HIV and the next generation -weighing up sons’ satisfaction versus daughters’ safety

nitikwana 2Circumcision will be discussed this week at the C.D.C.’s National H.I.V. Prevention Conference in Atlanta, which will be attended by thousands of health professionals and H.I.V. service providers.

When I visited South Africa in 2000, I remember reading an article in the Johannesburg newspaper – the financial section- which predicted that HIV virus would infect 1 in 4 of the work force in South Africa by the year 2010. Well I think the statistic was reached five years early. It has been a place where HIV has spread rapidly and for many reasons.

At the same time Africa presents a place of reference where by virtue of the vast numbers, research is can be of value. How and when we apply that research can take detours as the clash of culture and controversial issues complicate the advisories. I picked this up off the CDC website and it sent me to an Article in the New York Times on line, article by Roni Carin Rabin which published this week; he reports that public health officials are contemplating the promotion of routine circumcision for all baby boys born in the United States, to reduce the spread of H.I.V., the virus that causes AIDS. This is 2009.

Rabin says that the “topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention by the end of the year, has yet to be released.” In February 23, 2007 it was reported in Paris that trials showed that male circumcision more than halves the risk of HIV infection.  The trials, conducted in Kenya and Uganda and earlier in South Africa, found that men who were uncircumcised were twice as likely to catch the human immunodeficiency virus (HIV) compared with circumcised counterparts. The researchers have found that circumcision serves to protect the female partners of the tribes that were used in the studies. However it is clear that this did not take cognizance of sex between male and male where circumcision may not in fact impact the statistics.

In 2000 Robert Bailey of the University of Illinois, Chicago reported at the 13th International AIDS Conference about his studies of the Luo, a tribe of 3 million in Kenya who do not practice circumcision and who presented an unusually high percentage of HIV infection — around 30 percent in women and 25 percent in men.  He joined other researchers at that time, saying it “may be time for health officials to think about promoting circumcision in Africa as a way of helping to prevent the spread of HIV. “ The data were so dramatic that the trials in Kenya and Uganda were apparently halted ahead of schedule, for it would have been ethically wrong to continue them.

Would promotion now in the US turn into more than mere promotion? Perhaps promotion per se is valuable as long as it serves an educational purpose, one that enables parents to use the information to make their own decision. However to what extent is the CDC required to “protect” society. If it makes its promotion more declaratory and possibly even mandatory in the same way as we are required to have certain immunizations.

I can only imagine the controversy if there were to be such a recommendation here in the USA, albeit at this late stage in the timeline of this research and these conclusions. Are we notoriously slow to protect the women in our society – to protect the female interest above the satisfaction of the male? “Experts are also considering whether the surgery should be offered to adult heterosexual men whose sexual practices put them at high risk of infection. But they acknowledge that a circumcision drive in the United States would be unlikely to have a dramatic impact: the procedure does not seem to protect those at greatest risk here, men who have sex with men.” Again what about the women?

Till Newell and Marie-Louise Barnighausen calculate that in KwaZulu-Natal province, where HIV incidence is very high but circumcision rates very low, 35,000 new infections could have been prevented in 2007 alone if the 2.5 million men there had been circumcised. Experts in asserting this as preventative for Africa say they implementing circumcision should be approached with caution, because of how different cultures perceive it – some as ritual into manhood whereas others see it as emasculating.

In the US however the cultural considerations are vastly different. One can only imagine that the controversy will revolve around the esteem and satisfaction of the young man, the impact on him later and the ideal that perhaps he would consider circumcision of his own accord as a choice when he is older.

Rabin reflects on the fact that in the US circumcision rates have fallen in part because the American Academy of Pediatrics, in setting the guidelines for infant care, has not endorsed routine circumcision. “Its policy has said that circumcision is “not essential to the child’s current well-being,” and as a result, many state Medicaid programs do not cover the operation. The academy is revising its guidelines, however, and is likely to do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics. ”

I wonder how the anti-circumcision mothers will feel when it comes to weighing up their son’s satisfaction versus their daughters’ safety? 

 This is going to find an interesting path and maybe even something else to add to the healthcare debate. Who is going to pay? Surgery vs. AIDS Drugs…. ?

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