Scientific trials have shown that male circumcision can reduce, by up to 60 percent, a man’s risk of becoming infected with HIV during heterosexual intercourse.¹ As a result in 2007 UNAIDS and the World Health Organization (WHO) recommended circumcision as an important new element of HIV prevention.² Since then demand for circumcision has been increasing, and in Zimbabwe 700 men requested to be circumcised within just two weeks of the government starting the roll out of male circumcision services for HIV prevention.³ Male circumcision can be carried out at any stage; during infancy, childhood, adolescence or adulthood.

Mathematical models have predicted that one new HIV infection could be averted for every 5 to 15 men who are newly circumcised.⁴ It has also been suggested that six million new HIV infections and three million deaths could be prevented in twenty years if all men in sub-Saharan Africa became circumcised.⁵

These numbers are certainly impressive. However, with more countries aiming to introduce and rapidly expand male circumcision programmes, measures need to be taken to ensure their effectiveness, and research into the potential impacts of such interventions is crucial.

"A number of thorny issues arise related to promoting male circumcision as a public health intervention for HIV prevention…We absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’" - UNAIDS Chief Scientific Adviser, Dr Catherine Hankins

What is circumcision?

Male circumcision involves removing the foreskin, a loose fold of skin that covers the head of the penis. Many societies have been practising male circumcision for hundreds of years, and circumcision is often seen as a mark of belonging to a particular tribal or religious group. It is estimated that up to a third of all men are circumcised, though rates vary widely around the world.⁶

Circumcision and HIV

Since the 1980s, scientists have suspected that male circumcision might reduce rates of HIV transmission during sex. They observed that circumcised men are less likely to have HIV than uncircumcised men, and HIV is less common among populations that traditionally practise male circumcision than in communities where the procedure is rare. However, for a long time it was unclear to what extent this was an effect of circumcision itself, or whether other factors might also play a role.

To settle this issue, three trials were set up in sub-Saharan Africa, which together involved more than 11,000 previously uncircumcised men.⁷ Each man was randomly assigned to one of two categories: one group had their foreskins removed at the start of the study and the others remained uncircumcised. All men received extensive counselling on HIV prevention and risk reduction techniques. During the trials, researchers collected information about the men’s sexual behaviour to check whether it varied between the two groups; they found no significant differences.

The circumcision trials in Kenya and Uganda were halted on 12th December 2006, after an expert committee decided that to continue them would be unethical as there was already such clear evidence that circumcision reduces the risk of HIV infection.⁸ The results of the circumcision trials were as follows:

Location	Participants	Report published	Result in circumcised men
South Africa	3,274	July 2005	60% fewer infections 9
Kenya	2,784	February 2007	53% fewer infections 10
Uganda	4,996	February 2007	51% fewer infections 11

Taken together, these findings provide conclusive evidence that male circumcision, if performed safely in a medical environment, roughly halves the risk of a man becoming infected with HIV through heterosexual sex.

These findings provide conclusive evidence that male circumcision roughly halves the risk of a man becoming infected with HIV

There are several possible reasons why circumcision has this effect. The foreskin creates a moist environment in which HIV can survive for longer in contact with the most delicate parts of the penis, and the inner surface of the foreskin contains cells that are especially vulnerable to infection by HIV. A study of Ugandan men before and after circumcision concluded that observed decreases in anaerobic bacteria may play a role in reducing the risk of HIV acquisition.¹² Removing the foreskin also means that the skin on the head of the penis tends to become tougher and more resistant to infection. In addition, any small tears in the foreskin that occur during sex make it much easier for the virus to enter the body.

It is important to note that the proven benefit only applies to men. The studies so far conducted suggest that male circumcision probably doesn't have a substantial effect in reducing HIV transmission from an infected man to a woman.^{13 14} One particular trial in Uganda showed that 18 percent of women with newly circumcised partners became infected with HIV, compared to 12 percent of women with uncircumcised partners. The authors of the study, which involved 922 HIV infected men, concluded that the risk of HIV transmission could have been increased in the six weeks after circumcision due to unhealed wounds from the procedure.¹⁵ However, expanding male circumcision services could benefit women indirectly by lowering HIV prevalence among men, and therefore reducing a woman's risk of exposure to men infected with the virus.¹⁶

Further research is also needed into the effects of circumcision on the risk of HIV infection among men who have sex with men. Currently there is no conclusive evidence that circumcision reduces a man's risk of HIV infection during anal sex. However, one study in Australia found that circumcision was associated with a significant reduction in HIV incidence among men who have sex with men who reported a preference for the insertive, rather than receptive, role in anal intercourse.¹⁷

Advantages and disadvantages of circumcision as an HIV prevention method

The greatest advantage of circumcision is that it is a one-off procedure, with no ongoing costs or supply issues to worry about. Once a boy or man has undergone the procedure he will benefit from the preventive effect for the rest of his life. However, there are also disadvantages to circumcision as a universal HIV prevention approach which is why on its own, it is not a solution to the global HIV epidemic.

Effectiveness: Circumcision is much less effective than condom use at preventing HIV transmission. If used correctly every time you have sex, condoms provide highly effective protection against HIV infection,¹⁸ whereas circumcision only prevents around 50% of infections. Even if a man has been circumcised, he must still abstain, be faithful or use condoms to substantially cut his risk of infection. Moreover, unlike condoms, circumcision does not prevent pregnancy, and it is unclear whether it reduces the risk from other sexually transmitted infections.

Hazards of the procedure: Unlike other methods of preventing HIV transmission during sex, circumcision requires medical intervention. To carry out the procedure safely requires considerable resources; otherwise it can be very risky. Side effects of poorly performed circumcision can include serious bleeding and damage to the rest of the penis. Even more worryingly, if tools are not sterilised before each use then they can transmit infections: there is a real risk that circumcision could actually spread HIV if not performed properly. Also, newly circumcised men must wait a few weeks for their wounds to heal before having sex, and if they don't they are likely to face an increased risk of HIV infection through their broken skin. A study of a thousand men in Western Kenya found that 25% of circumcised males (35% in traditional circumcision and 18% in a clinical setting) experienced an adverse event, for example excessive bleeding, infection or excessive pain.¹⁹ In June 2010 it was reported that 20 fatalities were linked to unregulated circumcisions performed by unqualified surgeons in Eastern Cape Province, South Africa.²⁰

The Royal Dutch Medical Association (KNMG) holds the view that male circumcision among newborns and children cannot be justified as a routine procedure in any circumstances due to the associated medical and psychological complications.²¹  The risk of health complications, such as bleeding or swelling, arising from the circumcision procedure are traditionally thought to be lower among newborn children but some medical professionals dispute this.²² According to the KNMG "in so far as there are potential medical benefits, such as a possibly reduced risk of HIV infection" circumcision should be "put off until the age at which such a risk is relevant and the boy himself can decide about the intervention."²³ 

Effects on risk taking: If people become too confident about the protective effects of circumcision, they may engage in more high-risk sexual behaviour. Men who have been circumcised might stop using condoms, or be keener to visit sex workers. Women might find it harder to insist on condom use by circumcised partners. It is even possible that, in areas where circumcision is already widespread, publicity of the scientific findings could increase transmission of HIV.

Acceptability: Circumcision is normal in some communities; it is a common practise for many Jews, Muslims, and Americans.²⁴ Many cultures, however, have no tradition of circumcision, and some (including Hindus and Sikhs) are strongly opposed to it. Therefore it is unlikely that this intervention will be able to benefit all parts of the world. Furthermore, some men will have personal reasons for rejecting circumcision, even if their culture allows it.

Resources required: Safe circumcision, as performed in the clinical trials, demands considerable resources including trained staff, a clean clinic and sterile tools. Estimated costs vary between $25 and $500 per person in Africa. In many of the regions worst affected by HIV, health care infrastructure is extremely weak, and would struggle to provide widespread access to circumcision. Nevertheless, it has been calculated that rapid roll out of circumcision in high-prevalence African countries would save billions of dollars in the long term by reducing the number of people needing HIV treatment.²⁵

Possible effect on anti-FGM campaigns: Many agencies are working hard to eliminate female genital mutilation (FGM), a custom that is still common in some parts of the developing world. Promoting male circumcision in societies that practise FGM risks creating confusion or the perception of double standards.

So as there are a number of difficulties associated with circumcision as an HIV prevention approach, considerable care must be taken wherever it is promoted.

Implementing circumcision for HIV prevention

In March 2007 the WHO released the results of an expert consultation to determine whether circumcision should be promoted for preventing HIV infection.^26 27 The experts - including representatives of governments, civil society, scientists and non-governmental organisations - advised that promoting male circumcision "should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men."

Where should circumcision be promoted to prevent HIV infection?

UNAIDS and the WHO recommend that:

“countries with high prevalence, generalized heterosexual HIV epidemics that currently have low rates of male circumcision consider urgently scaling up access to male circumcision services.”

"High prevalence" is defined as above 3% of the general population, which includes many countries in sub-Saharan Africa. Overall, around 62% of African men are already circumcised, but in Southern Africa (the region worst affected by HIV) the rate is less than 20%. Studies have found high rates of acceptability for circumcision in a number of African communities, provided the procedure is safe, affordable and has minimal side effects or pain. Some countries were already experiencing increased demand for circumcision before the results of the trials in Kenya and Uganda were made public.

With respect to other parts of the world, it is recommended that:

“In settings with lower HIV prevalence in the general population, including where HIV infection is concentrated in specific populations at higher risk of HIV exposure, such as sex workers, injecting drug users or men who have sex with men, limited public health benefit would result from promoting male circumcision in the general population.”

It is therefore unlikely that circumcision will be strongly promoted for preventing the spread of HIV outside Africa. In particular, the intervention will not be advocated in Western countries, where HIV is less common and is largely transmitted through sex between men, a context in which circumcision has no proven benefit. Nevertheless it is suggested that:

“there may be individual benefit for men at higher risk of heterosexually acquired HIV infection such as men in sero-discordant partnerships and clients presenting at clinics for the management of sexually transmitted infections.”

How can circumcision programmes be implemented effectively?

Where circumcision services are provided, they should form part of a comprehensive HIV prevention package alongside provision of counselling and testing services, treatment for sexually transmitted infections, promotion of safer sex, and provision of condoms. Countries are advised to consider providing circumcision to men free of charge or at the lowest possible cost to the client, as for other essential services. Experts also stress the need for:

• culturally appropriate strategies
• well-trained practitioners working in sanitary conditions
• informed consent, confidentiality and absence of coercion
• counselling of men and their sexual partners to prevent them developing a false sense of security.

UNAIDS and the WHO advise that the greatest public health benefit would result from prioritising circumcision for young males (such as those aged 12-30 years), as well as men thought to be at higher risk for HIV (such as those being treated for STDs). Promoting circumcision of newborn babies should be considered as a longer-term strategy,²⁸ and circumcision for men already infected with HIV is not recommended.

What progress has been made in increasing circumcision services?

Many countries in sub-Saharan Africa with a low prevalence of male circumcision and a high prevalence of HIV, have begun taking steps to increase the availability of male circumcision services. Situation analyses, which will inform national strategies, have been completed or are underway in Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.²⁹

“Many countries in sub-Saharan Africa have begun taking steps to increase the availability of male circumcision services.”

Strong political commitment in Botswana and Kenya means that these countries have already officially established national strategies to scale-up circumcision for HIV prevention. Botswana has set targets to reach 80% of men under 49 years who do not have HIV, by 2014. Kenya aims to have a male circumcision prevalence of 80% by 2013, and 20,000 circumcisions have already been carried out under the scale-up programme in just one year. The South African government on the other hand, has not begun scaling up male circumcision for HIV prevention as readily as other countries in the region.³⁰ However, Zulu King Goodwill Zwelithini has announced the reintroduction of the practice among South African Zulus,

"In the context of the fight against HIV and AIDS, I should announce my intention to revive the practice of circumcision amongst young men" - Zulu King Goodwill Zwelithini³¹

In Zambia and Swaziland, a partnership has been launched to significantly expand services in order to circumcise 642,000 adolescent boys and men in the two countries over five years. The Bill and Melinda Gates Foundation has provided a $50 million grant to support the scale-up.^32 33

These ambitious initiatives have highlighted the challenges involved in promoting circumcision for HIV prevention. Many countries have reported that limited financial and human resources, and inadequate infrastructure, are serious concerns.³⁴ Systems for monitoring and evaluating circumcision programmes are important for ensuring that they are being implemented effectively and appropriately.³⁵

With the necessary mechanisms in place, initiatives being adopted by country governments to expand circumcision could represent a valuable new aspect of global HIV prevention efforts, and save millions of lives. However, it is widely recognised that such programmes are not a 'magic bullet' against HIV, and continued focus on proven HIV prevention measures, such as HIV testing and counselling and the promotion of condoms, must not be sacrificed.

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Sources

• NIAID (13 December 2006), 'QUESTIONS AND ANSWERS: NIAID-Sponsored Adult Male Circumcision Trials in Kenya and Uganda'
• The Clearinghouse on Male Circumcision for HIV Prevention, 'www.malecircumcision.org'.

References

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2. WHO & UNAIDS (2007, 28th March), ‘WHO and UNAIDS announce recommendations from expert meeting on male circumcision for HIV prevention’.
3. WHO (2009, June), 'Country experiences in the scale-up of male circumcision in the Eastern and Southern Africa Region: two years and counting'.
4. UNAIDS/WHO/SACEMA (2009, 8th September), 'Male circumcision for HIV prevention in high HIV prevalence settings: what can mathematical modelling contribute to informed decision making?'.
5. Williams B. G. et al (11 July 2006), "The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa", PloS Medicine 3(7)
6. Weiss H et al (2008), 'Male circumcision for HIV prevention: from evidence to action?' AIDS Journal 22(5)
7. Auvert B. et al (25 October 2005), "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial", PloS Medicine 2(11)
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9. Auvert B. et al (25 October 2005), "Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial", PloS Medicine 2(11)
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27. UNAIDS/WHO (28 March 2007) "New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications" [PDF]
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31. BBC (2009, 7th December), 'South Africa Zulus to revive circumcision to fight AIDS'.
32. Bill and Melinda Gates Foundation (2009, 11th June), 'Unprecedented scale-up of voluntary male circumcision begins in Swaziland and Zambia'.
33. IRIN (2009, 5th October), ‘Swaziland: ambitious target for male circumcision’.
34. WHO (2009, June), 'Country experiences in the scale-up of male circumcision in the Eastern and Southern Africa Region: two years and counting'.
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