Whither male circumcision in South Asia ?

[Dr Rajesh Gopal]

Though the vulnerabilities to HIV of the South Asia population have been clearly delineated, the moot point is if we are ready to implement a comprehensive strategic evidence-generated intervention (say in a large country like India) or not.

It is unfortunate that there is a tendency to consider male circumcision as an effective strategy for the Sub –Saharan countries with high HIV prevalence only.

It is ironical that the entire spectrum of predisposition to HIV and protection from the same; ranging from female ‘circumcision’ (read Female Genital Mutilation/Cutting-FGM/C) associated with heightened vulnerability to HIV and the male circumcision as an effective tool to prevent HIV, is presumed to be limited to African nations only.

The reality is, however, otherwise with many Asian nations with existence of the former abhorrent practice and the strong need to promote the latter.

We must devise a sound strategy based on the available evidence including the efficacious newer prevention technological intervention like male circumcision in this part of the developing world also.

A large proportion of the population of South Asia resides in the three populous countries viz. 1)India 2)Pakistan and 3) Bangladesh. The religions practiced by the majority of these countries are either Islam or Hinduism with a very few practitioners of Judaism and other religions like Christianity, Buddhism, Sikhism, Zoroastrianism, Jainism etc.

The largest and most populous country of South Asia (India) has about 82% Hindus who practise male circumcision very rarely (and exceptionally) only for surgical correction of conditions like phimosis / paraphimosis etc. Muslims are in a minority in India as contrasted with the neighbouring nations (Pakistan and Bangladesh) inhabited by majority of Muslim populations. Jews are in extremely small numbers in the three nations .

The two surrounding countries of India, viz, Pakistan and Bangladesh having predominant Muslim population with circumcised males (as male circumcision is carried out in early childhood for the majority of the boys as a religious ritual) with the need to take up no separate intervention besides just ensuring accessibility to hygienic and safe clinical circumcision to the male children.

India being a country with a heterosexual epidemic with a majority of boys and men not being circumcised would need male circumcision for those pockets which have high prevalence of HIV. The two north eastern states of India are characterized by primarily injecting drug use - driven epidemic but the other high prevalence states of India and 118 districts categorized as ‘A’ throughout the country, fulfill all these “essential” criteria and we must consider the option of male circumcision as a preventive strategy in these geographical areas to begin with.

The pandemic of HIV, though a global epidemic, needs to the visualized as a plethora of different epidemics which are topography, typology and culture specific. The country of India (with dimensions of a sub-continent) with huge socio-cultural and geographical variations provides a scenario where a simplistic ‘country specific’ model of HIV prevention will not yield results.

The intricacies of these local epidemics necessitate specific responses which are evidence-generated. Perceiving India as a nation will ‘low’ prevalence of HIV in the general population leads as to a conclusion that all the below-mentioned three mandatory pre-requisites of the strategic intervention of male circumcision (MC) for prevention of HIV do not exist (thereby obviating the role of prevention of HIV by MC). 1. Heterosexual epidemic 2. Low male circumcision prevalence 3. High HIV prevalence Effectiveness and feasibility of male circumcision as a preventive strategy as based on international evidence in general and the reports of the three randomized control trials [Kisumu (Kenya), Rakai (Uganda) and Orange Farm (South Africa)] in particular, clearly indicate that a comprehensive HIV prevention package must incorporate the multi-pronged approach of :-

1. Promotion of safer sexual practices
2. Management of STIs
3. Promotion of consistent and correct use of male and female condoms
4. Counselling and HIV testing facilities with increased access to other additional important interventions
5. Culture-sensitive amalgamation of male circumcision with clear recognition of only a partial protection being provided by it.

Male circumcision has strong cultural connotations implying also the need to deliver services in a manner that is culturally sensitive and that minimizes any stigma that might be associated with circumcision status. Countries should ensure that male circumcision is provided with full adherence to medical ethics and human rights principles, including informed consent, confidentiality and absence of any type of coercion. The problem of HIV and AIDS must be seen from the following perspectives and approaches:-

• Communication perspective
•Public health perspective
• Human rights perspective
•Gender perspective
•Health care service delivery perspective
•Economic perspective
•National vs regional/state perspective
•Political perspective
•Legal perspective
•Socio-cultural/religious perspective .

The role of social change communication and appropriate capacity building cannot be emphasized more in an intervention like male circumcision (more than just a bio-medical intervention with myriad interwoven cultural, social, religious, ethical and legal aspects) for prevention of HIV through effective targeted addressing of the environmental and societal issues through development and communication of key messages.

Carefully designed strategic interventions for scaling up of access to male circumcision services to identified/recognized at risk population, therefore, must be ensured in a time bound manner.

We all must work for that with appropriate advocacy, communication and social mobilization ensuring concerted collective action for policy formulation, chalking out of programmes and projects and development and implementation of suitable interventions.