Male Circumcision and HIV Prevention

As HIV continues to spread, the search for new and effective methods of prevention continues. Male circumcision is one of the proposed strategies, and shows potential in countries where circumcision rates are low and HIV prevalence is high. In a post April 5, Masimba Biriwasha mentioned some of the dangers he sees in establishing policies of male circumcision for HIV prevention. I want to go deeper into the issue.

In the past few years, many studies have indicated a reduced rate of transmission of HIV in men who have been circumcised compared to uncircumcised men of similar characteristics; some studies were even stopped due to ethical reasons because of the lower transmission rate identified in the groups of circumcised men. The results of these trials show an important reduction in HIV transmission (approximately 50%), not only within observational studies, but also in a randomized trial conducted in South Africa.

Although there continues to be doubts regarding how circumcision prevents HIV from being transmitted, some experimental evidence suggests understandable biological mechanisms for the lower transmission rates. This makes the results of these observations and trials all the more promising.

Statistical modeling for wide programs of circumcision in southern Africa estimate that 2 million infections could be prevented! And a cost-effectiveness analysis suggests that in sub-Saharan Africa this could also save money in the long run.

So … what do we make of all this? Should we start mass circumcision programs in countries with low circumcision rates and high HIV prevalence, such as Namibia, Zimbabwe and Botswana? Are there any other factors that should influence our decision?

The epidemiological benefits of circumcision as a public health policy are becoming quite clear, and the World Health Organization endorses it as an "efficacious intervention for HIV prevention". There are, however, a few issues that still need clarification, such as risk compensation of individuals who are circumcised, and how to deal with this. Risk compensation is the potential increase in risky behavior that individuals have when they feel their vulnerability to a disease reduced. In this case for example, this could mean the decrease in condom use amongst circumcised individuals, or the increase in the number of sexual partners, since the risk of HIV infection is thought to be no longer present or drastically reduced.

The problem is that it will be difficult to create public health campaigns that at the same time induce men to get circumcised and continue using condoms. However, this should not be a sufficient reason to completely halt the development of public health policies, but should point to efforts in developing novel risk reduction interventions and messages that are consistent with this kind of intervention.

The biggest problem however with a public health policy of mass circumcision is not on the epidemiological data, but on the ethical issues that may arise from such a policy. Circumcision is a normal procedure in the United States, where approximately 58% of newborns are circumcised. It is also a common procedure in the Jewish population, since it symbolizes a covenant with god and is mandated by him, and of course also in Muslim populations, where although it is not present in the Koran it is part of the sunnah (the laws based on the life of the Prophet) and is further justified as a hygienic procedure. However, by WHO estimates, the procedure is far from common in the rest of the world (certainly not common in Latin America!), and apart from the possible prevention of HIV and STDs, there is no medical reason for routine circumcision.

Ethical issues arising from such a policy need to be extensively debated before starting a massive intervention. Ideals of bodily integrity should be taken into account when the institution of such a policy is planned. Circumcision may be considered a violation of the human being's wholeness, and the integrity of the body is something that should be respected. The studies that have been conducted to provide the data on the effectiveness of circumcision only involved individuals who were 18 or older, so an informed consent took place and they accepted the procedure. However, it is not hard to imagine a situation like in the United States, where for supposed hygienic reasons circumcision is done to many newborns. Circumcision in the United States has become a cultural procedure, since no medical society endorses routine circumcision.

The situation here in Chile is quite different. The permanent removal of tissue from an individual that does not consent to this is not easily justifiable without falling into religious or cultural arguments There are many men who were circumcised as children that object to this practice, and there are increasingly more organizations raising awareness that circumcision is a violation of a child's human rights (see for example the work of the National Organization of Restoring Men, Doctors Opposing Circumcision and even a petition to the International Court of Justice in The Hague which includes it as torture and mutilation of children).

It is hard to disregard the importance that an intervention that has long term effectiveness and is not dependant on behavioral change could have; the confirmation of a health benefit alters the ethical perspective, since it is no longer a routine procedure with no scientific reasoning behind it. In my opinion, there is enough evidence to move forward regarding male circumcision as a public health policy, although careful monitoring of risk compensation should take place, and an open debate that involves the communities where this will happen should be started. This should not be only a top-down strategy to stop HIV transmission, but the ethical and cultural issues attached to it should also be addressed.

There is much to discuss on how such a policy should be implemented, what age groups will be part of the intervention, and of course, where the funds will come from. This last point is extremely important. Funds for such an intervention should not come from other preventive strategies already in place, or from funds dedicated to researching new strategies. We should not forget that even though male circumcision may save money in the long term, two thirds of the African population is already circumcised, and HIV continues to batter the continent.

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  • invalid-0

    Most of the half-million American men who have died of AIDS were circumcised at birth.

    Circumcision does not prevent AIDS, and has no business as part of health policy.

    It costs the UN just 3 cents apiece to give away condoms.

  • invalid-0

    The infrastructure required to support a massive circumcision program is beyond imagination.

    In my view, this is just one those things that keeps people in their business. SO much will be said, but little will be done.

  • moises-russo

    Thank you for the commentaries. The infrastructire issue mentioned is indeed important. However, the creation of such infrastructure implies the creation of health infrastructure in general. Unlike other HIV prevention strategies, the use of resources to create infrastructure for circumcision programs would not cannibalize resources from the rest of the health care system, and resources for this could be added to the general health budget, increasing fungibility of resources and avoiding parallel health spenditure. A protective intervention that does not depend on behavior can have positive effects, even if done only in areas where the infrastructure is available. I am sorry not to be aware at the moment of any studies as to the infrastructural viability of the strategy, and I would hesitate without evidence either to say it is absolutely possible or to say it is unimaginable.

    With regards to the other comment, well, apart from refering anyone to the articles that prove that circumcision has a preventing effect (all of which you can access using the links in the blog), there is not much more to say. The prevention is estimated in a 60% so this is by no means a strategy to implement by itself!

    As to the condoms…well, I couldn't agree more! But searching for new interventions to support the ones we already know effective is still an imperative, and while giving out condoms is one thing, getting men to wear them is another. Like I said in the blog, open debate should be started. Possibilities of improving prevention should not be easily discarded.

  • invalid-0

     “where although it is not present in the Koran it is part of the sunnah (the laws based on the life of the Prophet)” This expression (frequently used in anti-circumcision movement) gives a general (mistaken) sense that Islamic commands coming from Sunna do not have an obligatory authority in Muslim’s life, but they are free options!! To make it clear, using this word Sunna (to refer to what were told by prophet) has a compulsory power coming from Qur’an him self, [And whatsoever the Messenger (Muhammad) gives you, take it; and whatsoever he forbids you, abstain (from it)](Qur’an 7/59)
     Secondly, for Muslims, circumcision and clipping one’s nails are violating bodily integrity in the same degree? If there is any!!

  • invalid-0

    I just wanted to clarify that although the Sunnah is of great relevance in Muslim’s daily life, it does definitely not have the same power as the Quran.
    The role of the Sunnah is to provide Muslims with guidelines according to the Profet’s way of life and based on his sayings, teachings and practices, but its components are not equal in terms of importance and can therefore not have the same value as Quran’s rules. They range from “Sunnah Mustahaba” or “liked Sunnah”, which usually refers to the Profet’s personal habits such as wearing a beard, using henna or khol etc, and that Muslims are encouraged to follow, to “Sunna Muakada”, which is “stronly recommended Sunnah”, like Eid El Adha’s sacrifice.
    In that sense, most theologists agree that not all the Sunnah is compulsory, but only the teachings related to worship. The rest is appreciated, encouraged (with various degrees) but not mandatory.
    Now, back to circumcision; there have been some interesting researches and debates among the Muslim and Arab community and a few writers like Abu Sahlieh and Serhane have questioned its importance in Islam. But there seem to be a common agreement that circumcision is mandatory for Muslims 1/because it symbolizes their belonging to the lineage of Abraham through his son Ismael, 2/because it is part of the “Fitra”, and 3/ as mentioned by Dr Russo, because it is justified as a hygienic measure. Hence its becoming a sign of belonging to the “Umma”.

    My post must certainly look off board, but I just wanted to clarify the difference between Sunnah and Quran, as it can seem confusing.

  • moises-russo

    thanks amoona for your clarifications regarding the difference between Sunnah and Quran. I think they respond to Ghiath Alahmad's previous comments. I think these two posts confirm the general idea presented in my post, regarding the fact that circumcision as a routine procedure is not easily defendable without making reference to theologic or cultural explanations. As Ghiath Alahmad correctly writes, many scholars in the Muslim religion consider it to be in the same line as clipping one's nails…..if we apply modern human rights theory (which I am not qualifying here as superior or inferior to Muslim  traditions) one may be considered an irreparable violation of bodily integrity, and the other one is not.

    And indeed, most mulsims agree it is part of the fitra, which for those who are wondering, is the original state in which humans are created by God, and consists of five actions that distinguish muslims from the rest of humans and polythesits: circumcision, shaving the pubes, cutting the nails, clipping the moustache and plucking the hair under the armpits.

    The simple fact that we can have this discussion illustrates that starting policies along this lines should be done after open debate on some of these issues, since cultural, human rights and religious issues are also at stake.

    Thank you for the interesting discussion.

  • invalid-0

    This reminds me of the military industrial complex argument that a billion spent on weapons research will produce some little gadget for civilian use, and thereby justify otherwise unjustifiable expenditures. In these arguments, the proponent forgets to consider that the civilian gadget would cost only a million to develop alone. Circumcision is just like that. It may drive development of infrastructure at huge cost because the hype around it in a very emotional environment may attract funds. Then that new infrastructure will be used to provide prevention strategies that actually work. But the circumcision campaign will get all the credit and perpetuate on cultural grounds. There is no way that once the cultural meme for circumcision gets rooted in society that any discussion of ethical issues will be able to control it. Then ethical violations will beget further ethical violations. And so it goes.

  • moises-russo

    Thanks for commenting on this, it has been an interesting discussion on the matter. 

    I can´t really argue about industrial complex arguments. However, I think new public health proposals must always be analyzed. The references present in the article on the costs of circumcision actually analyze the issue considering the use of existing infrastructire in some settings. Furthermore, you can even see that the cost analysis includes follow up and tretament of surgical complications.

    As to the ethical discussion…..well, ethical analysis is not supposed to stop decission taking, but to help in making the most appropiate decissions with the information we have. In fact, thinking that circumcision can never be eliminated once established is exactly contrary to what many of us who fight against female genital mutilation actually think.

    In any case, I think the available evidence and an ethical analysis of the issue support my position. I do not agree with analogical analysis on public health matters.