Short text about male circumcision and its relation with HIV.

1. Male circumcision should be promoted in developing countries as a major means of HIV
prevention.
Felipe Mejía @FelipeMejiaMV mejia.medina.felipe@gmail.com
Master of Science in International Health. Heidelberg University.
Reproductive Health and HIV/AIDS
Introduction
According to UNAIDS for its AIDS epidemic 2009 report, the total number of people living with HIV
in 2008 was 33.4 million, among them 15.7 million of are women and 2.1 million children under 15
years old. The same data reported 2.7 million new infections due to HIV in 2008 and 2.0 million deaths
due to AIDS. Sub-Saharan Africa has the largest amount of people living with HIV accounting for 22.4
million with an adult prevalence of 5.2%. Of over 7400 new HIV infections a day in 2008, 97% are in
low- and middle-income countries, 6200 are in adults (15-49 years old), 48% women. Comparing to
2001, there has been a reduction in the total new cases by 0.5 million.i Even considering that the new
cases have decreased over the years between 2001 and 2008, HIV/AIDS remains as an important cause
of mortality and morbidity in the world especially in the poorest regions. Due to its continue spread,
developing new methods or extending existing ones which can protect large populationa against new
infections are still urgent.
Male circumcision has been analyzed for the past years as a possible procedure to protect men on HIV
infection. Indeed, three studies made in South Africaii, Kenyaiii and Ugandaiv have shown that it
reduces the probability of getting infected by 50% making it as a possible tool for a national policy in
developing countries. However, male circumcision programs depend on different factors which must be
under analysis according to particular cases.
Efforts similar to the mentioned above has been carried out previously for antiretroviral treatments,
showing that the integration with national policies, the civil society, all non-governmental
organizations and other different stakeholders as well as qualified health facilities and medical products
supply are required to achieve success. It is also important to stress that in non-endemic regions, male
circumcision programs may not be significantly. However, for endemic places as it is in Sub Saharan
Africa, the possible results may be greater. It was estimated for 2007 that in rural KwaZulu-Natal,
South Africa, male circumcision would prevent an estimated 35 000 new HIV infections in the 2·5
million men with the previous knowledge that most of them were circumcised.v
People’s acceptability:
In most of the countries in Sub Saharan Africa, male circumcision is common practice. Some studiesvi
have shown that 61% of men are willing to be circumcised and 81% of couples are willing to
circumcise their male children. However, for regions where this is an uncommon practice, this
intervention has more challenges and ethical in regarding to social, cultural and religious issues must be
addressed carefully.
Male circumcision Prevalence
The prevalence of male circumcision does not necessarily depend on the presence of religious activities
or a specific cultural basis as it is in some countries in Africa. Indeed, it does not depend also on
differences between developed and not developed countries. In USA more than 80% of new born were
circumcised in late 1970, 48% Canada and 24% UK. Yet USA has one of the highest prevalence of

2. male circumcision as a routine procedure with 84 to 89% in the 80’s. vii In developing countries where
male circumcision is a common practice for social or non social reasons, it is important to establish
what the prevalence is in order to set a base line for a future intervention.
Information, Communication, Education (IEC):
How to disseminate the information among the targeted people and integrate it to the other preventive
programs? Considering that the protective effect has been estimated as 50% as mentioned above, the
messages which want to get attention for the future circumcised men must make clear that male
circumcision is not always effective. So, it implies that the education among the population of interest
must be aware of other preventions tools and behaviors such as condoms, non promiscuous behaviors,
etc. WHO and UNAIDS must focus on the messages that recent circumcised men should restart sexual
activity only after six weeks.viii Should the information only go straight to men or should involve also
their partners? Should women be aware about male circumcision effectiveness?
Moral Hazard
In this concern, it is possible to question: will the knowledge of being circumcised reduce the
willingness to use condom? Will it increase the probability of risky behaviors? In the trial carried out in
Ugandaix there is no evidence which suggest such moral hazard. Although, male circumcision
counseling must consider this possible effect in any case.
Religious and cultural issues:
In places where communities practice male circumcision among their believes and who are reluctant to
HIV/SIDA campaigns, male circumcision may be a possible bridge of dialogue to persuade them and to
integrate them into safer practices and achieve cultural and community acceptance.
When to circumcise? Whom?
Some trials show that the effectiveness of male circumcision decreases with agex, others have shown
that male circumcision in new born or neonatal is safer and has less cost comparing to adolescent and
adultsxi. So, for male circumcision program seems to be better to do it at this age in places where this
procedure is not common especially considering that there are less risks associated to circumcisions
made in health facilities than in non clinical settings xii. Looking at this point, this kind of intervention
seems to be similar to vaccination where the risk group is not already exposed. It is also important to
investigate whether the male circumcisions made by trained health professionals and people from the
communities have the same effectiveness.
Male circumcision’s risks:
As it was mentioned, possible complications in male circumcision procedures can come out depending
on: age of the patient, training of the personnel who perform it , instruments used and quality assurance
of the procedures such as sterility among others. In the trial made in South Africa, 3.8% of the men
circumcised by trained personnel developed complications afterwards.xiii Male circumcision which
takes place in traditional areas where it is a common practice due to social or religious factors, as in
Africa, are related to high incidence of complications.xiv This is similar to the complications reported
for developed countries where male circumcision is common.xv

3. Integration with other programs/procedures/products:
There is no doubt that in case a male circumcision program is implemented; it must be parallel with
other prevention activities such as condom promotion and delivery, awareness campaigns, counseling
family planning, HIV tests, etc.
Vertical vs Horizontal approach:
Should an intervention like this require a vertical approach as it has been done for HIV/AIDS program
interventions? Or is it possible to integrate it into the neonatal care routine activities? These questions
should be formulated along with the next consideration:
“Although achieving high rates of circumcision might be beneficial, it should not be at the cost of other
disease prevention strategies—eg, antenatal care, malaria control, or nutrition. Since an internationally
agreed-upon public health goal is for all women to give birth in health facilities, offering male
circumcision to babies in clinics would at least not divert national resources from current efforts to
build systems, and might be a strategy that has multiple benefits” xvi
It also has to be studied how many surgeries are needed to prevent one new case of HIV positive which
depends on contextual factors as well as epidemiological. How cost effective for specific settings
would have an intervention such as this one?
Conclusion
Even considering the probable beneficial effects of male circumcision to prevent new cases of HIV,
public health authorities must consider the social cultural context of the place under interest, the
resources available, the trained available personnel, the male willingness, the possible clinical
complications and the respective awareness among the population, political and social implications.
The question ultimately is: “Is anything acceptable if it leads to a successful result?”
i
Unaids. (2009). AIDS epidemic update December 2009. Available:
http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp . Last accessed 25 Feb
2010.
ii
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of
male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298.
iii
Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a
randomised controlled trial. Lancet 2007; 369: 643–56.
iv
Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised
trial. Lancet 2007; 369: 657–66.
v
Welz T, Hosegood V, Jaffar S, Batzing-Feigenbaum J, Herbst K, Newell ML. Continued very high prevalence of HIV
infection in rural KwaZulu-Natal, South Africa: a population-based longitudinal study. AIDS 2007 Jul 11;21(11):1467-72.
vi
Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a
review. AIDS Behavior 2007;11(3):341-355.
vii
Bonner K. Male circumcision as an HIV control strategy: Not a “Natural Condom”. Reproductive Health Matters, 2001 ;
9, 18, pp. 143-155.
viii
WHO/UNAIDS Male Circumcision for HIV Prevention: Research Implications for Policy and Programming
WHO/UNAIDS Technical Consultation 6–8 March 2007 Conclusions and Recommendations (Excerpts). Reproductive
Health Matters 2007;15(29): pp. 11–14
ix
Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised
trial. Lancet 2007; 369: 657–66.

4. x
Bonner K. Male circumcision as an HIV control strategy: Not a “Natural Condom”. Reproductive Health Matters, 2001 ;
9, 18, pp. 143-155.
xi
Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol
2006; 175:1111–15.
xii
Bonner K. Male circumcision as an HIV control strategy: Not a “Natural Condom”. Reproductive Health Matters, 2001 ;
9, 18, pp. 143-155.
xiii
Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of
male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298.
xiv
Sharif R Sawires, Shari L Dworkin, Agnès Fiamma, Dean Peacock, Greg Szekeres, Thomas J Coates Male circumcision
and HIV/AIDS: challenges and opportunities The Lancet, Volume 369, Issue 9562, 24 February 2007-2 March 2007, Pages
708-713
xv
Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a
randomised controlled trial. Lancet 2007; 369: 643–56.
xvi
Sharif R Sawires, Shari L Dworkin, Agnès Fiamma, Dean Peacock, Greg Szekeres, Thomas J Coates Male circumcision
and HIV/AIDS: challenges and opportunities The Lancet, Volume 369, Issue 9562, 24 February 2007-2 March 2007, Pages
708-713