Mera, March 2007: Men's health: circumcision and HIV

By Michael Szpir, Managing Editor of Research Publications, Family Health International; Lindy Behrend, University of North Carolina, Chapel Hill, NC, USA; and Michael S. Stalker, Deputy Director of Technical Services, Family Health International, Research Triangle Park, NC, USA

There is now clear evidence that male circumcision reduces the transmission of HIV from women to men. In December 2006, the National Institutes of Health (NIH) in the United States halted two clinical trials, in Kenya and Uganda, on the grounds that it would be unethical not to offer circumcision to all the men taking part in the studies. Circumcised men in both trials had dramatically reduced rates of HIV infection -- a reduction of 53% in Kenya and 48% in Uganda -- compared to controls who were uncircumcised.¹

These results confirm a similar trial in South Africa, which showed that circumcised men were 60% less likely to be infected with HIV during heterosexual sex.² The Data Safety and Monitoring Board of the NIH stopped the South African trial during an interim analysis in 2005 and asked the clinicians to offer circumcision to the control group.

In February 2007, a re-evaluation of the data from the Kenyan and Ugandan studies revealed that some participants had been improperly classified or misdiagnosed. When these errors were considered, the protective effect of male circumcision proved to be as much as 60% in the Kenyan and Ugandan trials.^3,4

The three trials add weight to a growing number of observational studies that link male circumcision practices to reduced rates of HIV infection. Epidemiological studies, for example, reveal a striking correlation between geographic patterns of male circumcision and the spread of HIV in Africa. Countries in which less than 25% of the males are circumcised have an average HIV prevalence of 16.4%, whereas countries in which more than 90% of the males are circumcised have an average prevalence of 0.9%.⁵ Areas with low rates of male circumcision generally correspond to areas with a high prevalence of HIV -- within the 'AIDS belt' in the eastern and southern parts of the continent. In contrast, circumcision is a common practice in the countries of West Africa, where rates of HIV tend to be low.⁶

Some scientists have argued that male circumcision could substantially reduce the burden of HIV in Africa. Although men would be the initial beneficiaries, male circumcision could lead to fewer infections among women in those parts of the world where HIV is spread primarily through heterosexual intercourse, according to Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Diseases in the United States. One dynamic simulation model suggests that male circumcision is equivalent to an intervention -- such as increased condom use or a vaccine -- that reduces transmission in both directions by 37%.⁷ The same model predicts that the expansion and introduction of safe procedures for male circumcision could avert 2 million new HIV infections and 300 000 deaths in sub-Saharan Africa over the next 10 years.

The results of these trials and projections will soon come to shape healthcare systems as providers will undoubtedly struggle to meet the demands. The provision of safe, voluntary male circumcision on a broad scale will require investments in healthcare throughout Africa. Providers, policy makers, and society will also need to anticipate potential barriers to male circumcision services. As the global consensus on male circumcision evolves, the international public health community may need to prepare for the introduction of surgical procedures in areas where male circumcision is not currently offered.

Culture, medicine, and circumcision

The practice of removing the foreskin from the penis has important cultural and religious meaning in many parts of the world. Muslim peoples maintain male circumcision as one of the rules of cleanliness. In some African cultures, the procedure is often an integral part of a young man's ritual initiation into manhood. When a boy is circumcised, his social standing is elevated, he becomes a man.

Male circumcision has also been introduced for health reasons. Conditions such as recurrent balanitis (inflammation of the glans penis) and phimosis (in which the foreskin cannot be fully retracted) occur more often (or only) in uncircumcised men. The health benefits were recognised by 19th-century physicians, who applauded the effectiveness of the procedure and began to encourage routine circumcision in the latter half of the century. Cultural beliefs and the practice of medicine have become intertwined with circumcision ever since.

Figure 1. Map of Africa showing HIV seroprevalence in relation to male circumcision practices

Societies that rely on traditional healers to ritually circumcise boys often do not wish to convert to medical circumcision, which is perceived as an affront to a long-standing tradition. With the expected increase in demand for the procedure, the role of traditional healers in providing safe, voluntary circumcision in the new, HIV-prevention environment may warrant further exploration.

Many ethnic groups also believe the custom is unnatural and some expressly forbid it. These peoples often regard the lack of circumcision as part of their cultural identity. Even here, though, attitudes are changing. Non-circumcising tribes, such as the Sukuma of Tanzania, now seek the procedure because of the purported benefits to health and sexual pleasure. Schoolboys also seem to associate male circumcision with modern hygienic practices, and this has increased its popularity.

The rates of infant-male circumcision in Africa are also on the rise. This may be significant if it turns out that males need to be circumcised before their 'sexual debut' to be protected against the acquisition of HIV. One study found a protective effect when boys were circumcised before the age of 20, but no significant effect after that age.⁸ Another study found no significant difference in HIV prevalence in those circumcised before and after their sexual debut.⁹ The relative ease of circumcision in neonates makes this an interesting question. Although the circumcision of neonates would delay its impact on public health, it may lower overall costs. Further research needs to assess the effects of age on the protection offered by male circumcision.

The next steps

According to the World Health Organization (WHO), there are signs that the demand for safe and affordable circumcision services is growing fast, especially in some of the southern African countries. This comes with its own set of challenges, not the least of which is a shortage of adequately trained surgeons -- precisely in those countries where the intervention holds the most promise. The integration of male circumcision into existing services will require tailored strategies that vary by geographic region, socio-cultural influences, and the existing healthcare infrastructure. Qualified physicians, such as surgeons, and access to sterile instruments should be a basic requirement of these services.

There is also the related question of how to engage traditional circumcisionists who, though not formally trained, play a large role in the procedure in some contexts. This cultural element raises policy-level questions about accreditation, quality control, and supervision. The tension between formal and traditional services, particularly in those societies that value traditional healers, must be addressed openly and with mutual respect. It would be helpful to include traditional healers and circumcisionists in national task forces to ensure that cultural issues and questions of quality healthcare are addressed.

It may also be prudent to offer male circumcision as one part of a package of reproductive health services for men. People need to understand that male circumcision does not confer full protection. It should be used alongside other protective measures, such as the reduction of risky behaviors and the use of condoms. Comprehensive services will maximise the educational potential of the intervention, but it will also challenge logistical systems. Providing safe circumcision services alongside antibiotics and contraceptives will be difficult at the periphery of the healthcare system.

Can male circumcision be accepted by cultures that do not engage in the practice? If so, policymakers need to consider the costs of introducing the practice and the particular needs that may be unique for each group. Anthropologists may also come to play a larger role in such assessments. This may be an enormous undertaking -- a marketing approach to promote male circumcision may increase both the demand and the acceptance of the practice.

Although male circumcision presents challenges due to its cultural significance, the potential benefits for the individual and the population are too great to ignore. With careful planning, interventions that increase the practice of male circumcision may dramatically decrease the impact of HIV/AIDS in sub-Saharan Africa.

References

1. NIH press release: Adult male circumcision significantly reduces risk of acquiring HIV. Trials in Kenya and Uganda stopped early.
2. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Medicine 2:e298.
3. Bailey RC, et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. The Lancet 369:643-656.
4. Gray RH, et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet 369:657-666.
5. Bongaarts J, Reining P, Way P, Conant F. 1989. The relationship between male circumcision and HIV infection in African populations. AIDS 3:373-377.
6. Moses, S, Bradley JE, Nagelkerke NJ, Ronald AR, Ndinya-Achola JO, Plummer FA. 1990. Geographical patterns of male circumcision practices in Africa: association with HIV seroprevalence. Int J Epidemiol 19:693-697.
7. Williams BG, et al. 2006. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Medicine 3:e262.
8. Kelly R, et al. 1999. Age of male circumcision and risk of prevalent HIV infection in rural Uganda. AIDS 13:399-405.
9. Caldwell JC and Caldwell P. 1994. The neglect of an epidemiological explanation for the distribution of HIV/AIDS in sub-Saharan Africa: Exploring the male circumcision hypothesis. Health Transit Rev (supplement) 4:23-46.

This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk).