Make circumcision safer, say researchers

The HIV prevention benefits of rolling out large-scale male circumcision programmes could be lost due to a lack of training and resources to carry out the procedure safely.

The World Health Organisation and UNAIDS recommended male circumcision as a HIV prevention strategy in 2007 after clinical trials in Uganda, Kenya and South Africa found the procedure could reduce a man's risk of contracting HIV by as much as 60 percent. But public health experts have expressed concern about whether male circumcision can be safely provided to large numbers of adult men.

Only 1.7 percent of men in Kenya and 3.6 percent of those in South Africa who participated in the highly controlled and well-resourced trials experienced complications after being circumcised.

However, a study carried out in Bungoma district in western Kenya, published in the September issue of the World Health Organisation's monthly Bulletin, has revealed that 35 percent of male participants experienced complications after being circumcised by traditional practitioners, and 18 percent after being circumcised at a clinic.

Out of 1,007 boys interviewed two months after being circumcised, 25 percent had experienced "adverse events", including excessive bleeding, infections and pain while urinating. The researchers estimated that the procedure had resulted in permanent damage to about 6 percent of the boys.

Although traditional circumcision is the norm in Bungoma, more and more parents are taking their sons to be circumcised at public and private clinics. This allowed the researchers to compare the incidence of complications after both traditional and medical circumcisions.

Although more than twice as many traditionally circumcised boys reported suffering an adverse event, researchers described the rate of medically circumcised boys who suffered complications as "very high compared to rates observed in developed countries and in clinical settings".

After interviewing 41 traditional and medical practitioners and observing a number of procedures, they concluded that more formal training was needed, but that many adverse events were also the result of using blunt or unsterilised cutting instruments, and a lack of sufficient sterilisation equipment and material for dressing wounds.

A higher rate of adverse events after procedures in private clinics (22.5 percent) versus public clinics (11 percent) was probably due to private facilities reducing their costs by replacing their instruments less frequently.

The vast majority of men who participated in the clinical trial in Kenya healed within a month, but in the Bungoma study 24 percent of traditional cases and 19 percent of medical cases had still not healed 60 days after the operation.

Apart from this "unnecessary suffering", the authors noted that "Since many of these young men are sexually active, such a long period for healing could expose them to elevated risks of HIV infection through an open wound."

In fact, 4.5 percent of the participants had already engaged in sex by the time they were interviewed. In communities like Bungoma, where circumcision is practised widely, the authors recommended encouraging parents to take their sons to be circumcised at earlier ages, before they became sexually active.

In the past year a number of countries, including Uganda, Kenya, Zambia and Swaziland, have launched national campaigns to start promoting male circumcision as an HIV prevention tool.

Read more:

At the Cutting Edge - male circumcision and HIV

Male circumcision - a gamble for women?

How safe is traditional circumcision?

The cutting edge (multimedia)

But the authors of the Bungoma study warned that extensive training and resources would be necessary before health facilities in sub-Saharan Africa were ready to start offering safe circumcision services, and called for more attention to be given to making traditional circumcisions safer in the parts of eastern and southern Africa where it is widespread.

"If the practices in these communities continue to be largely ignored, the gains to be achieved by promotion and provision of circumcision for HIV prevention may well be undermined," they concluded.

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