Voluntary Medical Male Circumcision partially protects against HIV, HPV and Herpes

Modeling based on a timeline where 80 percent coverage of Voluntary Medical Male Circumcision (VMMC) of men age 15-49 is achieved by 2015 suggests that more than 20 percent of new HIV infections would be averted by 2025, with financial savings of an estimated USD 16.6 billion in future medical costs, said Cindra Feuer, Communications and Policy Advisor, AVAC - Global Advocacy for HIV Prevention at AIDS Vaccine 2012.

There are over 40 observational studies among heterosexual men, which show that circumcised men have about a 60% reduced risk of HIV compared to uncircumcised men. There were three randomised controlled trials conducted in Sub Saharan Africa that showed circumcised men were at 60% less risk of HIV than uncircumcised men.

“All these three trials were stopped by independent Data Safety Monitoring Boards as the effect was so strong and it was thought unethical to not offer circumcision to men in the control arm" had said Dr Helen Weiss, Reader in Epidemiology and International Health, The London School of Hygiene and Tropical Medicine (LSHTM) at AIDS Vaccine 2011. 

There are biological mechanisms by which the foreskin increases the risk of HIV.  The foreskin is rich in HIV target cells that are particularly attracted to HIV that is why uncircumcised men are at high risk of HIV compared to circumcised men.

CIRCUMCISION IS PARTIALLY PROTECTIVE, NOT COMPLETELY
In Southern Africa which has the highest prevalence of HIV and quite low rates of circumcision, circumcision is being provided medically and voluntarily and being scaled up. Over half a million men have been circumcised for HIV prevention in Southern and Eastern Africa. There is no evidence of serious adverse events and no evidence that men changed their sexual behaviour following circumcision. Earlier there was a concern that men might increase their risky behaviour if they think that they are completely protected. So it is important to get the message across that circumcision is partially protective, not completely.

VMMC INDIRECTLY BENEFICIAL FOR WOMEN TOO: PREVENTS HPV, HERPES
Voluntary Medical Male Circumcision (VMMC) is indirectly beneficial for women, said Cindra Feuer.” If we lower the HIV rate in a community then women also benefit from VMMC indirectly” said Cindra. 

Voluntary Medical Male Circumcision (VMMC) only directly protects transmission from female to male partner. It doesn’t protect against HIV transmission from male to female partner. 

Another additional fact women and men should be aware of is that Voluntary Medical Male Circumcision (VMMC) also reduces transmission risk of human papilloma virus (HPV) and Herpes. “If a man is circumcised he is less likely to transmit HPV and herpes to the woman. HPV causes penile cancer in men and cervical cancer in women. Also herpes and HPV can facilitate HIV infection so it is a great benefit to reduce the risk of HIV, HPV and Herpes by VMMC.

MEN TO ABSTAIN FROM SEX FOR SIX WEEKS AFTER VMMC
After getting voluntarily and medically circumcised, men should abstain from sex for six weeks. It is very important for both women and men to know this fact. If men who undergo VMMC don’t abstain from sex for six weeks, then the risk of transmitting HIV is high. 

Another fact to educate men and women is about partial efficacy: 60%. Cindra Feuer cautions: “VMMC is not a silver bullet – one should not increase one’s risk if the partner is circumcised. Comparatively, infant circumcision is easier because there are less nerve endings, lesser risk of infection,” and the caution of abstaining from sex for six weeks is irrelevant for infants.

SCALING UP CIRCUMCISION INCREASES HIV TESTING
A good aspect of circumcision is that we have a strategy for young heterosexual men that seem to be very acceptable in many settings. Before men are offered circumcision they are asked to get tested for HIV – and a knock-on effect is that it is also increasing the number of young men coming forward for HIV counselling and testing services.

VMMC is a great opportunity to bring men into sexual and reproductive health clinics, said Cindra Feuer.

The WHO and UNAIDS played a key role in providing guidelines about how circumcision should be scaled up, providing tools and guidelines which address key issues, holding meetings for people from different countries to get together and share experiences and learning, and also providing a model for liaisoning with communities and other stakeholders, including the ministries of health and impressing upon them the need of strong leadership and political buy-in. 

In many parts of Africa, male circumcision is done culturally regardless of religion. In West Africa, almost all men are circumcised in infancy, however in Eastern and Sub Saharan Africa circumcision is less common and is being scaled up. 

CIRCUMCISION AND HIV PREVENTION AMONG MSM
Whether male circumcision will prevent HIV transmission among men who have sex with men (MSM) depends upon the sexual practices. Circumcision will not protect a man who is a exclusively or predominantly a receptive partner, however if a man predominantly practices insertive anal intercourse there is evidence that circumcision reduces his risk of acquiring HIV.

OTHER CHALLENGES
There are not enough trained healthcare providers to roll out VMMC and in many countries political will to scale up this public health intervention is also lacking.

Kenya has done really well in VMMC but other African countries need to scale up to meet the 2015 targets. VMMC is being recommended by WHO in 13 African countries (US added a 14th country - Ethiopia) as an approach for HIV prevention – because substantial HIV is spread heterosexually in Africa.

VMMC has already been included as part of the standards of care package for those participating in some vaccine studies in South Africa.

All force to the campaign: Africans Telling the Truth About VMMC: www.truthaboutvmmc.org

Bobby Ramakant – CNS 

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