31 Oct, 16 | by Leslie Goode, Blogmaster
Recent trials have shown male circumcision (MC) to be associated with a reduced HIV incidence of up to 60%. For this reason UNAIDS has included ambitious goals for circumcision (20 millions MCs) as a major component of its HIV prevention strategies for 14 priority countries in sub-Saharan Africa (STI/blogs/Roll-out of UNAIDS voluntary male circumcision). The achievement of this objective has met with considerable obstacles on the supply side – for instance, the lack of trained practitioners (STI/blogs/Roll-out of UNAIDS voluntary male circumcision; Kaufman & Ross/STIs); but constraints on the demand for MC have, if anything, proved still harder to surmount (STIs/blogs/cultural constraints on uptake of circumcision). The existence of circumcision as a traditional cultural practice amongst some populations can lead to its perception in other cultures as alien and externally imposed – even hostile to one’s own tradition (David/STIs; Madhivanan & Klausner/STIs; STIs/blogs/cultural constraints on uptake of circumcision). Also, its traditional association with a certain phase in the life cycle can give rise to the feeling among older members of the community that it is inappropriate for people of their age (Mbabazi/STIs).
The cultural problems affecting demand have led some to reconsider the possible contribution of early infant circumcision (EIC) as a prevention tool – albeit on a longer view that the one envisaged by existing UNAIDS targets (Gray & Kigozi/STIs). Kankaka & Gray (K&S), in a recent paper reporting a trial of such an intervention in Rakai Uganda, seem to corroborate (largely) positive findings of earlier investigations of EIC in other sub-Saharan countries (Young & Nordstrom (Y&N) (Kenya); Plank & Lockman (Botswana); Bowa & Stringer (Zambia)) that would indicate EIC could ultimately prove a highly effective form of prevention. Of course, supply side problems with the recruitment and retention of adequately trained personnel remain. For this reason, K&S – as indeed Y&N before them – investigated the impact of task-shifting from physicians to less highly trained practitioners; in the Uganda study, infants were randomly assigned to either ‘clinical officers’ (i.e. assistant physicians) or registered nurse midwives (RNMWs). Another feature of this study geared to testing the feasibility of the extension of EIS to remote areas was the decision to substitute topical analgesia for the dorsal penile nerve block used in earlier studies. The trial assessed the safety of EIS (Mogen Clamp) as performed by more junior cadres of medical staff, and rated the degree of pain/discomfort experienced by the infants in terms of Neonatal Infant Pain scores (NIPS) – as well as testing out, in some rudimentary way, the acceptability of the intervention to mothers.
On all accounts, the trial produced very satisfactory results. The rate of adverse events with RNMWs was low, and indeed comparable to rates that might be expected with physicians (1.6%), and the NIPS scores suggested that 76% of infants experienced mild pain or less, and only 1.6% experienced severe pain. So far as the supply-side difficulties are concerned, these results are encouraging. There could, of course, also be demand-side constraints with EIS, equivalent to those observed with adult circumcision. Yet, of the 701 infant-mother pairs registered as potential participants, 74% (no.= 525) consented (as compared to 60% in the Botswana study (Plank & Lockman), but only 11% in the Zambia study (Bowa & Stringer)). Maternal satisfaction rates were 99.6% for clinical officers, and 100% for RNMWs. The cultural acceptability may vary somewhat between populations – yet, to the extent that EIS remains distinct from cultural practices, its dissemination may be less at risk of being perceived in non-medical terms as an alien or hostile cultural imposition. Moreover the evidence suggests that experience of pain increases with age.