Male circumcision no guarantee

Male circumcision does reduce risk, and can if other precautions are taken, reduce risk of infection significantly, but it is neither a cure-all nor a guarantee against infection or even a guarantee against a high risk of infection. The connection between male circumcision and risk of HIV infection was first noticed in Tanzania in the early 1990s. Research then and there suggested strongly that the coastal population had a significantly lower infection rate than communities in the interior. After a lot of head-scratching the only difference that researchers could come up with was that the coastal population was largely Muslim and the interior largely Christian. Further rapid research suggested that the religious element was not a factor; the percentage of both populations indulging in high risk behaviour was roughly the same. In fact the coastal areas, because of the ports and the tourists, were more likely to see imported sexually transmitted diseases. After more head-scratching the researchers zeroed in on the fact that all Muslim men are circumcised, usually as babies or small boys unless they are adult converts, so more research was done. The circumcision factor is probably the most likely explanation for lower infection rates in the Muslim world, Western Europe and North America where the practice is common for religious or cultural reasons. It would explain, for example, the lower rates in West Africa as compared to East Africa despite the similarity in culture and lifestyle. Male circumcision, it is generally agreed, helps reduce infection in two ways. The first relates to just how hard it is to spread HIV among a totally healthy population. A healthy HIV negative man has just one chance of becoming infected in about 500 contacts with an otherwise healthy but HIV positive woman. For the negative healthy woman the chance is about one in 300 contacts with the healthy but positive man. However, if the HIV-negative person has a genital sore of any kind, the risk rises dramatically to about one in two contacts. There are many STDs around, and one of the most common in Africa is the soft sore chancre, a sore that is relatively easy to detect visually but which produces no pain or discomfort. A circumcised male will usually notice such a sore within hours of it appearing, while an uncircumcised man may go for months before noticing it. The second advantage of male circumcision is that it toughens the membrane, making infection by the HIV virus less likely. But to gain full advantage of this effect the male has to be circumcised before puberty. So a circumcised male has some protection just by being circumcised and can diagnose other STDs that can create the entrance for HIV infection very much more easily and quickly. But that diagnosis has to be followed by action, seeking treatment as soon as possible, otherwise circumcision is totally useless. And it must be remembered by those men seeking circumcision before indulging in, or resuming, an unprotected high-risk lifestyle that it is far from foolproof. Some mention that condoms are not foolproof, especially against something as small as a retro-virus. They are correct but a quick calculation shows just how effective they are. If condoms were just 95 percent effective against HIV transmission, and the true figure is much higher, that would reduce the risk of infection for a man from one in 500 contacts to one in 10 000, giving the most high-risk male at least an even chance of dying of something else besides AIDS. The other advantage of condoms is that they prevent the spread of other STDs, the ones that create easy gateways for HIV. So far as women in high-risk lifestyles are concerned, there still remains little alternative to ensuring that their male partners use condoms. So condoms remain, and must remain, the primary choice of those who want a high-risk life with multiple partners. Male circumcision can decrease the risk but because so many who indulge in high-risk unprotected behaviour in Africa are already infected with HIV it has to be coupled with other methods of preventing infection. It is a simple, cheap, worthwhile and useful minor operation, especially if done on young boys, but does not protect women from infection and does not offer a simple cure-all to prevent infection.

May 2006
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