Authors: David Patient and Neil Orr, May 9 2014        Empowerment Concepts

No doubt you have seen or heard about the massive public drive to get men circumcised? If you haven’t, it’s referred to as Voluntary Male Medical Circumcision (VMMC), and government and numerous international agencies are either implementing it or advocating for it.

Up until a few years ago, circumcision was done mainly for religious or cultural beliefs. There has been vigorous debate around whether or not is should become standard practice, as it is in parts of the world such as the USA, where you have to request that your male child not be circumcised shortly after birth. It’s a very heated and divided debate, as some say it is genital mutilation and is performed against the free will of the child. There has also, up until a few years back, been no real medical justification to circumcise. The exception has been in situations where penile hygiene is poor, which is linked to increased penile cancer. However, where penile hygiene is practiced regularly, there is no medical advantage to circumcision.

The VMMC campaign tells teenage boys and men to get circumcised as it reduces the risk of becoming infected with HIV, so pop down to your local clinic and get the snip. However, what the campaign does not tell men is the why and the how of HIV transmission via the foreskin.

For many years, the standard HIV prevention message has been the use of condoms. Very little was understood about how men get infected with HIV and the pathways through which transmission happens. That is no longer the case.  There is now a great deal of research demonstrating that it is not necessary for there to be a cut or an opening or a wound on the penis in order for HIV to be transmitted. It is important to emphasize that an open wound, such as those caused by genital ulcers, definitely increases the chances of HIV being transmitted from person to person, including in men. What is important to know is that there is another route of female-to-male transmission that does not involve damaged skin on the genitals. All it takes is simple contact by the foreskin with HIV-infected fluids …

The Why and How of HIV Transmission.

The foreskin has an outer skin, and an inner membrane. The membrane of the foreskin is one of only three locations in the human body where a very specific set of cells live, called Langerhans Cells. These cells are also found in the membranes of the anus and in the female vagina. And guess where most HIV transmission occurs during sex? The question is why HIV transmission occurs in these specific three places.

Langerhans cells are what are known as antigen-presenting cells (antigens are germs and other substances that can harm the body) or Dendritic cells. These cells are the ‘Bounty Hunters’: In a nutshell (pun intended) these little chaps are designed to find any germ (from outside your body) that you have not been previously exposed to, and then capture and kill that germ. That’s not all: Once the germ has been captured (and hopefully killed), the Langerhans Cells then bring it back into your body and carry it to the CD4 cell, usually in the lymph glands. This little journey from the foreskin, vagina or anus to the CD4 cell takes about 48 hours. Once the CD4 cell receives the captured germ (usually dead), it instructs B Cells to make antibodies against that germ. It’s a nice neat system of getting a sample of germs out there, and then developing weapons against it before you get infected with it.

Unfortunately, this system has a weakness when it comes to HIV: It does not take HIV’s determination to survive into consideration. HIV also has a few tricks up its sleeve, one of which is to cover itself with lipid (fat) that it steals from the CD4 cell where it was born. Instead of being killed by the Langerhans Cell, HIV is protected by this layer of fat, and arrives safe and sound when delivered to the CD4 cells in the lymph glands. Instead of being a dead specimen, it turns around and infects the CD4 cell it was delivered to. And there you have infection, delivered by your own body, courtesy of the Langerhans Cells. In other words, in this form of HIV transmission, your body does all the work, and HIV just goes along for the ride. HIV does not ‘invade’: It is taken hostage and then released.

In a man, there is a high concentration of Langerhans cells located in the foreskin, hence the call for circumcision. The more Langerhans cells present, the higher the risk of this scenario happening in the absence of consistent condom use. VMMC drastically reduces the number of these ‘bounty hunter’ Langerhans Cells. That is the simple biological reason why voluntary male medical circumcision is being advocated to reduce HIV female-to-male transmission.

None of this would be necessary if all men wore condoms correctly and consistently. However, if you haven’t already figured it out, this just isn’t happening: Our latest national prevalence rates (SA National HIV Prevalence, Incidence and Behaviour Survey, 2012) show that about one-quarter (27.4%) of people use condoms consistently, while the majority (52.9%) don’t condoms at all. More importantly, condom use by men of all ages has decreased overall, compared to previous years.

In contrast, the practice of circumcision (traditional and medical) of men is increasing, not decreasing. In total (2012), almost half (46.4%) of all South African men aged 15 years and older report being circumcised. The percentages vary from province to province, with Limpopo and the Eastern Cape having the highest circumcision rates (about 3 out of 4 men), and Kwa-Zulu Natal (1 in 4) and the Northern Cape (1 in 5) having the lowest circumcision rates. Overall, roughly 50% of all circumcision is done in the traditional manner, though the ratio of traditional to medical circumcision varies from age group to age group, and location to location. Significantly, about 40% of uncircumcised men say they are interested in getting circumcised (SA National HIV Prevalence, Incidence and Behaviour Survey, 2012). 

With all this in mind, let’s have a look at some of the myths and facts about circumcision:

Myth #1: Male Circumcision Totally Prevents Female-to-Male HIV Transmission

Voluntary male medical circumcision (note the emphasis upon medical, not traditional, circumcision) apparently results in a reduction of about 60% in the probability of female-to-male HIV transmission. However, as often noted, VMCC does not totally eliminate the chances of female-to-male HIV transmission: It just lessens to chances of this happening. Condoms are still advised for circumcised men.

The first urban legend that has emerged around circumcision is that if you are circumcised then you cannot get HIV. This is not true!

In medical circumcision, removing up to about 60% of the foreskin results in about 60% of the Langerhans cells being removed. There is still 40% of these cells left. The entire foreskin cannot be removed otherwise there would be no room for ‘expansion’ (i.e., during an erection). If too much skin is removed, getting an erection would be both painful and pretty dangerous as what skin is left after the circumcision, allows for ‘growth’ during sexual arousal. Within this context, circumcision is a harm or risk-reduction method, not a prevention method. Nor does it prevent infection with other STIs. Remember, even after circumcision, there are still a lot of Langerhans cells still on the remaining foreskin, so while it reduces the risk of transmission dramatically, it is not by any stretch of the imagination, ‘the solution’ to inhibit transmission from an infected individual to a man. Circumcision simply reduces the risk.

Myth #2: Circumcised Men Don’t Need to Use Condoms

Related to Myth #1 is the belief that if a man is circumcised he doesn’t need to worry about condoms. Not true! Being circumcised is not a fail proof prevention in the absence of the use of a condom. The two go hand in hand. Many men feel that because they are circumcised that they don’t have to worry about using condoms and nothing could be further from the truth. It is the combination of the medical circumcision AND habitual (all the time) use of condoms that make up the risk reduction strategy. Not one or the other but BOTH.

Myth #3: Traditional and Medical Male Circumcision Are Similar

There is no such thing as a standard traditional male medical circumcision. Each culture or tribe has their own method of male circumcision that can range from a simple ritual cutting (without removal of any skin) of the foreskin, to the cutting a hole in the top of the foreskin and pushing the head of the penis through the hole so that the foreskin hangs below the penis head, to the removal of an unmeasured and varying amount of the foreskin, depending on the person doing the circumcision.

As far as voluntary male medical (VMMC) circumcision is concerned, it is the removal of up to 60% of the foreskin that lessens the risk of transmission. Unlike traditional circumcision, VMMC is a standardized procedure.

We advise men who have had a traditional circumcision to go to their doctor and ask them to check to see whether the correct amount of foreskin has been removed. If it has not, then the clinic can do a very quick procedure and remove what needs to be taken off. It would also be a good idea to go to the clinic after a traditional circumcision to check for any infections after the procedure.

Myth #4: VMMC Prevents Traditional Coming-of-Age Rituals

Coming-of-age processes – often called ‘Going to the Mountain’ – are important for many people. There are, in some communities, serious negative consequences for a young man to avoid this process. For example, he may be shunned in tribal council meetings because he’s ‘not a man’ yet, even if he’s been medically circumcised. Obviously, this has greater impact in more traditional communities, compared to urban settings. It is also the case that many traditional values and cultural concepts are imparted in these processes. 

Many traditional healers and leaders involved in traditional coming-of-age processes have been very supportive of standardizing circumcision, and ensuring that the proper procedures are followed to ensure safety, even inviting medical personnel to conduct the circumcision itself. For example, the King of the Zulu nation is highly supportive of VMCC, and of finding ways to integrate this procedure into the coming-of-age process. Not only can this cooperation be achieved, it is already being achieved in many areas.

Success has been obtained in training traditional healers in doing VMCC, which will probably become the norm. The alternative is to bring medical personnel in to do the circumcision itself.

Unfortunately, there are also those few who have abused coming-of-age processes for financial and other reasons, and these are the people we typically hear about on the news. We sincerely hope that stringent monitoring, certification, and publicity will sort this out.

Conclusion

VMCC is here to stay, and we believe that it will become the norm, even in traditional processes. It reduces HIV transmission at a fraction of the price of treating those infected, so there is strong public financial reasons to get behind VMCC efforts. However, we have to be realistic that VMCC is not an ultimate solution to HIV prevention in men. Instead, it is (hopefully) one of several risk-reduction strategies that will cause a decrease in new infections.  

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