The Nation (Nairobi)
April 13, 2000

Nairobi - Clinical studies conducted recently across Africa show a clear association between circumcision and HIV seropevalence. It may well be the poor genital hygiene among non-circumcised males that elevates their risk of contracting HIV, reports OSCAR OBONYO

Recent studies comparing HIV/Aids rates among circumcised and uncircumcised men in Africa now show, on average, three times more HIV infection among the uncircumcised.

Clinical studies conducted in the continent over the last five years show evidence of geographical clusters of high seropositivity in certain countries.

According to Dr Stephen Mosses's lead study, "Geographical Patterns of Male Circumcision Practice in Africa: Association with HIV Seroprevalence", ethnic groups where adult HIV levels were below one per cent in sub-Saharan Africa, 97 per cent of the males are circumcised, and where the levels were above 10 per cent, only six per cent of males are circumcised.

Dr Moses, who has reviewed 30 studies, primarily from Africa, reveals that this association has been observed in studies carried out among more than 40 circumcising and non-circumcising communities across Africa.

Lack of male circumcision has been associated with high levels of HIV in sub-Saharan Africa, which according to the World Health Organisation (WHO) represents 68 per cent of the global infection.

In Kenya, the data is telling. Some of the communities that traditionally do not practice circumcision are most ravaged by the pandemic.

According to statistics of the National Aids and Sexually Transmitted Infections Control Programme (NASCOP), the largest non-circumcising community in the country - the Luo, for instance, is worst hit by HIV/Aids.

Basing their arithmetic on Kenya's big tribes, researchers note that the Luo who constitute only 12.38 per cent of the country's population account for 29.2 per cent of the HIV/Aids cases as compared to the Kikuyu of central Kenya who constitute 20.78 per cent and the Luhyia of Western Kenya 14.8 per cent (1995) yet they account for only 9.2 per cent and 9.1 per cent of the cases, respectively.

Biological evidence points to increased susceptibility (among uncircumcised males) of the flesh under the foreskin to inflammation, abrasions during intercourse and prolonged viral survival due to warmth and moistness under the "sheath" of the uncircumcised.

Dr William Cameron, an associate professor at the University of Ottawa in Canada, who has co-authored several African studies, reveals that several studies have established that such sexually transmitted diseases as syphilis and chancroid occur more frequently among the uncircumcised.

Researchers argue that it may well be the poor genital hygience among non-circumcised male rather that their non-circumcised status that elevates their risk of contracting HIV.

A number of reasons have been floated, though, to explain the apparent ease of HIV transmission among non-circumcising ethnic communities in Kenya. Social, economic and cultural factors have been implicated in the elevated risk of transmission, including polygamy, widow inheritance, population mobility and sexual networking.

NASCOP reports that by 1998, adult HIV prevalence had increased to about 13.9 per cent. The prevalence in urban and rural areas is estimated to be 17-18 and 12-13 per cent respectively. Close to 400 people die everyday due to HIV related diseases, says NASCOP in its latest report, "Aids in Kenya: Background Projections Impact Interventions Policy".

Despite the devastating impact, the government and medical authorities have refused to divulge information on the link between HIV/Aids and circumcision claiming such a disclosure is "tantamount to licensing circumcised Kenyans to have unprotected sex".

"Though it is increasingly becoming evident that there is a link between the two, there are fears in some quarters that such information should not be relayed to the public,' a medical doctor at Kenyatta National Hospital who sought anonymity says.

Government authorities ought to be embarrassed of advancing such simplistic arguments, argued Mr. Edmond Kwena. "Most Kenyans are now an informed and educated lot and the assumption that they need to be protected from making erroneous decisions is an abuse to this country"

Noting that the crucial challenge lies in how and not whether to relay the information, Kwena says that it is this very lack of openness that has made Kenya lag behind in the Aids campaign in the continent.

Most recently, a study in the lake side town of Kisumu by Mark Tyndall and Allan R. Ronald also found out that more uncircumcised men than their circumcised colleagues having contact with commercial sex workers recorded a higher HIV positivity rate.

However, Isabelle de Vencenzi and Thiery Mertins in their study (1994), "Male Circumcision: A role in HIV Prevention?" argue that the association between HIV and circumcision is weakened when factors such as contact with commercial sex workers, ethnic origin and birth place are adjusted for.

"Such inconsistent findings suggest that researchers cannot, at this stage, recommend male circumcision as a policy in controlling HIV infection,' they say.

Evidence from studies validating circumcision as a control measure is, however, outweighing. In 1986, Dr Thomas Wiswell studied records of more than 200,000 male infants born in US Army hospitals worldwide. He found that circumcised boys were ten times more likely to suffer from urinary-tract infections (UTIs). He discovered, too, that 1.4 percent of uncircumcised male infants suffered UTIs in the first year of life. Wiswell's figures translated into 5,000 to 10,000 UTIs a year.

"There is overwhelming proof that circumcision may protect against foreskin infections and sexually transmitted diseases including HIV/Aids. One gets multiple benefits from one procedure."

*An Impact Feature