Can circumcision stop AIDS in TT?
SEAN DOUGLAS Sunday, December 19 2004
RECENTLY a Mr A Phillip of Tunapuna wrote a candid letter to the editor of Newsday saying he had just got himself circumcised in order to cut his risk of contracting AIDS/HIV. Phillip wrote: “I have just returned from England where I got myself circumcised. This is because I read in the London Times that the incidence of AIDS is near zero in those who are circumcised. Here is a simple and cheap way of prevention.” He urged men in Trinidad and Tobago to follow his lead.
This idea was previously mooted last September to local health professionals at an AIDS sensitisation workshop at Crowne Plaza by Dr Michael Johnson, director of the Caribbean Regional Programme of the United States-based Centre for Disease Control. Johnson said: “Countries with low rates of male circumcision, except Uganda, have higher HIV rates than countries with circumcision.” Sunday Newsday investigated how widely accepted was the idea that circumcision can cut the spread of AIDS/HIV. We found startling results of studies being done internationally. But perhaps even more startling, was the muted reaction to these studies by persons in Trinidad and Tobago, a country in the grip of an AIDS/HIV epidemic in which an estimated 30,000 persons are infected. Despite a recent Kenyan study that circumcision can cut by 90 percent a man’s risk of catching AIDS/HIV, in Trinidad and Tobago these findings are hardly known in medical and governmental circles! And the findings are even less promoted among the public! The Boston Globe recently stated the Kenyan study found that uncircumcised men have an HIV rate which is 11 times greater than men who were circumcised.
The Boston Globe added: “A second study in India has found that uncircumcised men have a seven times higher rate of infection.” This study of 2,000 Indian men was published in The Lancet, with the BBC News on March 26 citing it as proof that circumcision and not differences in sexual behaviour was responsible for different AIDS rates in east/south Africa and west Africa. The Boston Globe continued: “In Africa the countries with the highest rates of HIV infection are in the far south, which have very low circumcision rates. Countries in West Africa and the island nation of Madagascar have lower HIV prevalence and very high male circumcision rates.” The article attributed low HIV rates to circumcision rather than to conservative religious beliefs and sexual behaviour, based on findings in Madagascar. The island has a population of just 10 percent Muslim and 90 percent non-Muslim, but with nearly 100 percent of boys being circumcised. While Madagascar has a very high rate of general STDs, it has a very low HIV rate of 1.4 percent.
More support for circumcision came from the United States Agency for International Development (USAID) at its website www.usaid.gov in an article on “Male circumcision and HIV prevention.” USAID said scientists had known of the link since the 1980s, including an analysis of 38 studies, mostly from Africa. The USAID story said: “A sub-analysis of 16 of these studies found an estimated 70 percent reduction in HIV infection among higher-risk men. “A two year cohort study of male partners of HIV-positive women in Rakai, Uganda, in which 40 of 137 uncircumcised men became infected, compared with zero of 50 circumcised men.” The USAID article explained why uncircumcised men were more vulnerable to catching HIV than those circumcised. “The tissue of the internal foreskin absorbs HIV up to nine times more efficiently than female cervical tissue, mainly because it contains Langerhans and other HIV ‘target cells’ in much greater quantities than the cervix or other genital tissue including other parts of the penis.” Moreso said UNAIDS, the internal foreskin has a mucosal surface which is particularly susceptible to tears and abrasions and consequently infection by STDs and HIV.
But according to the Boston Globe story, international organisations have not yet endorsed mass circumcision as a weapon against AIDS. And things are no better in Trinidad and Tobago. Private doctors told Sunday Newsday that men were not aware of the latest research and were not debating circumcision as a way to combat AIDS/HIV. Aranjuez general practioner, Dr Varma Deyalsingh, said that while he usually performs about 15 circumcisions per year, he has not yet had a single patient request the operation as a preventative against AIDS/HIV. Despite the studies, Dr Deyalsingh said: “We have not gotten any increased incidence of circumcision.” Added to the lack of interest in circumcision, he said, was the fact that local men seem to be afraid to face the knife. Deyalsingh said: “We find that when we broach the idea of circumcision, men tend to be fearful — study or not. In our culture men are paranoid about circumcision.”
He said the chief reason adult men seek circumcision was to remedy an existing medical problem, such as painful intercourse or a persistent fungal infection of the penis called Balanitis occurring in diabetic men. Yet other men request the operation in order to desensitise their penis to remedy a problem of premature ejaculation. Deyalsingh reiterated he personally had done no circumsicions requested as a preventative against AIDS/HIV. From anecdotal evidence, he estimated the percentage of men in the country who had been circumcised as being “the Muslim population plus two or three percent of the general population,” or a total of about seven or eight percent of the total population. But circumcision seems quite widely available in Trinidad and Tobago. Deyalsingh said GPs like himself can do the operation in their office for about $500 to $1,000, while a specialist surgeon in a nursing home using a general anaesthetic would charge $2,000 to $3,000.
Mount Hope Hospital told Sunday Newsday that they offer circumcisions on adult males for a cost of $1,331. Medical doctor and former minister of health, Dr Hamza Rafeeq, agreed from observing his own practice, that locally there had been no increase in men seeking circumcision to prevent AIDS. “I don’t think word has got around yet about circumcision with respect to AIDS.” Asked if he thought that there should be a local lobby to promote circumcision, he said the findings in the Boston Globe needed to be backed up by reports published in medical journals to first convince the medical community to sell the idea. Rafeeq said: “I’ve not seen the scientific research yet. But we would support anything that could stem the flow of AIDS.” Minister of Health, John Rahael, was not aware of the research but instead refered Sunday Newsday to Chief Medical Officer Dr Rohit Doon, who we were unable to reach.
Gynaecologist and former head of ASJA, Dr Ibrahim Mansoor, had not seen the latest study from Kenya. However he thought that circumcision had many health benefits including against AIDS, STDs and cervical cancer in women, but did not see it as a magic bullet against AIDS. “It doesn’t prevent AIDS but reduces it. Circumcision is not the panacea for AIDS, which instead requires abstinence and self-control.” He said that while he was regarded as a circumcision specialist and has performed many operations including on non-Muslims, he had not had a single request from an adult male who was specifically seeking protection from AIDS/HIV. Sunday Newsday was unable to learn whether any of our public health bodies support circumcision as a strategy against AIDS. We were unable to contact Dr Amery Browne at the National AIDS Coordinating Committee (NACC), Dr Bilali Camara at the Caribbean Epidiomology Centre (CAREC), or Chief Medical Officer, Dr Rohit Doon.
But given the many articles on the Internet on major news agencies like the BBC and NBC going back to 2000 supporting circumcision against HIV, are we being too reticent to grasp this simple remedy to our AIDS crisis? Will some of our local authorities be reluctant to approve circumcision, in the same way they are reluctant to approve the use of condoms, because they are afraid of being seen as giving a sexual licence to people? Or will Trinidad and Tobago soon see an increase in circumcisions?