By Dr Klaus Hornetz

That male circumcision reduces the chances by over 50 per cent of contracting the HIV virus is not in dispute.

In fact, compelling evidence from three random surveys conducted in Kenya, Uganda and South Africa present male circumcision as a pertinent preventive measure against HIV infection – an aspect that led the World Health Organisation and the Joint United Nations Programme on HIV and Aids to strongly recommend male circumcision as an important part of comprehensive HIV and Aids prevention package.

Kenya has officially embraced male circumcision as a key preventive measure against HIV infection and has rolled out a male circumcision programme that targets uncircumcised men.

transmission.

Nevertheless expert research makes the following pertinent observations:

In epidemiology there is a fundamental difference between "protection" and "decreasing risk".

From a biological perspective, male circumcision decreases the transmission risk - statistically – by about 50 per cent.

At the same time there is conflicting evidence in the literature on the risks of circumcised males engaging in ‘risky’ sex contacts. This means that for a negative man who is circumcised engaging in risky sex contacts, there is a smaller but still significant risk to contract the virus.

There have also been reports from other researches that circumcised males have an increased risk of transmission, contradictions?

Transmission risk is dependent on many factors: number of risk contacts, prevalence of sexually transmitted infections, use of condoms etc.

Male circumcision can lead to decreased risk perception. Having then two (unprotected) risk contacts instead of one would equalise the protection "gain" and expose the circumcised men to the equal risk of an uncircumcised man with one risk contact.

As an example of such a negative mechanism, overwhelming evidence from developed and developing countries show that the availability of antiretroviral drugs has led to decreased risk perception and subsequent increase in infection. We see the same challenge with the current circumcision debate.

Therefore promoting male circumcision without effectively promoting the reduction of risk behaviour and the use of condoms might lead to an increase in risk of contracting the virus.

Campaigns.

We must in fact be concerned that the current male-circumcision "wave" may result in the ‘opposite of what its aims’ to achieve. The campaigns, we have observed, point to the lack of adequate information on reducing risky contacts or the need to use condoms, even when one is circumcised. Prevention messages must include all relevant risks for the specific community we are addressing.

Lack of risk perception is the major factor leading to risky sexual behaviour and subsequent HIV transmission in Kenya (KAIS 2007). This means that 83 per cent of HIV – positive Kenyans engaging in sex don’t know they are positive!

Prevalence

According to Kenya Aids Indicator Survey (KAIS) 2007 the highest HIV prevalence in Kenya is found among fishing communities around the lake. The lowest affected are (polygamous) nomads in the North-Eastern region. In his view, following the current ("mono-causal") reasoning of the male circumcision discussion, we could comfortably conclude that abandoning fishing or engaging in nomadism and polygamy would protect us from HIV/Aids! The fallacies resulting from mono-dimensional explanatory models are constructed along such roads. Unfortunately some Kenyan media and politicians have taken up such reasoning with zest and rigor.

The previous recipe for survival: (A)bstain; (B)e faithful or use (C)ondoms is still valid. Male circumcision in addition can decrease (but not eliminate) the transmission risk during "unprotected sex with an HIV – positive partner.

— Dr Hornetz is a medical doctor, epidemiologist and head of GTZ Health Sector Programme.