'A-B-C', the mantra that will have left an indelible mark on the memory of every CWB volunteer past or present. 'A' of course stands for 'Abstain', 'B' for 'Be faithful to one partner' and 'C' which is articulated as 'use protection'. At CWB the protection referred to is specifically 'condoms' though elsewhere it has been replaced with 'circumcision'.

In Europe, male circumcision is most commonly associated with certain religions. In parts of Africa it is customary among members of certain ethnic groups. For example the Kikuyu, the largest ethnic group in Kenya traditionally circumcise teenage boys as a rite of passage into adulthood. Increasingly, African governments are promoting voluntary male circumcision to prevent transmission of HIV.

Clinical trials

Three large clinical trials conducted in South Africa, Kenya and Uganda suggested that the risk of HIV passing from a HIV positive woman to a circumcised man is lower. They report that the risk of HIV being transmitted is reduced by 48-60% in men who have been circumcised compared with those who have not.

Why has it been successful in reducing HIV transmission?

A number of theories have been put forward to explain this phenomenon though none of them is concrete.

One of the explanations states that the foreskin may tear more easily during intercourse. Alongside this, circumcised skin is believed to develop a protective layer of keratin after the skin has healed post-operatively.

There is also a theory that states that there is a higher density of Langerhans cells in the foreskin which have an affinity for HIV particles. The explanation most recently published is that the foreskin contains a high concentration of anaerobic bacteria which increases the risk of inflammation and trauma thus increasing HIV transmission risk.

A combination of these mechanisms may explain the reduced HIV infection rates reported in the trials mentioned.

Arguments against

There are also a number of arguments opposing the expansion of voluntary circumcision programs.

• The studies quoted all have some methodological flaws. There are various components which would introduce bias into the trials and question the validity of the results reported.
• The risk of HIV transmission from circumcised HIV positive males to females has not been investigated.
• None of the trials previously published has investigated whether HIV transmission risk is affected in men who have sex with men.
• A possible consequence of circumcision is that men may believe they are immune to HIV and shirk condoms.

What about condoms?

Correctly used condoms are believed to lower the risk of HIV transmission by between 80 and 95%. They are a cheap and very effective method of prevention.
HIV infection rates in Uganda show the impact of condoms when used as part of a comprehensive prevention strategy that uses the 'A-B-C' method. In 1992 the HIV infection rate was as high as 18%, among the highest in the world. The Ugandan government then embraced the 'A-B-C' approach which included increasing the availability of condoms. By the beginning of this century the infection rate had fallen to 6% proving the effectiveness of a three-pronged strategy.

Where do CWB sit on this subject?

Governments across Africa are clearly attracted by the idea of reduced infection rates among circumcised men in the clinical trials reported. The procedure is seen by many organisations as being a relatively cheap intervention which only needs to be carried out once and doesn't require much medical follow up. The governments of Kenya and Uganda have seemingly embraced this development, with circumcision prevalence among men being 84% and 25% respectively.

While circumcision may be a desirable approach for some men in Africa, it could increase the risk of complacency among those who opt for it. Whatever the scenario, it is probably still the case that there is no safer protection against HIV than a correctly used condom.

As an organisation committed to passing on sound evidence based HIV prevention messages to children and young people, CWB continues to promote the full 'A-B-C' message where 'C' stands for condom.