Editor's Choice

Male circumcision and HIV infection

Clutching at straws to prevent the HIV/AIDS epidemic has included strident advocacy for male circumcision (MC) from some quarters, especially following three randomised controlled trials from South Africa, Kenya and Uganda in 2006 - 2007 that show a protective effect of MC. Three contributions in this SAMJ contest the value of MC in the prevention of HIV.

Connolly and colleagues¹ analysed a sub-sample of men aged 15 years and older who participated in the first population-based survey on HIV/AIDS in 2002. Of the men 35.3% were circumcised. The factors strongly associated with circumcision were age >50, rural blacks and speaking SePedi or IsiXhosa. Blacks were significantly older (mean 18 years) compared with other race groups (3.5 years). Among blacks, circumcisions were mainly conducted outside hospital settings. Since they found that circumcision and HIV were not associated, they concluded that MC had no protective effect in the prevention of HIV transmission. They also noted that most circumcisions among indigenous ethnic groups in South Africa are conducted under unsterile conditions.

Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about. Sidler, Smith and Rode² note that substantive indications for the procedure are lacking and review the evidence for the possible value of neonatal circumcision in reducing HIV infection rates. They cite reviews that question the necessity of non-therapeutic infant circumcision, showing that it has neither short- nor long-term benefits, and other reports that circumcision does not prevent sexually transmitted diseases. On this basis they conclude that neonatal non-therapeutic circumcision to combat the HIV crisis in Africa is neither medically nor ethically justifiable. Furthermore, promoting circumcision might worsen the problem by creating a false sense of security and therefore undermining safe sex practices. Education, female economic independence, safe sex practices and consistent condom use are proven effective measures against HIV transmission.

The accompanying editorial by the Myers team of father and son³ largely concurs with the findings of the two papers. They therefore suggest that the duty of parents may to be err on the side of caution, and defer the procedure until the child can make an autonomous decision. At a societal level MC may be unjust in so far as it could compete for resources with more effective and less costly interventions and disadvantage women.

Namaqua dwarf adder bites

Case reports are rarely accepted for publication in the SAMJ even if they comprise more than one case, as in the report on Namaqua dwarf adder envenomation by Bryan Maritz.⁴

However, we found several compelling reasons to publish this one, namely that it has pretty pictures (on the cover and in the article), and that we learn something about nature along the west coast of southern Africa and that the Namaqua dwarf adder (Bitis schneideri) is also dealt with in the pet trade. However, most importantly, the 4 cases described appear to comprise by far the largest series published to date and thus add considerably to our knowledge on the subject. Readers will be reassured that the venom is generally not dangerous and very unlikely to result in fatalities in human victims.

BCG surgical complications

Bacille Calmette-Guérin (BCG) immunisation at birth is recommended for all asymptomatic infants in South Africa, irrespective of HIV exposure. While acknowledging the risk of disseminated BCG and not recommending BCG vaccination for children with symptomatic HIV infection, the national policy does not take into consideration the fact that most vertically transmitted HIV-infected neonates are asymptomatic at birth. Karpelowsky and colleagues⁵ provide a case series of 17 HIV-infected patients with surgical complications of BCG vaccination. They conclude that the risks of BCG vaccination in HIV-infected infants are significant, that current recommendations are not satisfactory, and that a change in policy is required to prevent the harmful effects of this vaccine in a high-risk group of patients. There is a need to stratify patients and vaccinate them according to a protocol that takes impaired immunity into consideration.

Media altruism

Bad news dominates the media to the extent that we almost become immune to it. So some good news is refreshing, and Chris Bateman, SAMJ news editor, relates how Carte Blanche, the hard-hitting M-Net television investigative programme, embarked on a R20 million fund-raising blitz for children's hospitals to mark their own 20th anniversary.⁶ The huge success of the Red Cross Children's Hospital Trust in obtaining public support to serve the children of this country also serves as an inspiration to others.

JP de V van Niekerk

1. Connolly C, Simbayi L, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002. S Afr Med J 2008: 98; 789-794.         [ Links ]

2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV/AIDS infection rates. S Afr Med J 2008: 98; 762-766.         [ Links ]

3. Myers A, Myers J. Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practical. S Afr Med J 2008: 98; 781-782.         [ Links ]

4. Maritz B. Namaqua dwarf adder (Bitis schneideri) envenomation. S Afr Med J 2008: 98; 788.         [ Links ]

5. Karpelowsky JS, Alexander AG, Dix Peek S, Millar AJW, Rode H. Surgical complications of bacille Calmette-Guérin (BCG) infection in HIV-infected childen: Time for a change in policy? S Afr Med J 2008: 98; 801-804.         [ Links ]

6. Bateman C. Media 'knight' breathes life into paediatric icu's. S Afr Med J 2008: 98; 740-744.         [ Links ]