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HIV
infection rates are much higher in sub-Saharan Africa
compared to Northern African countries |
Forget
arguments on the origins of HIV-AIDS or why the virus is largely concentrated in
sub-Saharan Africa
.
To
date, few issues seem to have divided AIDS researchers more than the perceived
correlation between the spread of HIV and male circumcision.
At
the center of the hypothesis that male circumcision does provide a measure of
protection against HIV-AIDS are puzzling discrepancies in HIV prevalence beween
different countries and regions, despite the presence of what seems to be
similar risk factors.
For
example, rates of HIV infection continue to be much lower in Asia
’s Philippines (0.06 percent of the adult population), Bangladesh (0.03 percent) and
Indonesia (0·05 percent), compared to Thailand (2.2 percent), India (0.8 percent), and
Cambodia (2.4 percent).
Infection
rates are also much lower in Africa’s Nigeria (4.12 percent), Ghana (2.38 percent) and
Kenya (11.64 percent), compared to Namibia (19.94 percent), Botswana (25.10 percent) and
Zimbabwe (25.84 percent).
It
is this startling disparity between West and Southern Africa
that has led researchers to conclude that the missing link is because unlike in
Southern Africa, in much of West Africa
circumcision is an ingrained cultural and traditional practice that has worked
to keep HIV at bay.
There
is no disagreement on the fact that HIV-AIDS is predominantly spread through
sexual intercourse. The argument centers around protection men reportedly derive
from the removal of the foreskin, to the extent that circumcision reduces
infection by up to 50 percent.
Over
45 Studies Have Examined the Link Between HIV and Circumcision
Pro-circumcision
researchers argue that the skin on the inside of the male foreskin is
"mucosal", similar to the skin found on the inside of the mouth or
nose. This mucosal skin reportedly has a high number of Langerhan cells, which
are HIV target cells rich in white blood cells or doorway cells for HIV.
"HIV
looks for target cells like the Langerhans; it's a lock and key," Edward G.
Green, senior researcher at Harvard University told The Washington Times recently. "The rest of the skin on the penis is
armor-like."
Dr.
Jimmy Gazi, who is acting-president of the Zimbabwe Red Cross Society and also
chairman of the Southern Africa Development Community (SADC) AIDS Scaling
Committee, says that due to the “moist, mucosal surface” on his penis,
“the uncircumcised male has a much higher chance of having a micro laceration
in the glands and inside the foreskin than the circumcised male.” This
exposes him to a greater risk of getting sexually transmitted diseases and HIV.
However,
Gazi says that although circumcision is a
good practice for those who subscribe to it, he would not put it as a major
factor in hindering the transmission of HIV-AIDS.
It
is now over 10 years since the first study on the increased risk of HIV
infection among uncircumcised men was published. Since then, at least 45
scientific inquires have been performed to examine the link between HIV and
circumcision.
Studies
in Botswana Show Widespread Acceptance of Circumcision
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2.4
million people died of AIDS in sub-Saharan Africa in 2002 |
One
of the earlier investigations on the issue is a comparative study of four
African cities conducted by UNAIDS in 1999. Two West African cities, Cotonou in
Benin , and Yaounde the capital of Cameroon , were found to have low HIV infection rates of three percent and four percent
respectively among men aged 15-49. The other two sites, Kisumu
, Kenya , and Ndola in Zambia, had infection rates of 20 percent and 23 percent respectively for the same
population group.
In
Cotonou and Yaounde, nearly all men in the study reported being circumcised. Only 10 percent of the
men in Ndola and less than 30 percent of the men in Kisumu, meanwhile, had undergone the
procedure. Furthermore, the study found, ''HIV prevalence was below eight
percent in men circumcised before their sexual debut and 25 percent in
uncircumcised men.''
Despite
studies like this, the medical body is still divided on the preventative
benefits male circumcision might have. One thing that some
anti-circumcision researchers point out is why the United States has the highest rate of HIV infection amongst industrialized countries while
the great majority of the male population in the United States is circumcised.
Potentially,
however, a pro-circumcision verdict within the medical community would allow for
a relatively cost-effective mass circumcision campaign in much of
resource-strapped Southern Africa
where, according to the International Federation of the Red Cross and Red
Crescent Societies, “a gradual slide into destitution is underway which
triggers further spread of HIV and ever-greater vulnerability to common disease
and disaster.”
The
Red Cross adds that “the situation is slowly overwhelming Southern Africa
and the longer-term projections are startling.” Such a grim prognosis on
prospects for the region suggests that any new weapon in fighting HIV-AIDS would
be more than welcome.
The
Gaborone-based Botswana Harvard Aids Institute for HIV Research and Education
says that if supported by clinical trials, male circumcision might be an
acceptable method of preventing HIV transmission among adults and adolescents.
The
institute has gone on to assess the acceptability of circumcision among adults
and children through a cross-sectional survey
at nine geographically representative locations in Botswana. Results have shown widespread acceptance of
the practice if it was performed free of charge in a hospital setting.
‘We
might be convinced but we need to see more long-term studies’
Among
those who believe the virtues of male circumcision must be recognized is Dr.
Mariam Esat, an infectious disease specialist based in Zimbabwe. She says part of the reason why there is a dearth of publicity on the
perceived benefits of male circumcision is that “medical insurance (in Zimbabwe
) doesn’t pay for it, certainly not adult circumcisions and not as a
prophylactic against HIV.”
The
Dean of the College of Health Sciences at the University of Zimbabwe, Professor
Ahmed Latif, says scientific evidence does prove that circumcision in children
allows the skin to keratinize (harden) like the back of the hand, thereby
affording a great deal of protection against infections.
On
the other hand, he says, the inner surface of the foreskin is made of mucosal
membrane, which gives it a very large area of contact because it is folded into
itself.
“We
are very aware of the association between HIV and circumcision, but we are
waiting for further confirmatory data,” Professor Latif says. “We might be
convinced but we need to see more long-term studies.
“Just
like we know that there is a link between alcohol and the spread of HIV, we
should also be tackling this. But everything takes place slowly,” says
Professor Latif.
Much
like most things pertaining to HIV-AIDS, the link between the virus and male
circumcision is still inconclusive. The fact that the World Health Organization
has not yet given a cue in this area means it could be many years before
Southern Africans know whether circumcising their baby boys is tantamount to
inoculating them against HIV-AIDS.
Sources:
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UNAIDS
press release. Lusaka, 14 September 1999
. “New research links dramatic HIV rates in girls to older partners”
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University
of California, Center for HIV Information. “Viewpoint: Male Circumcision and HIV Infection:
10 Years and Counting.” Daniel T Halperin, Robert C Bailey. The Lancet, 354
(9192): pp. 1813-15.
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Health
System Trust. Kaiser Daily HIV/AIDS Report 5/7/00
. Male circumcision - a defense against HIV?
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Kurt
Shillinger, Boston Globe Correspondent, 11/05/99
, Male Circumcision Cited For Differing HIV Rates Among Africans.
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The
Botswana-Harvard AIDS Institute Partnership. “Male circumcision: an
acceptable strategy for HIV prevention in Botswana”, P Kebaabetswe, S Lockman,
S Mogwe, R Mandevu, I Thior, M Essex and R L Shapiro.
Wilson Johwa
is an independent journalist and photographer based in Zimbabwe . You can reach him
at: wilsonjohwa@yahoo.com.
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