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Daily Nation (Kenya) - Horizon magazine
-sorry, link no longer available
Thursday December 26, 2002
Circumcision study lands into problems
By ARTHUR OKWEMBA
The Kenyatta National Hospital Ethical and Research board is uncomfortable
with a study just months after it authorised a local researcher to
circumcise adult males at Kisumu to establish whether there is a
correlation between circumcision and HIV transmission.
Sources say the researcher ran into trouble when the board began thinking
he was betraying some of the agreed aspects of the research.
It immediately – last October – named a committee to investigate. The team
finished its work early the next month, according to board secretary Prof
A. Quantai.
But Prof Quantai would not reveal the findings, saying the board must
first meet to discuss them.
She said: "We are going to take a position on the matter by the second
week of January. What people need to know is that corrective measures are
being taken for the mistakes made."
However, informed sources claimed the board's concern was that those
involved in the research had altered an approved questionnaire without its
knowledge.
There is also some worry about the number of people already circumcised
and about exporting volunteers' specimens abroad for further analysis.
Although local scientists have been known to do such exportation in good
faith, it is said their foreign counterparts take advantage of such
specimen to carry out unauthorised research.
And, in the event, they often make medical breakthroughs that benefit only
their countries and, through patents, only themselves.
Asked for comment, Prof Ndinya Achola, principal investigator in the
study, says he cannot comment since the matter is confidential and under
consideration by the board.
Prof Achola says: "I have explained the science of the study clearly to
the board and they were comfortable. For the ethics of the study is
something we left to them to decide and I cannot comment on it when they
are still looking into the matter."
This revelation is the latest in a study that has generated a lot of
interest and debate among researchers. Many have questioned its whole
safety and ethics.
What preoccupies some of them is that, if circumcision is not hygienic, it
can cause complications, which have killed some men.
Prof Achola has since argued that, in their study, they use doctors and
clinical officers to carry out the circumcision. Besides, their activities
are being supervised by Kenyan and American Data Safety Monitoring (DSM)
experts.
The study, which began six months ago, seeks to find out whether
circumcised men are less likely than otherwise to be infected with the HIV
More than 300 young males have been circumcised since it began. The study
requires them to be sexually active, aged between 18 and 25 and be HIV-
negative. [While it is necessary that they be HIV- so that conversion to HIV+ can be detected, this introduces selection bias: those who are already resistant to HIV will be preferentially chosen, along with those who have just been lucky.] They will be monitored for two years immediately after being circumcised.
More than 600 young men out of the expected 2,000 have volunteered since
the study began. Interest has been beyond the researchers' expectations.
A number of scientists, however, claim that people are being given
incentives to take part and being made to believe they are HIV-proof once
circumcised.
According to Prof Achola, although volunteers get free medical attention
whenever ill, no incentives are given to lure them into participating.
He insists the issue of the volunteers thinking they are insulated from
HIV infection has been thoroughly tackled. He is aware, says he, that,
after circumcision, some young men may engage in unsafe sex thinking they
are safe.
"Our approach is to educate them on HIV/Aids and we emphasise to them that
no authoritative evidence has been produced to indicate circumcision
reduces HIV infection," he stresses.
The study, funded by America's National Institutes of Health, is said to
be the first in the world that attempts to come up with hard data on
correlations between HIV infections and circumcision.
South Africa initiated its own a few weeks ago and Uganda plans to launch
one soon. HIV experts think that, if the studies prove the hypothesis,
then they will provide evidence for circumcision to be added to a list of
public interventions in preventing HIV/Aids.
A few weeks ago, in an interview, Prof Achola insisted that all he wants
is to verify earlier studies, which just compare HIV infection rates
between communities circumcising men and those that do not.
He says: "We want to provide evidence based on practical results to
justify or refute what other studies involving the comparison of untested
phenomenon say."
HIV experts have also demanded that studies be done to produce hard data
showing a relationship between circumcision and HIV infection, especially
in Africa, where three quarters of the world's victims are claimed to
live.
What has spurred interest in the whole issue are indications of
circumcised males with low viral loads showing less likelihood of
transmitting the virus to their female partners. [But viral load is widely variable, unpredictible, and usually unknown. And if circumcised men with high viral loads are no less likely to transmit HIV than intact men with high viral loads, this suggests any protective effect is actually quite weak.]
However, the same scientists have been confronted with cost and ethical
issues, raising a lot of reservations about the whole approach to managing
HIV/Aids.
James Ntozi, a Makerere University lecturer, has warned of money being
diverted from other social needs to meet circumcision costs. [An excellent point.] Or, if the
exercise is donor-dependent, then the programmes might not work.
In one its issues, The Horizons, a research organ of the Population
Council, has raised fears that, in that case, "men may use their
circumcision status as a reason for not using condoms, while women may be
less inclined to insist on condom use if their male partners are
circumcised."
"In this scenario," it adds, "women are in increased risk of contracting
the virus and this may reduce the potential benefits of male circumcision
on HIV transmission." [If any.]
Another fear is that the rate of female genital mutilation (FGM) in areas
where the practice exists may shoot up if men's circumcision is linked to
HIV prevention.
Equally emotive arguments have raised ethical questions about the age at
which a person needs to be circumcised for the practice to be effective.
There are worries that older men may be left out in the strategy, since
studies elsewhere in Africa show that circumcision, as a measure against
HIV infection, is more effective if done before or soon after puberty
begins. [If it is less effective, what would be the point of including them?]
In a 1999 research on the age of male circumcision and HIV infection risk
in rural Uganda, Kelly Kiwanuka found that males circumcised before
puberty – between 13 and 20 – had a much reduced risk compared with their
uncircumcised counterparts. [As usual, this ignores culture: age of circumcision is closely connected to culture, which in turn affects such crucial factors as age of first intercourse.]
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