing two million HIV infections and 300,000 deaths in their country during the next 10 years. In December 2006, the Data Safety Monitoring Board that was overseeing the Kenyan and Ugandan male circumcision trials announced that the operation was a safe and effective way to reduce HIV infection among men. The trials in Kisumu and Rakai, Uganda, involved adult, HIV-negative heterosexual male volunteers who were randomly divided into two groups – one group was circumcised and the others were not. Findings from these trials showed medically circumcised men who practiced penile-vaginal intercourse to have more than 50 per cent less chance of acquiring HIV than non-circumcised men. The men were followed for two years. In the Kisumu trial, circumcision reduced by 53 per cent chances of acquiring HIV among the 1, 391 men in the study, who were all between 18 and 24 years old. There were 1,393 uncircumcised men or in the placebo group. Similar results were registered in the Rakai trial in Uganda, which involving 4,996 HIV-negative men aged between 15 and 49 years. Results in this study showed that the operation reduced HIV acquisition by 48 per cent among the 2,474 circumcised participants. The Kenyan trial began in 2002 as a collaborative venture between Universities of Nairobi, Illinois and Manitoba trial. When the results of Kisumu and Rakai trials came out, NIH Director Elias Zerhouni praised them as a milestone in the war against HIV/AIDS. “These findings are of great interest to public health policymakers who are developing and implementing comprehensive HIV prevention programs,” he said. National Institute of Allergy and Infectious Diseases (NIAID) Director, Anthony S. Fauci, whose organization supported and conducted the studies, added: “We now have confirmation—from large, carefully controlled, and randomized clinical trials— showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse.” After impressive results, it was agreed that all men who participated in the study as a placebo group were to be offered circumcision as well. This means the 1,393 volunteers in Kisumu who participated in the trial were circumcised. According to Zerhouni, male circumcision performed safely in a medical environment complements other HIV prevention strategies and is likely to lessen the spread of HIV/AIDS, especially in sub-Saharan Africa. More than 2.8 million new infections occurred in 2006 in this region, according to the UNAIDS estimates. Although the intervention is going to benefit men more than women in the short term, scientists behind the study believe reduction of HIV infections among men will have a knock-on effect for women in the long term. They further think the success of circumcision as a preventative strategy is guaranteed if integrated into a comprehensive prevention plan known as Abstinence, Be faithful, and Condoms, Prevention strategy, or ABC. The good news are, another study is now underway to determine whether circumcision of male partners reduces women’s risk of acquiring HIV from infected circumcised men. Other scientists want trials to explore the possible impact of circumcision on HIV transmission during anal sex or on the health impacts on women, such as reducing rates of cancer of the cervix. The interest in circumcision started many years ago when researchers in Africa and Asia discovered low HIV prevalence in communities that circumcised their males compared to those where the practice was not done. The foreskin has been found to trap HIV next to the mucosal surface of the penis for a longer period of time, allowing the virus to survive longer in this moist environment and infect the person in question. It has been further shown that small tears in the foreskin during sexual intercourse opens entries for the virus, increasing the risk of infection. Circumcision advocates say the operation allows the penile shaft and glans to develop more epithelial (penis skin) keratinization, making it less susceptible to viral invasion. The circumcision procedure used in the Kenyan trial was what is called the foreskin clamp method, which takes 25 minutes to complete. The sleeve method, which takes 30 minutes, was used in the Uganda study. An AWC-Feature              |
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