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Making progress on prevention: TAC Policy Brief on Voluntary Male Medical Circumcision

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A goal of the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 (NSP) is to reduce new infections by half over the five-year period of the plan. Is it difficult to measure progress towards this goal because of a lack of reliable data on HIV incidence. Nevertheless, policy improvements around voluntary male medical circumcision and prevention of mother-to-child transmission (PMTCT) will significantly reduce new infections.

This is the first part of a two-part TAC policy brief. This part deals with voluntary male medical circumcision and the next one, which will be released in early 2010, deals with PMTCT.

Part One: Voluntary Male Medical Circumcision (VMMC)


It is two and a half years since TAC published its briefing on VMMC. [1] Since then, in Southern Africa, over 3,000 VMMCs have been carried out by the Family Life Association of Swaziland. Zambia has performed nearly 8,000 and Zimbabwe just under 1,300. Yet comparatively little progress has been made making this affordable intervention (about R300 per VMMC) available beyond Orange Farm in South Africa, where several thousand circumcisions have been performed in an ANRS sponsored research project. PEPFAR, the Global Fund and the Gates Foundation have committed to funding VMMC, but South Africa has not made use of this opportunity. [2]

The key recommendation of this brief is that the South African National AIDS Council (SANAC) needs to move quickly to adopt a policy that promotes the scaling up of VMMC and that the Department of Health must ensure this policy is implemented. It is at over four years since the results of the first circumcision trial were published; South Africa should have scaled up beyond Orange Farm by now.

Evidence for the benefts of VMMC
The evidence that circumcised heterosexual males have less risk of contracting HIV is compelling. Three randomised controlled clinical trials conducted in high-prevalence areas in sub-Saharan Africa, whose resuts have been published in reputable medical journals, have found that the risk of HIV-negative males contracting HIV is reduced by 50 to 60% when they are circumcised. [3], [4], [5] Evidence from two of these trial settings, Orange Farm and Rakai, Uganda, shows that VMMC also reduces the risk of men contracting Human Pappiloma Virus (HPV). [6], [7] A trial in Rakai also found that VMCC reduces the risk of men contracting Herpes Simplex Virus-2 (HSV-2). [7]

The benefits of VMMC for the female partners of circumcised men have also been shown. Women partners of circumcised men are less likely to contract trichomoniasis and bacterial vaginosis. VMMC also reduces the risk of symptomatic ulceration in HIV-negative men and women and HIV-positive men. [7], [8]

A UNAIDS/WHO/SACEMA expert review of mathematical models of VMMC found:

* There would be large benefits of male circumcision among heterosexual men in low male circumcision, high HIV prevalence settings. The review found that one HIV infection would be averted for every five to 15 male circumcisions performed
* They found that the cost of averting one HIV infection ranges from R1,125 (US$150) to R6,750 (US$900) using a 10 year time horizon.
* Critically they found that women benefit indirectly from reduced HIV prevalence in circumcised male partners and that VMMC service scale-up "acts synergistically with other strategies to reduce HIV disease burden." [9]

A review of the risks and benefits of circumcision for women, published in The Lancet in July, states:

Although circumcision of HIV-infected men does not seem to directly reduce HIV risk for their female partners in the short term, women will benefit from male circumcision programmes. Wide-scale roll-out of male circumcision is expected to lead to decreasing HIV prevalence in communities over 10—20 years, in both men and women, by averting new infections in men and onward transmission to their partners.8 On a shorter timescale, a woman's HIV risk would be substantially reduced if circumcision prevents her male partner from acquiring HIV. Indeed, anecdotal reports suggest that interest in circumcision in young men in the first roll-out programmes in Africa is in part being driven by women's preference for circumcised partners. Finally, women with circumcised partners, irrespective of HIV serostatus, face decreased risk of sexually transmitted infections such as Trichomonas vaginalis, bacterial vaginosis, herpes simplex virus type 2, and human papillomavirus. [10]

Circumstances where VMMC has no proven benefits for HIV
There are circumstances where VMMC appears to have no proven benefits for HIV:

* Circumcised HIV-positive men do not have a lower risk of passing HIV to their female partners. A trial testing this was ended early by its Data Safety Monitoring Board because of futility. (NB: The 2007 TAC briefing indicated that there was some evidence this was benefit of circumcision. This was based on the best evidence at the time, but is now not supported by the evidence.) [11]
* There is no compelling evidence that VMMC reduces the risk of transmission in homosexual sex.

Evidence for the safety of VMMC
No surgical procedure is risk-free, but the evidence for the safety of VMMC is considerable:

* Over 50,000 VMMCs have been performed in sub-Saharan Africa as part of trials and projects to reduce the risk of transmission from HIV. There are no reported cases of serious permanent adverse events.
* The balance of evidence indicates that VMMC does not cause sexual dissatisfaction or dysfunction. [12]

No evidence for risk compensation
An argument offered against VMMC is that it will result in risk compensation behaviour, i.e. that men would take sexual risks in the belief that they are protected from HIV transmission. Furthermore, that this risk-taking would have negative effects on women's rights.

No evidence has been offered for this view. It is often simply asserted. But a study of risk compensation behaviour in one of the three trials found that it did not occur. [13] In a real world setting in Kenya, i.e. outside of a trial, no evidence was found of risk compensation behaviour. [14]

It is important that counselling at VMMC sites and public messaging on VMMC emphasises that VMMC is not completely protective against HIV transmission and using condoms for sex remains necessary to reduce the risk of contracting HIV.

Other arguments against circumcision are dealt with by Halperin et al. (2008). [15]

Promoting VMMC is consistent with human rights

VMMC is consistent with a human rights approach to health-care. It should always be implemented in accordance with these principles:

* It must be voluntary or, in the case of infants, must be done with parental or guardian consent.
* It must be accompanied by proper counselling on the need for practising safer sex, the offer of HIV testing and referral to treatment facilities for people who are HIV-positive.
* It must not undermine women's health.

There are several projects in Sub-Saharan Africa that already meet these criteria, including the Orange Farm project in South Africa. They should be used as models for scaling up VMMC.

The slow progress in rolling out VMMC means we are losing an important opportunity. The delay in making this essential health intervention available is inconsistent with human rights, for both men and women, as well as sound public health care.

[1] TAC. 2007. Male circumcision and HIV prevention : A TAC Briefing.
[2] Swaziland data was obtained via personal communication with the programme co-ordinator of the Family Life Association, Dr Ladislous Chonzi. The data for Zambia and Zimbabwe was obtained via personal communication with Scott Billy of the Society for Family Health. Also personal communication with Emmanuel Njeuhmeli of PEPFAR.
[3] Auvert et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25.
[4] Bailey et al. 2007. Lancet. Feb 24;369(9562):643-56. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial.
[5] Gray et al. 2007. Lancet. Feb 24;369(9562):657-66. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.
[6] Auvert et al. 2009. J Infect Dis. 2009 Jan 1;199(1):14-9. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa.
[7] (1, 2, 3) Aaron et al. 2009. NEJM. Volume 360:1298-1309. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis.
[8] Gray et al. 2009. Am J Obstet Gynecol. 2009 Jan;200(1):42.e1-7. The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda.
[9] UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. 2009. Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision Making? PLoS Med 6(9): e1000109. doi:10.1371/journal.pmed.1000109
[10] Baeten et al. 2009. The Lancet, Volume 374, Issue 9685, Pages 182 - 184, 18. Male circumcision and HIV risks and benefits for women.
[11] Wawer et al. 2009. Lancet. 2009 Jul 18;374(9685):229-37. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial.
[12] Doyle et al. The Impact of Male Circumcision on HIV Transmission. J Urol. 2009 Nov 12.
[13] Mattson et al. 2009. PLoS ONE. 2008; 3(6): e2443. Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial.
[14] Agot et al. 2007. J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):66-70. Male circumcision in Siaya and Bondo Districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision.
[15] Halperin et al. 2008. Future HIV Therapy September 2008, Vol. 2, No. 5, Pages 399-405. Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics.

Thanks to Dirk Taljaard and Bertran Auvert for feedback.


Not a magic bullet, a Magic Nail

TAC is to be hailed for its heroic work against pseudo-science and for evidence-based medicine, and for turning the SA government towards effective HIV/AIDS treatment and prevention. Unfortunately circumcision does not fall into the latter category. 

A 2003 Cochrane review found there was not sufficient evidence to support circumcision; a 2009 review found there was.  What made the difference was three randomised controlled trials. They were not, however, double-blinded (of course) or placebo controlled, and were all cut short as soon as they reached significance. The dropout rates were several times higher than the known infection rates in both experimental and control arms of the trials, and the men were encouraged to be tested for HIV elsewhere, which could affect dropping out in a way that skewed the result (finding you had HIV after a painful and marking operation to prevent it would be a powerful disincentive not to continue with the trial). Any biases in the trials would have been powerfully influenced by the wish of both experimenters and participants for a positive outcome. There is some suggestion that the experimental arm were more intensively counselled to practise safe sex than the control arm, and the experimental arm were instructed to abstain from sex for six weeks after their operations, or use condoms - a message that would be reinforced by the operation itself. (They would hardly be encouraged to stop using condoms after six weeks!) Non-sexual transmission was ignored. The HIV status of partners was unknown. Different methods were used in the three trials, removing different amounts of skin, yet the "protective effect" was the same.

These trials were widely publicised as "proving that circumcision reduces HIV infection by 60%" when in fact all that happened was that less than two years after circumcising a total of 5,400 men, 64 of them had HIV, compared to 132 of the control groups. The whole weight of the trials - and the wild extrapolation to "millions will be saved" rests on 73 men out of 5,400 who hadn't contracted HIV - yet.

A study in Uganda found 18% of the partners of circumcised HIV+ men contracted HIV while only 12% of the partners of the control group did, but it was halted "for futility" (there was no ethical need to halt it) before it reached statistical significance, so it is entirely possible that circumcising men increases the risk to women - who are already at greater risk. Researchers were quick to blame the victims for resuming sex too early, but the keratinised mucosa of the circumcised glans (abrading that of the partner), and the loss of some thousands of nerve endings (promoting more vigorous sex), suggests another, more direct mechanism.

In at least six African countries, more of the circumcised men have HIV than the non-circumcised, according to the National Health and Demographic Surveys. This remains unexplained. Shouldn't some effort be made to explain it before undertaking mass circumcision campaigns?

"A well implemented male circumcision program will incorporate HIV testing and education, condom skills negotation and training, provision of condoms, family planning and screening for STIs." And under such a programme, we can certainly expect that the HIV infection rate will go down, but it will be the Nail Soup method of HIV prevention. (A traveller came to a farmhouse and offered to make the occupants Nail Soup in return for a night's shelter. He threw a large nail in a pot of boiling water and said - “A well-implemented Nail Soup recipe will incorporate herbs, spices, vegetables and meat." In the morning he went on his way, refreshed after a night in a comfortable bed, minus the Nail, with some gold coins in his pocket and the thanks of the family ringing in his ears for the wonderful Magic Nail that made such delicious Nail Soup.)

"The men in line who you claim to have heard must not normally wear condoms." It is at least plausible that men who think circumcision protects them from AIDS will give up using condoms after they are circumcised. The studies that claim to show they will not, were held on the same paid volunteers for circumcision as the ones that claim to show protection from HIV, and "no adverse effect of male circumcision in sexual function, satisfaction, sensation, sensitivity" and conducted by the same small group of researchers, who all had a vested interest in outcomes favourable to circumcision.

Voluntary adult male circumcision is one issue. Men have the right to choose to have parts cut off their own bodies. Non-therapeutic infant circumcision is quite another. Men can only exercise that right if it is has not been pre-empted by others. Increasingly, voices are being raised that non-therapeutic circumcision of minors is a human rights abuse, and it is already restricted under South African law.

Foolhardy to procede

As the article notes, HIV incidence has not been reliably measured.  Until it is, proceding with a risky mass-circumcision campaign would be fool-hardy. 

It is not at all clear that circumcision is actually responsible for reduced HIV transmission.  In fact it was announced in August that the men circumcised in these grand African HIV experiments were 50% MORE likely to transmit HIV to a female partner.  And anywhere men are lining up for circumcision many can be heard to remark they are doing it so they won't need a condom.  Yet most of the US men who have died of AIDS were circumcised at birth.  Non-circumcising cultures like Sweden and Japan have HIV rates as low as 95%-cut Israel's.  Clearly circumcision is neither neccessary nor sufficient to thwart AIDS. 

Promote condom acceptance. 

Prudent to proceed

The campaign is sound. It is unrelated to condom usage. Research trumps what you claim to hear in line. The men in line who you claim to have heard must not normally wear condoms so it is good they are lining up. Circumcision works in conjunction with condoms to save lives.

It offers a high level of protection and it has no impact on condom usage. The issue has been studied  in a study and it was found that it did not occur. The issue was also looked at in Kenya and there was no evidence that condom usage declined as a result.

HIV in the US is usually spread through intravenous drug usage or homosexual sex and circumcision provides no or less protection respectively. In Africa however it is often passed on with heterosexual sex so it would be foolhardy not to proceed.

Circumcision has additional benefits. A study of African women's sexual satisfaction before and after their husband was circumcised found that they preferred the cut version. Circumcision also reduces the risk of a number of illnesses apart from AIDS.

Circumcision is the only PROVEN intervention for HIV reduction

 The comments above demonstrate a lack of knowledge of the medical literature and are extremely naive, if not mischievous. The evidence in favor of male circumcision for HIV prevention is massive. It is supported by the WHO, UNAIDS, the Cochrane committee, the World Bank, NIH and the CDC, who would not provide such support if the evidence was now not overwhelming. Most HIV infections in men the USA are from insertive anal intercourse, which circumcision at birth or any other time will not prevent. Yet studies in the USA show circumcised men have lower HIV infection whether they are heterosexual or insertive-only homosexuals. Comparing rates in different countries fails to take into account an enormous number of other epidemiological factors and is pseudo-science.

Circumcision prevents urinary tract infections in infancy by 10 fold and over the lifetime UTIs affect 1 in 3 uncircumcised men but only 1 in 20 who are circumcised. Circumcision prevents phimosis, paraphimosis, inflammatory dermatoses, poor hygiene, other STIs (syphilis, chancroid, trichomonas, high-risk [cancer-causing] types of human papillomavirus, genital herpes, etc) in men and their sexual partners. Penile cancer (seen in 1 in 500 uncircumcised men) is virtually absent in men who are circumcised, especially when circumcised at birth. Women with uncircumcised male partners are at 5 times higher risk of cervical cancer and chlamydia infection, the latter being a cause of infertility, pelvic inflammatory disease, pelvic pain and ectopic pregnancy.

There is no adverse effect of male circumcision in sexual function, satisfaction, sensation, sensitivity, as confirmed by large randomized controlled trials. The female partners in these studies were strongly in favor of the outcome. The science thus refutes the propaganda of the anti-circumcision movement.

For more information and a free brochure please visit

Professor Brian Morris, School of Medical Sciences, The University of Sydney

Access to safe male circumcision is a human right

Basic human rights include access to safe medical care and procedures that offer significant and substantial personal benefit. Male circumcision has been unequivocally demonstrated to reduce the risk of HIV infection by between 50% and 60%.  Male circumcision has the potential to alter dramatically the trajectory of the HIV epidemic here in South Africa.

Human rights advocates should call on the local governments to provide safe and low or no cost circumcision immediately.  The denial of such a procedure is human rights abuse.  Parents have the right to be educated about the well known benefits of newborn male circumcision including lifetime lower risk of HIV infection, genital herpes infection, genital ulcer disease, urinary tract infection, kidney disease, penile warts, penile cancer and cervical cancer in female partners.

A well implemented male circumcision program will incorporate HIV testing and education, condom skills negotation and training, provision of condoms, family planning and screening for STIs.  South Africa has a great opportunity to engage men in sexual and reproductive health.  Let's not squander that chance.