Circumcision & HIV

On 12 December 2006, an expert committee called a halt to two large studies of male circumcision and HIV. There was already such clear evidence that circumcision reduces the risk of HIV infection, that to continue the trials would be unethical. This news caused great excitement among some HIV experts. According to Dr. Kevin De Cock, director of the HIV/AIDS Department of the World Health Organisation:

“If decisions are made to scale [circumcision] up by different countries, it does have the potential to prevent many tens of thousands, many hundreds of thousands, and perhaps millions of infections over the coming years.” - ¹

There are mathematical models to support this statement, suggesting that six million new HIV infections and three million deaths could be averted over the next twenty years if all men in sub-Saharan Africa became circumcised. ²

These numbers are certainly impressive. But how easy will it be to implement mass circumcision in the countries worst affected by HIV? And how might this affect uptake of other HIV prevention strategies?

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 it 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.

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 eleven thousand previously uncircumcised men. 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 intact. 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 large differences.

The results of the trials were as follows:

Location	Participants	Report published	Result in circumcised men
South Africa	3,274	July 2005	60% fewer infections ³
Kenya	2,784	February 2007	53% fewer infections ⁴
Uganda	4,996	February 2007	51% fewer infections ⁵

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. In fact, when the results are adjusted for men who moved between the two groups, the estimated benefit is even higher - around 65%.

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. If the foreskin is removed then 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. It is not entirely clear whether male circumcision also reduces the risk of HIV transmission from an infected man to a woman. The studies so far conducted suggest that it probably doesn't have a substantial effect.⁶ ⁷

Why circumcision is not a “magic bullet” against HIV

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 many reasons why circumcision is far from being the solution to the global HIV epidemic.

Effectiveness: Circumcision is much less effective than condom use at preventing HIV transmission. If used consistently over the long term, condoms are at least 80% effective, ⁸ 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. Moreover, unless newly circumcised men wait a few weeks for their wounds to heal before having sex, they are likely to face an increased risk of HIV infection through broken skin.

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, including most Jews, Muslims and Americans. 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. ⁹

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.

In conclusion, the news that circumcision can reduce risk of HIV transmission is very welcome; this intervention can now be added to the list of proven prevention strategies. However, circumcision is definitely not an easy solution to the global AIDS epidemic. The many difficulties associated with this intervention demand that great care be taken wherever it is promoted.

What are the recommendations for promoting circumcision to prevent HIV infection?

In March 2007 the World Health Organisation (WHO) released the results of an expert consultation to determine whether circumcision should be promoted for preventing HIV infection. ¹⁰ ¹¹ 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." They recommended 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, the experts 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 was 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.”

Where circumcision services are provided, the experts said 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. The experts also stressed 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.

The experts advised 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). They also said that promoting circumcision of newborn babies should be considered as a longer-term strategy. Circumcision for men already infected with HIV was not recommended.

Support from donors and governments

Following the publication of the WHO recommendations, the world's two largest supporters of HIV prevention in the developing world have endorsed the expansion of circumcision services.

Kent R. Hill, an assistant administrator for the U.S. Agency for International Development, has said that circumcision "is going to be one of the major interventions in the international arsenal" against AIDS. The U.S. government is inviting countries to apply for circumcision funding as part of its PEPFAR initiative.¹²

Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, TB and Malaria has said his agency would also support circumcision projects.¹³

Some African governments, including those of Zambia, Kenya and Rwanda, have already launched efforts to widen access to circumcision.¹⁴ ¹⁵ ¹⁶ However leaders in South Africa and Uganda have said they oppose the idea.¹⁷ ¹⁸