|South African Medical Journal attacks WHO circumcision push|
Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate “roll-out” of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the WHO, under pressure from American money, has sought to enforce mass circumcision on African men.
Male circumcision and HIV infectionSouth African Medical Journal, Vol. 98, No. 10, October 2008
1. South Africa: No difference in HIV incidence between cut and uncut menObjective. To investigate the nature of male circumcision and its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3,025 men aged 15 years and older who participated in the first national population based survey on HIV/AIDS in 2002. Chi-square tests and Wilcoxon rank sum tests were used to identify factors associated with circumcision and HIV status, followed by a logistic regression model.
Results. One-third of the men (35.3%) were circumcised. The factors strongly associated with circumcision were age >50, black living in rural areas and speaking SePedi (71.2%) or IsiXhosa (64.3%). The median age was significantly older for blacks (18 years) compared with other racial groups (3.5 years), p <0.001. Among blacks, circumcisions were mainly conducted outside hospital settings. In 40.5% of subjects, circumcision took place after sexual debut; two-thirds of the men circumcised after their 17th birthday were already sexually active. HIV and circumcision were not associated (12.3% HIV positive in the circumcised group v. 12% HIV positive in the uncircumcised group). HIV was, however, significantly lower in men circumcised before 12 years of age (6.8%) than in those circumcised after 12 years of age (13.5%, p=0.02). When restricted to sexually active men, the difference that remained did not reach statistical significance (8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for possible confounding.
Conclusion. Circumcision had no protective effect in the prevention of HIV transmission. This is a concern, and has implications for the possible adoption of the mass male circumcision strategy both as a public health policy and an HIV prevention strategy.
Full article here. PDF available on request.
Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo, Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002
S Afr Med J 2008; 98: 789-794
2. Neonatal circumcision does not reduce HIV/AIDS infection ratesA second article by Sidler et al argues that there are profound objections on grounds of effectiveness, cost and ethics to the use of circumcision as a a tactic against AIDS. The article opens as follows:
Non-therapeutic, non-religious circumcision is the surgical procedure most commonly published about, but for which substantive indications are lacking. Since its introduction to the USA during the Victorian period, when it was thought that it prevented masturbation, medical justifications for the procedure progressed to prevention of various infective conditions (sexually transmitted diseases, penile and cervical cancer) and controlling of the sexual drive. Recent Joint United Nations Programme on HIV/AIDS/World Health Organization (UNAIDS/WHO) policy proposes male circumcision for the prevention of HIV/AIDS.
HIV/AIDS in Africa is mainly spread by multiple concurrent heterosexual relationships, compounded by female subjugation and poverty. Condoms, although highly protective, are infrequently used, particularly among circumcised males.
The HIV/AIDS crisis demands extraordinary curtailment measures. It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. Repeated publications of matching opinions do not necessarily lead to solid scientific evidence and policies.
They rather suggest that the peer review process of journal publication may be unreliable. Information overload can cause limitations, for example influencing expert and public opinion with ideological and pseudoscientific content. This context and such therapeutic misconceptions contribute to circumcision still being practised as a non-therapeutic infant procedure. This mainly applies to English-speaking countries, where circumcision appears to have become a medicalised ritual. In contrast, in Europe non-therapeutic circumcision is not the norm.
Many reviews question the necessity of non-therapeutic infant circumcision, showing it to have neither short- nor long-term medical benefits. It has been suggested that parents should be granted responsibility and final decision making authority after having thoroughly considered all the relevant facts. The reported increase in demand for preventive circumcision, long before publication of results of the three randomised controlled trials (RCTs) in South Africa, Kenya and Uganda that have shown that circumcision is partially protective against HIV, suggests that informed proxy consent, within the context of the HIV/AIDS epidemic and the prevalence of poverty and ignorance, has to be seriously questioned. The desperate hope and need for action of people ravaged by HIV/AIDS, rather than solid scientific evidence, may be driving the increased demand for preventive circumcision.
A recent Centers for Disease Control (CDC) and WHO report confirms previous reports that circumcision does not prevent sexually transmitted diseases (STDs). Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.
Rest of article here with references. PDF available on request
Male non-therapeutic infant circumcision is neither medically nor ethically justified as an HIV prevention tool. Circumcision is not equivalent to successful immunisation, is being practised with decreasing frequency in English-speaking countries, and is becoming illegal in South Africa under the new Children’s Act. There are far more effective prevention tools costing considerably less and offering better HIV reduction outcomes than circumcision.
Finally, the WHO and UNAIDS appear to be basing these multi-million-dollar prevention programmes on limited and in some instances biased information. In order to prevent confusion and parents making misguided decisions on behalf of their infants, and to offer effective help in alleviating the suffering that is being created by HIV/AIDS, a much broader review process would be called for. Such a process would involve more objective scientific opinion, and the involvement of a representative panel of African experts, such as paediatric surgeons and neonatologists.
D Sidler, J Smith, H Rode, Neonatal circumcision does not reduce HIV/AIDS infection rates
South African Medical Journal, Vol. 98, No. 10, October 2008, 764-766
3. Editorial: Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicableTwo articles [1, 2] published in this issue address male circumcision (MC). Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence.
Sidler et al.  state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference  in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners). 
The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006-2007 show a protective effect of MC. However, Garenne  has subsequently shown from observational data that there is considerable heterogeneity [inconsistency] of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994-2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.
These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.
Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal.
If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions  and disadvantage women.
Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006-2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries. Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention.
A Myers Humanities student, University of Cape Town
J Myers School of Public Health and Family Medicine University of Cape Town
Corresponding author: J Myers (firstname.lastname@example.org)
1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.
2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766.
3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008).
4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008).
5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.
6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8.
7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008).
8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008). October 2008, Vol. 98, No. 10 SAMJ
Lawrence Green et al, Male circumcision is not the HIV vaccine we have been waiting for, Future HIV Therapy, Vol. 2, 2008
Robert Van Howe and J. Steven Svoboda, Neonatal circumcision is neither medically necessary nor ethically permissible: A reply to Clark et al, Medical Science Monitor, Vol. 14, 2008