What Does Male Circumcision Mean for Canadians?

Recent news of the results from clinical trials examining the impact of circumcision on the transmission of HIV that were happening in three African countries – South Africa, Kenya and Uganda - has resulted in much debate both overseas and in Canada. There was an estimated 50-60% reduction in the risk of HIV infection for men who were circumcised in these trials. As the first method to be shown as effective against reducing the rate of HIV transmission in many years, this is understandably something that we as a society must address. However, the issues surrounding the use of male circumcision as a HIV prevention method for men are quite varied and complex.

The Biology Behind Male Circumcision

There are several factors that make it plausible that male circumcision would reduce the risk for HIV acquisition. The foreskin contains high concentrations of specific target cells (Langerhans, CD4+, and macrophages) that are all involved in HIV infection. In addition, the actual structure of the foreskin may act as a reservoir for HIV-containing secretions which could result in prolonged contact after exposure. 1 There may also be more skin disruptions that could allow for HIV transmission. 2

Male Circumcision as Prevention

There are several fundamental points about this intervention that must not be overlooked. Firstly, it is effective for reducing, but not eliminating, the transmission of HIV for men. Secondly, it is a biomedical intervention that must be done in the proper setting with trained healthcare practitioners. Finally, as with all HIV prevention methods, consideration must be given to the rights and needs of the individuals who will be affected by the promotion of circumcision as a method of preventing HIV transmission.

Many high prevalence countries have already begun to look at, and in some cases implement the use of male circumcision. However, rolling out a biomedical intervention globally is an enormous task that will require substantial resources and community acceptance. We have yet to attain the complete roll out of treatment to those most in need across the globe. The lack of adequate healthcare infrastructure, resources, the cost of medications, qualified personnel and the commitment of the country are just some of the things that have come into play when looking at why people are not getting much needed treatment.

The expense of such an intervention needs to be clearly looked at, especially in countries that are unable to get basic resources, prevention options like condoms, and treatment to those who need it currently. When looking at male circumcision as an option, its provision globally should not come at the price of reducing or eliminating already existing, life-saving interventions.

Ultimately, it is another prevention option that should be available to those who choose it as such – more along the lines of a harm reduction approach to prevention. To date, no global body has embraced or recommended universal male circumcision as an HIV prevention option. In fact, the World Health Organization opposes this type of recommendation, but it should be part of a comprehensive HIV prevention package that includes testing and counseling, treatment for sexually transmitted infection (STIs), the promotion of safer sex practices and the provision of male and female condoms. 3

When considering the use of male circumcision in Canada as a prevention option there are several factors that must be considered. First, we need to consider the current state of the epidemic here, as well as the differences between the epidemics in the African countries where the research was conducted and Canada.

Current State of the Epidemic

Many African countries have what is termed by the UNAIDS as generalized epidemics. That means that it is not contained within any section of society, and that more than 1% of the population carries the virus. In Canada, we have a concentrated epidemic which is defined by behaviours in groups exposing them to a high risk of HIV infection. 4

While male circumcision has been shown to decrease, but not eliminate, a man’s risk of acquiring HIV in certain settings, we are in a similar situation to the US where it is still very unclear if male circumcision could, or even should, impact HIV prevention strategies in Canada.

The epidemic within Canada still has the highest prevalence rates within the gay men and men who have sex with men populations (almost 59% of all positive HIV test reports among adults). 5 The percentage reported through heterosexual contact is 11% with 6.6% being attributed to heterosexual contact amongst men.

The impact that male circumcision will have on unprotected anal intercourse has not yet been determined. Research has indicated that the concentration of HIV in rectal secretions may be higher than in blood, semen, vaginal or cervical secretions. Limited data from trials amongst men who have sex with men (MSM) in the US in the late 1990s suggests that there may be a decreased risk of HIV infection with circumcision. 6 However, a more recent small cross-sectional study performed in Australia found no association between circumcision and risk of HIV infection. 7

Given the results of these studies and the concentration of the HIV epidemic in North America in the MSM population, there is no way we can expect to repeat the widespread impact seen in the trial sites in Africa.

Another factor is that the studies were done in areas where HIV subtypes A, C and D are prominent. In Canada, the dominant subtype is B. Studies have shown that subtype B shows different behavior when attaching to cells known to be involved in the replication of HIV, and in fact, makes attachment easier. Male circumcision removes some of the target cells for HIV, however, it is not known if subtype B will undo some of the protective effects of fewer target cells by giving an easier mechanism for infection.

Circumcision in Canada

In Canada, the rates of male circumcision have been declining. Recent data from the Canadian Institute for Health Information indicated that 9.2% of male newborns were circumcised in 2005. 8 However, these data do not take into account procedures that were done in doctors’ offices or childhood (which is the normal procedure in Canada).
Should we make a comment about cultural acceptance here? Is it something that has been promoted more as a cosmetic issue than a health one? When did that shift take place?

Another factor that must come into consideration is that male circumcision in Canada is currently considered a cosmetic surgery that, when done at birth, parents must pay for. If this is to be considered a viable prevention option for people, the cost of the procedure must again be covered under our country’s healthcare system.

Acceptability

Researchers were able to fully enroll participants in three separate trials on male circumcision in three separate African countries. This could indicate a willingness to participate in trials where the epidemic is so prevalent and prevention and treatment options are limited, if they even exist. In Canada, circumcision, when it is performed, is performed on newborns. Adult male circumcisions are usually done for medical reasons, such as for preputial cancer, and therefore we do not know the willingness of adult men to be circumcised as a prevention option. However, it would be interesting to find out whether this would be a viable option for Canadian men if shown to be effective in reducing the transmission of HIV through both vaginal and anal intercourse.

Another issue around acceptability would be that of cultural or religious norms. As a multicultural society, we are required to take this into consideration if we are to widely promote the use of male circumcision as an option for HIV prevention. Promoting male circumcision amongst some groups would be as unacceptable as promoting male non-circumcision in other groups where it is traditionally practiced.

Protective Effects

It is important to note that this biomedical prevention option only reduces the transmission of HIV, and does not eliminate it. Therefore, messages about its effectiveness must be clearly understood by everyone. It is also important to understand that results on the protective effect that male circumcision has for females will not be released until 2008. Early results show that viral load and circumcision may have an impact on decreasing transmission to women. 9
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Another factor is the influence that this can have on women’s health, especially since women are more vulnerable because of biological and socioeconomic factors. For instance, will male circumcision increase the demand for unprotected intercourse being placed on women who are working within the sex trade industry? What legal implications will this have when looking at issues of disclosure and sexual assault? The advent of male circumcision as HIV prevention does provide a level of protection for men, but it will also provide an increased level of risk for women who have lost that much more in their capacity to negotiate for the use of condoms. In Canada, of the positive test results for women, 53.2% of the cumulative HIV positive test results are attributed to heterosexual contact.

Circumcision for HIV Prevention in Canada

Ultimately, it is important that we use caution before broadly emphasizing or instituting the use of male circumcision as a prevention option in Canada. The differences between the North American and African HIV epidemics, and the large gaps in knowing what impact it will have on anal intercourse leave this a less than ideal option for large-scale prevention in Canada. However, since this information has been widely reported in the media, it is important that it be accurately covered in prevention information for Canadians in a way that is accessible. It will be a challenge to talk about partial efficacy for only part of the public.

There has been some discussion of using male circumcision for targeted communities in the US. However, targeted messages around circumcision as an HIV prevention method will have a disproportional negative impact on those communities who are already marginalized and oppressed.

Male circumcision needs to be part of a comprehensive prevention package that includes risk reduction, access to testing and counseling, and access to condoms. It is also vital that we continue to pursue other prevention technologies such as preventive HIV vaccines, as well as vaginal and rectal microbicides.


Footnotes

1 http://aids.net.au/AIDS-mccoombe-2006.pdf
2 http://sti.bmj.com/cgi/content/abstract/82/2/101
3 http://www.who.int/hiv/mediacentre/news68/en/index.html
4 http://data.unaids.org/pub/GlobalReport/2006/2006_Epi_backgrounder_on_methodology_en.pdf
5 http://www.phac-aspc.gc.ca/publicat/aids-sida/haic-vsac0606/pdf/haic-vsac0606.pdf
6 http://www.biomedcentral.com/1471-2458/7/35
7 http://www.cirp.org/library/disease/HIV/grulich1/
8 http://www.cirp.org/library/statistics/Canada/
9 http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm