Male circumcision helps reduce HIV transmission, but not foolproof

KENYA: It has been established that male circumcision can reduce HIV and Aids transmission by about 60 per cent. This finding is based on clinical studies in different parts of Africa on the connection between male circumcision and HIV transmission.

According to the World Health Organisation (WHO), by 2013, 35 million people were living with HIV globally with two thirds of them from sub-Saharan Africa. In Kenya, the prevalence level stood at 5.6 per cent. So, what is so special about the male prepuce – the foreskin that covers the glans penis?

The answer lies in the cell type found underneath the epidermis - Langerhans cells - the immune cells that are primary targets for HIV transmission.

Following infection, Langerhans cells not only serve as reservoirs for replicating virus, but also transport the virus to nearby lymph nodes. These cells are found in very high concentrations in the underside of the foreskin. They are the “sentinel cells” of the immune system.

They pick up an antigen – a foreign substance that triggers an immune response - for processing. By doing so, they take in the virus, internalise, process and presents it to other immune cells.

The anatomy of the foreskin additionally amplifies the risks. The foreskin is delicate and very susceptible to tears during intercourse. These tiny injuries promote inflammation, allowing the virus to come into closer contact with target immune cells.

The moist environment that forms under the foreskin also enhances the growth of microbes on the penis’s tip, further stimulating immune responses at this site. At the very least, the foreskin increases contact time with the virus in case of unprotected sexual intercourse when infectious fluid becomes trapped.

However, circumcision alone cannot be the magic bullet for HIV control.

The prevalence of HIV in Europe, a largely non-circumcising population, is 0.4 per cent compared to 4.5 per cent for Africa where many people undergo circumcision.

“You cannot eat a sweet with its wrapper” is a common phrase among advocates of unprotected sex. Commercial sex workers in Nairobi unpretentiously say “live” is sweeter and narrate how most of their customers insist on sex without using condoms.

“Live” sex may be good for business. It reduces the time spent per client, meaning they get to “serve” more clients.

In Nyanza, there was an increase of 18 per cent in male circumcision, but the HIV prevalence rate went up by 0.2 per cent because those circumcised do not take time to heal before engaging in risky sexual behaviours.

Lesson? Male circumcision provides only partial protection. A comprehensive HIV prevention package including the provision of HIV testing and counselling services; treatment for sexually transmitted infections; promotion of safe sex practices; provision of male and female condoms and promotion of their correct and consistent use are important components in the fight against the virus.