Saturday, July 24, 2010

Male circumcision, a proven HIV prevention strategy, overshadowed by another one years from fruition

VIENNA, Austria – Much of the buzz at the XVIII International AIDS Conference that just finished here was around the encouraging news of a microbicidal gel that trials have shown to be almost 40% effective, although we are still years away from having a product on the market. Meanwhile, male circumcision (MC), a proven and effective HIV strategy that reduces transmission by nearly 60% and is already available, got much less attention, though it finally got some, and for that we can be grateful.

Two years ago in Mexico City, nary a word was said about male circumcision — and certainly not in a plenary meeting — despite its proven effectiveness. I organized a press conference on male circumcision for PSI, which was successful in generating some media buzz and attention, including The Economist, which called it the one bright spot in prevention at the conference. In fact, I think that press conference resulted in an improved environment for MC. However, donors and governments, for the most part, continued to do nothing to scale up an intervention that could have saved millions of lives with one notable exception.

In December 2008, the Gates Foundation became the first donor to scale up MC, quietly providing funding for PSI to expand its male circumcision pilot project in Zambia to two other countries (a third country was added later). There was no fanfare, no announcement, as everyone was concerned about provoking a negative reaction for an intervention that addressed long-standing cultural practices.

However, there was no significant negative reaction and now the environment seems to have changed. MC seems to be going mainstream. Both Bill Clinton and Bill Gates mentioned MC in their speeches in Vienna. In particular, Bill Gates could hardly stop talking about the wonders of MC, calling it and prevention of mother-to-child transmission two of the interventions that “are so effective that in endemic countries it is more expensive not to pursue them.” While more than 41 million men in sub-Saharan Africa could benefit from the procedure, he said, just 150,000 have been circumcised in the past few years.

“I have to admit: When it comes to circumcision, I used to be one of the sceptics,” he said in his speech. “I thought: ‘Sure, it reduces transmission by nearly 60%. But there’s no way that large numbers of men will sign up for it. I’m glad to say I was wrong. Wherever there are clinics available, men are volunteering to be circumcised in far greater numbers than I ever expected.”

The Council attempted to monitor the major media coverage of this conference, and our unscientific analysis showed male circumcision to be the second most covered story on the first two days of the conference (after the microbicidal study, of course), with stories in Agence France Presse, Bloomberg News, Los Angeles Times, The Guardian, die Presse, Frankfurter Rundschau, Le Point, Le Figaro, Prensa Latina, Radio Canada, Radio France Internationale and Reuters, among others.

It wasn’t quite that high profile at the conference itself but it was certainly more evident than in Mexico City, with a number of oral and poster presentations on different aspects of MC. This has not come a day too soon. For every man we reach with male circumcision services that he already wants, the fewer new HIV infections will be produced in the future. It is an intervention whose time seems to have come.


  1. As someone who lived the first 49 years of his life with a foreskin before having myself circumcised a few weeks before my 50th birthday and having now lived for 7 years as a circumcised man I fail to see what all the fuss is all about.

    Male circumcision should be adopted as standard practice in all countries, you don't have to be a genius too see the advantages circumcision offers not just from a health standpoint but also sexually.

    My one regret is that I didn't get myself cut year ago.

  2. Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they've been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms".

    The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

    ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

  3. "Male circumcision should be adopted as standard practice in all countries, you don't have to be a genius too see the advantages circumcision offers not just from a health standpoint but also sexually."

    You might want to check out the following:

    Canadian Paediatric Society
    "Recommendation: Circumcision of newborns should not be routinely performed."
    "Circumcision is a 'non-therapeutic' procedure, which means it is not medically necessary."
    "After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.

    RACP Policy Statement on Circumcision
    "After extensive review of the literature, the Paediatrics & Child Health Division of the Royal Australasian College of Physicians has concluded that there is no medical reason for routine newborn male circumcision."
    (almost all the men responsible for this statement will be circumcised themselves, as the male circumcision rate in Australia in 1950 was about 90%. "Routine" circumcision is now *banned* in public hospitals in Australia in all states except one.)

    British Medical Association: The law and ethics of male circumcision - guidance for doctors
    "to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate."

    The Royal Dutch Medical Association
    "The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications."

  4. "For every man we reach with male circumcision services that he already wants, the fewer new HIV infections will be produced in the future."

    Well, for the 5,400 men the three trials reached with the male circumcision that they wanted (since they were paid volunteers for it), 73 men didn't get HIV in two years who might have (assuming the trials really demonstrated what everybody involved was hoping they would, and their expectations had no effect on the non double-blinded, non placebo-controlled trials).

    That works out at about one fiftieth of a man fewer getting HIV for every man circumcised - in areas where HIV is rampant. Is that really bang for the buck?

  5. What's more of a concern is that no-one really knows what the effect is on male-to-female transmission, or on condom use. The one RCT I mentioned earlier showed a 54% higher risk based on a very small sample. A 1993 study found that "partner circumcision" was "strongly associated with HIV-1 infection [in women] even when simultaneously controlling for other covariates."

    We don't know if the increased risk is 0%, 54% or 108%. Since about 19.5% of the intact men in Swaziland will already be HIV+ *, this is a very risky strategy, and there is a real chance that the overall rate of HIV infections will go up.

    (* 21.8% of circumcised men in Swaziland are HIV+ btw)

    I think it's unrealistic to expect that men who have been circumcised and told it lowers their risk of being infected with HIV, are then going to use condoms just as often. If condom use drops by even a small amount, then there will almost certainly be a rise in new infections, amongst both men and women.