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Scientific trials have shown that male circumcision can reduce a man’s risk of becoming infected with HIV during heterosexual intercourse by up to 60 percent. 1 2 These findings have led to the decision by UNAIDS and the World Health Organization (WHO) to recommended circumcision as an important new element of HIV prevention. 3 Since the decision was made the demand for circumcision has been increasing. In Zimbabwe 700 men requested to be circumcised within just two weeks of the government starting the roll out of voluntary medical male circumcision (VMMC) services for HIV prevention. 4
It is suggested that one in five HIV infections could be prevented by VMMC by 2025, if countries in Eastern and Southern Africa continue to introduce and rapidly expand VMMC programmes. 5 Alongside this scale-up, research needs to continue into the effectiveness and potential impacts of circumcision as an HIV prevention method.
What is circumcision?
Male circumcision involves removing the foreskin, a loose fold of skin that covers the head of the penis. The procedure can be carried out at any stage; during infancy, childhood, adolescence or adulthood. Many societies have been practicing 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 and 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.
How does circumcision prevent HIV?
There are several ways in which the foreskin acts as HIV’s main ‘entry point’ during penetrative sex between an uninfected man and an HIV-infected person. The inner surface of the foreskin contains a higher proportion of the cells that HIV targets, such as T-cells. Conversely, the inner foreskin has less keratin, a protein found in the skin, which has a protective effect. 12 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. 13 Circumcision can reduce the likelihood of genital ulcers, which increase HIV-risk. In addition, any small tears in the foreskin that occur during sex make it much easier for the virus to enter the body. 14
The effect of circumcision on male-to-female sexual HIV transmission
The effect of circumcision on male-to-female HIV transmission has not been extensively researched. One particular trial involving 922 HIV infected men in Uganda found circumcision did not reduce HIV transmission to uninfected female partners. 15 The findings suggested that the risk of HIV transmission could even have been increased in the six weeks after circumcision due to unhealed wounds from the procedure. Another study found that male circumcision was not significantly associated with women's HIV risk. 16
Although more research is needed in this area, the evidence suggests that women will benefit from the scale-up of voluntary medical circumcision programmes in the long-term. Properly carried out circumcision programmes have the potential to lower HIV prevalence among the male population, reducing a women's exposure to HIV-positive men. Between 2009 and 2011, a number of studies looked at the potential impact of implementing VMMC in 14 priority countries in eastern and southern Africa. They showed that if 80 percent of men in the region were circumcised over the following 5 years, 3.4 million new HIV infections would be prevented, and $15.6 billion would be saved in treatment costs. 17 Another study has claimed that mass VMMC programmes could reduce the incidence of transmission from males to females by up to 46 percent. 18
The effect of circumcision on male-to-male sexual HIV transmission
Male circumcision has also been found to reduce risk for ‘insertive only’ men who have sex with men. 19 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. 20 Another study conducted in Peru and the United States of America concluded that circumcision had no significant protective benefit for male-to-male sexual HIV transmission. However, there may have been a reduced risk among those who took the insertive role. 21
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 a person has sex, condoms provide highly effective protection against HIV infection, 22 whereas circumcision only prevents around 50 percent 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.
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. 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; 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 percent of circumcised males (35 percent in traditional circumcision and 18 percent in a clinical setting) experienced an adverse event, for example excessive bleeding, infection or excessive pain. 23 In June 2010 it was reported that 20 fatalities were linked to unregulated circumcisions performed by unqualified surgeons in Eastern Cape Province, South Africa. 24
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. However, to date, there have been no reports of condom use being abandoned where circumcision programmes have been implemented. 25 Additionally, in places where circumcision has become popular, it can also be used as a good entry-point for men to learn their HIV status, and therefore reduce the risk of infecting sexual partners. 26
Acceptability: Circumcision is normal in some communities; it is a common practise for many Jews, Muslims, and Americans. 27 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. In addition, some men will have personal reasons for rejecting circumcision, even if their culture allows it.
A study into the acceptability of male circumcision among women in the most HIV prevalent province in Kenya (Nyanza), found that 77 percent of the women prefer circumcised sexual partners, as opposed to uncircumcised men. 73 percent of the women knew that HIV infection to a man was less likely if he was circumcised. This suggests a cultural change in how women both understand and prefer circumcised men in this area. 28
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 voluntary medical male circumcision in high-prevalence African countries would save billions of dollars in the long term by reducing the number of people needing HIV treatment. 29
Perceptions of female genital cutting (FGC): It has been identified that in communities where FGC is practised and male circumcision for HIV prevention is promoted, some may be led to believe that FGC could also reduce the risk of HIV infection. 30 In one survey of 494 women from communities in Kenya, Namibia, South Africa, Swaziland and Uganda, almost 1 in 4 incorrectly thought FGC could protect women from HIV. 31
Effects on transmission of other STDs: Some studies show that circumcision has an effect on the transmission of other sexually transmitted diseases. For example, the HIV transmission and male circumcision trial conducted in Rakai, Uganda, found that in addition to reducing the incidence of HIV infection, male circumcision also reduced the incidence of herpes simplex virus type 2 (HSV-2) and the prevalence of human papillomavirus (HPV) among men and adolescent boys. 32 Results from the trial also showed a reduced prevalence and incidence of HPV infections among the female partners of the circumcised adolescent and adult men. 33
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 WHO released the results of an expert consultation to determine whether voluntary medical male circumcision should be promoted for preventing HIV infection. 34 35 The experts - including representatives of governments, civil society, scientists and non-governmental organisations - advised that promoting VMMC "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 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 percent of the general population, which includes many countries in sub-Saharan Africa. Overall, around 62 percent of African men are already circumcised, but in Southern Africa (the region worst affected by HIV) the rate is less than 20 percent. 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. 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.”
Who should circumcision programmes target?
A 2014 study explained the benefits of circumcising young people of this age range, rather than adults. These included:
- In many places, it is more culturally and socially more acceptable for adolescents to be circumcised than adults.
- If performed before becoming sexually active, the benefits of VMMC are long tierm for both the individual and public health.
- If VMMC occurs before an individual starts entering sexual relationships, there are fewer concerns about sexual abstinence, allowing enough time to heal, and pressure from partners to engage in sex before healing.
The study also highlighted different strategies to encourage adolescents to be circumcised. In Zimbabwe, a popular reggae artist released songs for the radio and images for billboards to promote VMMC, highlighting it as fashionable. Adolescents were encouraged to bring a friend to be circumcised, spreading its health message. Promoting VMMC during school holidays is another way to encourage adolescents to come forward, when they have the holidays to heal. 37
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 voluntary medical male circumcision 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 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, 38 and circumcision for men already infected with HIV is not recommended. A 2010 UNAIDS report also suggested that older men need to be reached, in order to achieve a target of 20 million more males becoming circumcised across Eastern and Southern Africa and to maximise the population-wide prevention benefits of VMMC. 39
What progress has been made in increasing circumcision services?
In 2011, UNAIDS and PEPFAR jointly launched a five-year action framework to accelerate the use of voluntary male circumcision for HIV prevention in southern and eastern African countries. The framework suggested a target of providing VMMC to 80 percent of adult men, in 14 priority countries by 2015, which would avert an estimated 3.4 million new infections by 2025. 40 41
Many countries in sub-Saharan Africa have begun taking steps to increase the availability of male circumcision services: Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. 42 By the end of 2010, most priority countries had put in place the key services needed in a circumcision programme, including stand-alone clinics, routine facility-based services and outreach or mobile circumcision services. 43
- Kenya’s Nyanza province has rapidly scaled up VMMC, managing to circumcise 54 percent of the men they aim to offer VMMC to by 2015. 44
- Swaziland and Ethiopia have reached at least 20 percent of their 80 percent target, by the end of 2011, and are also the only countries to offer circumcision as part of their infant care programmes. 45
- As of 2012, Tanzania has reached at least 47 percent of its 80 percent target. Circumcision rates increased more for younger men between 15-24. However, uptake of VMMC was higher in more affluent and educated sectors of society, and the campaign appeared to have reached few 25-34 year olds. 46
- A partnership in Zambia and Swaziland aims 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. 47 48
- The South African government has not begun scaling up male circumcision for HIV prevention as readily as other countries in the region. 49 However, Zulu King Goodwill Zwelithini has announced the reintroduction of the practise 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 Zwelithini 50
Many countries have reported challenges such as limited financial and human resources, and inadequate infrastructure, amongst others. 51 Systems for monitoring and evaluating voluntary medical male circumcision programmes are important for ensuring that they are being implemented effectively and appropriately. 52 The Tanzania study found that more educated Tanzanians tend to adopt preventative behaviours such as VMMC earlier, lowering their risk of contracting HIV. The report concluded that efforts going forward should focus on increasing VMMC adoption amongst more vulnerable men, and implied that education was the key to the programme’s success within all sectors of Tanzanian society. 53 It is also important that continued focus is put upon proven HIV prevention measures, such as HIV testing and counselling and the promotion of condoms.
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- 48. IRIN (2009, 5th October), ‘ Swaziland: ambitious target for male circumcision
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- 50. BBC (2009, 7th December), ' South Africa Zulus to revive circumcision to fight AIDS'.
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