THEORETICAL FRAMEWORK
CHAPTER 3 LITERATURE REVIEW
3.5. Male circumcision and HIV prevention
3.5.1 The ethics of male circumcision
A lot of debates has generated in favour and against the adoption of male circumcision as a strategy against HIV infection. A major concern has to do with what is often referred to as
‘ethical baggage’ of male circumcision, premised on the right of consent normally vested in the individual concerned. There are also disagreements as to whether there are sufficient evidences, on the basis of current data, to justify wide scale adoption of circumcision as a preventive strategy. However, it is also evident that no existing protective device has been
proved to be 100% effective, condom use included. Hence it has been argued that any positive impact on reduction in female-to-male transmission would contribute to the overall reduction in spread of the pandemic, in the long run.
Some framework has been proposed, based on age of the person to be circumcised, and the long-term and short-term effects assessed (Rennie, Muula & Westreich, 2007); these are:
neonatal, preadolescent, and adult circumcisions. The intention is to examine exactly the right age (soon after birth, just before sexual debut, or at some point after sexual debut) to focus if circumcision would be adopted as a preventive strategy. There are arguments for and against each point from medical, public health and ethical perspectives.
In neonatal circumcision, the strategy is to circumcise a male child soon after birth as done in most of West African countries and in USA, with its attendant advantages. Studies have shown that protection is greater when circumcision is done early in life because of the thickening of the foreskin of the penis as one grows older. The foreskin in newly born babies is thin and healing is faster, usually within a week. The risk of having sex with a partially healed penis in adults (risk compensation), with an attendant enhanced risk of infection, is averted completely.
In terms of cost, neonatal circumcision could be integrated into existing reproductive health clinics and postnatal care programmes for babies. The risk of missing school, if done at adolescent is averted and long hospital admission (Cassell, et al., 2006), in case of adults, are avoided. Consequently, the programme in cheaper to run and is accessible to all male children born into a country. Coverage could therefore be essentially universal. The right of consent is
vested in the parents, just like in all other decisions taken on children before they reach the age of reason.
One major reservation for neonatal circumcision is that the impact on the HIV pandemic is delayed and would only be felt between 10 and 20 years later. It, however, provides some level of hope that those children circumcised at birth have the probability of being infected with HIV (and other STDs) significantly minimized.
In pre-adolescent circumcision, where circumcision is practiced as a rite of passage from boyhood to manhood, it can be assumed that the procedure would be feasible and acceptable, when adopted as a HIV prevention strategy. The adoption would simply involve incorporating a new rationale into an existing practice. A model that integrates HIV-prevention into pre- adolescent circumcision traditions has been successfully implemented on a small scale in Kenya (Grant, Brown & Michen, 2004). One major challenge of adopting large-scale preadolescent circumcision would be the need to modify some traditional practices (e.g., utilizing the same ritual knife among a number of initiates, which poses HIV transmission risk) to align them with good health practices. Secondly such practice would also be complemented with counselling services that discourage initiates from being involved in sexual activities when the penis is not completely healed or giving up other preventive strategies. On ethical grounds, at pre- adolescent, a child’s consent may be very important, particularly when the surgery is irreversible
There are advantages and disadvantages of adopting preadolescent circumcision. Offering circumcision to boys at school may lead to lower uptake of services than promoting neonatal services because of the implications of having to stay away from school for the surgery.
Adequate facilities may not be available in rural areas to provide the service. Risk compensation could also be a problem. However, preadolescent circumcision could realize benefits quickly by immediately reducing the rate of infection among this high-risk group, particularly if the procedure is combined with HIV counselling and education among this vulnerable group who are at the fringe of sexual activities.
In adults there are some advantages associated with adult circumcision including having an immediate individual and epidemiological benefits, like in preadolescents (but not in neonatal) circumcisions. The problem of assent and parental consent is also removed. However, concentrating circumcision effort on adults who have been sexually active means missed opportunities for HIV prevention. In the circumstance where health budgets are thin, the logistic of implementation is complex. The issue of which adults should be offered the services, within the highest risk groups, like trunk drivers, soldiers, and teachers, would have to be addressed. Accessing the facilities within the health care system may be very costly and of less efficiency in terms of the number of interventions needed to make any meaningful epidemiological impact. Absenteeism from work for the surgery by adults could have economic implications.
The fundamental issue with male circumcision, irrespective of the age when the surgery is done is that the procedure should be safe, culturally acceptable (where it is a cultural practice), rights of the individual respected and combined with counselling and testing services. A number of fatalities have been reported from a number of schools of circumcision in Eastern Cape of South Africa, where the procedure is managed by traditional practitioners (See Figure 1.4). It is therefore very important that the capacity of traditional practitioners to practice under safe environment when circumcision is adopted under national health programme should be addressed decisively.
Kahn, Marseille and Auvert (2006) estimated cost-effectiveness for a hypothetical cohort of 1000 newly circumcised South African adult men in the general population and concluded that adult male circumcision would likely be cost-effective HIV prevention strategy, even when it has such a low coverage. It was estimated that over 20 years large net savings would be generated after adjusting for HIV infection averted (HIA) medical costs, put at $181 in programme cost per HIV prevented. This is obviously much cheaper than all other available interventions which have mixed data on effectiveness, and therefore cost effectiveness uncertain. Male circumcision is therefore considered to be economically inexpensive medical intervention for HIV. If the projection from this study is anything to go by, male circumcision would even be more cost effective when administered post-natal.
(Source: Sunday Times (South Africa) of 19 July 2009)
Figure 1.4: An example of a newspaper report on the abuse of traditional circumcision