/ 26 July 2012

Circumcision: A case of all or nothing?

To ensure the full benefit of protection from HIV the entire foreskin must be removed.
To ensure the full benefit of protection from HIV the entire foreskin must be removed.

More than half of South African men are now ­circumcised and most of them have been circumcised fully; in other words, the entire foreskin of their penises has been removed, not just part of it. That is according to the third "National HIV Communication Survey", the results of which were released at the International Aids Conference in Washington DC in the United States this week.

Research has shown that men who are fully circumcised are 60% less likely to acquire HIV from their female partners than uncircumcised men. Over time, this preventive benefit increases. A South African study has shown that circumcision reduces men's risk of getting infected with HIV by up to 76% after three years.

About 10000 respondents between the ages of 16 and 55 across all nine provinces were interviewed for the survey between February and May this year. Men were asked whether they had been circumcised and shown ­pictures of full, partial and uncircumcised penises. They then had to identify which picture resembled their penis best.

The study, which was jointly conducted by Johns Hopkins Health and Education South Africa, loveLife and Soul City, revealed that, of the men in the country who had been circumcised, 48.1% had been circumcised medically and 50.1% traditionally. Of those who had been traditionally circumcised, nine out of 10 said they had their entire foreskin removed.

The findings that male circumcision reduces men's risk of getting infected with HIV are based on findings in which study participants' entire foreskin was taken off. A concern with traditional circumcision practice is that none or only part of the foreskin is often removed. The effect of partial foreskin removal on HIV acquisition is unknown.

Communication survey
A study by the Desmond Tutu HIV Centre at the University of Cape Town, which was published in last month's South African Medical Journal, produced notably different results to those of the communication survey. Of about 200 mostly Xhosa men from Nyanga outside Cape Town who were enrolled in the study, 74% reported that they had been traditionally circumcised. Upon medical examination, it emerged that 27%, a percentage almost three times higher than that reported by the communication survey, had some or all of their foreskin remaining. Fourteen per cent (27) of the study participants were HIV infected, of whom most (21) reported that they had been traditionally circumcised.

According to research co-author Professor Linda-Gail Bekker, the difference in results could be attributed to the Cape Town study being focused on a much smaller sample and only on Xhosa men, whereas the communication survey was a national study involving men from several ethnic groups that might have different circumcision practices to those of Xhosa men.

Another difference was that the men in Bekker's study were medically examined – a doctor checked whether every participant's self-reported circumcision was indeed a full circumcision. In the communication survey, no medical assessments were done and the results were based on the men's own perception of the state of their penises.

The national HIV communication survey revealed that there was a huge increase in knowledge about the HIV-reduction benefits of medical male circumcision, with 47% of men and women now knowing that medical male circumcision reduced the risk of HIV infection, compared with 8% in 2009.

According to the survey, about one million men intend to get circumcised within the next year and 80.5% of them would prefer to be medically circumcised. However, although 66% of men in the South African Medical Journal study were aware of the preventive benefit of medical circumcision, most were unwilling to undergo it, stating religion, culture, notions of manhood and social disapproval as reasons.

Simplifying the procedure
According to health department deputy director general Dr Yogan Pillay, 529520 medical circumcisions have been conducted in South Africa.

"Once we have World Health Organisation-approved medical male circumcision devices, which we expect late this year or early next year, we intend to train traditional circumcisers to use them so that we are able to better ensure that men who are circumcised traditionally have their entire foreskin removed," he said.   

Medical circumcision devices make it possible to do bloodless circumcisions and simplify the procedure hugely. Studies have shown that one such device, the PrePex, can be  administered safely by junior nurses without the supervision of doctors.

But such devices first need to be vetted by the WHO, entailing an extensive scientific review and trial process, before large donors will fund their use  

Health Minister Dr Aaron Motsoaledi, who attended the launch of the communication survey results, said his department would do whatever it took to ensure that all South African men in need of medical circumcision were given access to it.

According to mathematical modelling studies, 20% of new HIV infections in South Africa will be averted by 2025 if 4.3-million men between the ages of 15 and 49 are fully circumcised by 2015.

"We need to meet demand, but must also ensure that circumcised men know they should still use condoms because the procedure is not foolproof protection against HIV," Motsoaledi said.  

Mia Malan works for the ­Discovery Health Journalism Centre at ­Rhodes University