Male circumcision receiving attention
By DARLINGTON MWENDABAI
HUMANITY’s quest to find a cure for HIV/AIDS is now leading researchers to options like male circumcision that is believed to reduce the infection rates.
Local and International researches indicate that male circumcision would reduce the risk of male infection.
Circumcision prevalence varies in Africa from 80 to 90 per cent in the Muslim influenced countries of West Africa.
Kenya has 85 per cent, Uganda 25 per cent while Botswana and Zambia have 10 to 15 per cent.
It is estimated according to a Scientific Modeling study published in July 2006 that the widespread adoption of male circumcision throughout Africa could avert up to 5.7 million HIV infections by 2026.
Other studies suggest that male circumcision reduces the risk of male acquisition of HIV by 60 per cent as a South African study last year had observed.
In the mid 19th century a researcher Hutchinson proposed that the use of male circumcision could reduce sexual transmission of infections (STIs).
Since then, the suggestion has generated interest in HIV/AIDS prevention quest in Africa, including Zambia.
The ecological data shows large discrepancies in HIV prevalence within Africa. The key difference which has been noted in male circumcision rates is that where male circumcision rates exceed 80 per cent, HIV prevalence is below 10 per cent.
Meanwhile, where circumcision rates are below 20 per cent the prevalence of HIV is close to and often exceeds 20 per cent.
Meta-analysis of 38 studies, mainly African, found circumcised men were less than half as likely to contract HIV.
Sub-analysis of 16 studies of higher risk men found circumcised men 70 per cent less likely to contract HIV.
Ten prospective studies all suggest a reduced risk for circumcised men. The most impressive of these studies was done in Rakai, Uganda, among discordant couples followed up for 18 months.
In this group, 40 of 137 uncircumcised men sero-converted during an 18-month follow-up period, while none of 50 who were circumcised sero-converted.
In vitro studies show that the inner foreskin absorbs HIV more easily than the rest of the penile skin.
Circumcision was believed to reduce the risk of male infection because it removes the vulnerable tissue, the foreskin which contains longerhan cells, a type of cell particularly vulnerable to HIV infection.
The area under the foreskin was also vulnerable to trauma and was more likely to become in-braded if vaginal lubricates was not present.
With this in mind JHPIEGO (Johns’ Hopkins programme on reproductive health, obstetrics and gynecology) started a programme to scale up male circumcision services in Zambia.
The estimated cost of setting up this service at the University Teaching Hospital (UTH) was US$20,000.
Dr Kasonde Bowa, who is in charge of the site at UTH, said Zambia was a typical sub-Saharan African country as it had a low male circumcision rate of 17 per cent and a high HIV prevalence rate16 per cent.
UTH site was one of three selected.
Chainama
The other two being George clinic and Chainama clinic in Lusaka. Several activities from July 2003 to August 2005 preceded the setting up of these sites.
An acceptability local study was conducted to determine the safety and community response to male circumcision services in Zambia.
It was found that many people wanted their children circumcised if it was found safe, affordable and in a hospital setting.
As result, in August 2004 a male circumcision service was set up at the urology out-patient clinic in UTH.
The urology out-patients’ clinic sees an average of 50 patients per day for general urology.
Dr Bowa explained that up to 70 per cent of patients were seen for prostate diseases.
A minor procedure room located at the clinic performs an average of six cases per day, most of which are diagnostic endoscope procedures.
With the support of JHPIEGO a dedicated space for male circumcision was set up with an operating theatre.
Two clinical officers were trained in male circumcision and were selected to perform these services.
Two nurses were trained as counsellors and chosen to provide pre-operative counselling.
The patients were asked to pay a minimum fee of K10,000 as hospital fee for all minor procedures.
Data forms for collection of patient information and follow-up were provided. In addition, patients were provided information about safe sex practices, condom use and written post-operative instructions.
The patients are advised not to have sex for six weeks after circumcision and to always use a condom.
Three days per week were initially provided for male circumcision services. Information was provided to all out-patient surgical areas about the commencement of these services.
In-house referrals or self-referrals were all accepted.
The surgical technique used was the Dorsal Slit method. This is the recommended method for male circumcision by the JHPIEGO training manual.
Local anesthesia was used in all adult patients.
Dorsal nerve block with a supplementary ring block with two per cent plain lignocaine is used. The maximum volume on an adult patient is 10 mls.
In children, particularly those under five years, additional sedation with analgesic dose of ketamine, valium and atropine were given.
An interim analysis of 230 circumcised patients was done. This showed that the majority of the patients were from low-income groups and lived in high density housing.
Fifty-seven per cent of patients were from low-income groups. The age range was from six months to 70 years.
The large majority were in the age bracket of 15 to 35 years. These made up 40 per cent of the patients who had circumcision done.
The largest number was discovered to be Bemba with 25 per cent, which is traditionally a non-circumcising tribe, but makes up 32 per cent of the population of Zambia.
The second groups were Chewa, Ngoni and the Luvales at 22 per cent.
It was discovered that 85 per cent were unmarried males and 92 per cent were Christians.
In Zambia, Christians make up 95 per cent of the religious groups.
Dr Bowa explained that most of self-referrals were at 91 per cent and a small number referred through VCT centres.
The indication for circumcision was non-medical in the majority of cases. Over 80 per cent of the clients felt that male circumcision was hygienic and healthy.
They had no medical condition that warranted a medical circumcision. There was no major complication in these cases.
The average duration of the procedure was 30 minutes and no complications were noted in 90 per cent of clients up to three months of follow-up.
With no hope for the HIV/AIDS cure, female circumcision was discouraged by many medical personnel.
However, the promotion of male circumcision in the fight against the epidemic seems to be receiving positive attention by both African governments and their publics at the moment.
