Male circumcision is not a panacea for HIV prevention
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7565.409-a (Published 24 August 2006) Cite this as: BMJ 2006;333:409All rapid responses
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Male circumcision and its relation to HIV and STD remains a
controversial issue and certainly we need more research before drawing any
conclusion.Readers may wish to read:
"For example, a study conducted in Kigali, Rwanda, of 837 married men
who volunteered for HIV testing showed that uncircumcised men had a
statistically significantly higher prevalence of HIV infection than
circumcised men. This was despite the fact that they had a relatively low-
risk profile; that is, they reported fewer lifetime sexual partners and
prostitute contacts than circumcised men, were more likely to live in
rural areas with lower HIV prevalence rates, and were less likely to
report a history of sexually transmitted disease.1
In the United States, on the other hand, data from the 1992 National
Health and Social Life Survey, a nationally representative sample of 1,511
men and 1,921 women between the ages of 18 and 59, showed that there was
no evidence of a prophylactic role for circumcision in regard to sexually
transmitted diseases (STDs). In fact, circumcised men were slightly more
likely to have had both a bacterial and a viral STD in their lifetime.2
References
1.Seed J, Allen S, Mertens T, et al. Male circumcision, sexually
transmitted disease, and risk of HIV. J Acquir Immune Defic Syndr Hum
Retrovirol 1995;8(1):83-90.
2.Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States.
Prevalence, prophylactic effects, and sexual practice. JAMA
1997;277(13):1052-57.
Competing interests:
None declared
Competing interests: No competing interests
There are so many errors and mistatements in Ms. Berer's letter that
I do not have the time to attempt replying to nearly any of them.
However, I would like to briefly respond to her final assertion, re the
Ethiopia case. First of all, a very large national survey (conducted by
Family Health International some three years ago) reported a male
circumcision prevalence of just under 80%, which is high but is certainly
not the universal ("almost 100%") prevalence that she alludes to. Also, a
number of Ethiopian men (some from the large Oromo ethnicity in
particular) become circumcised relatively later in life, sometimes only in
their 30s, by which time they may have already become infected with HIV.
Finally, and most importantly, if you check the most recent UNAIDS
data (http://data.unaids.org/pub/GlobalReport/2006/2006_GR_ANN2_en.pdf),
you can see that the official estimate of adult HIV prevalence in that
country is now only sligtly above 2%, median, which is hardly (by African
standards) a "very high" level. (By contrast, I'm currently based in
Swaziland, where estimated adult prevalence is 43%, and very few men are
currently circumcised, although there has been a recent great surge in
interest in circumcision, as reported in several recent news stories in
the New York Times, etc. (and as was mentioned by Stephen Lewis in his
forceful closing speech in Toronto last week).
In any event, Ethiopia certainly appears to be the (non)exception
that proves the rule. In fact, after at least 7 decades of this pandemic
in Africa, it is perhaps curious that there is still not a SINGLE country
in Africa/the planet which has an HIV prevalence of over about 5-6%, where
nearly all men are circumcised. (Ie, nearly all of west Africa, etc.)
Sincerely,
Daniel Halperin, PhD.
University of California, San Francisco
dhalp@worldwidedialup.net
Competing interests:
None declared
Competing interests: No competing interests
I appreciate the caution in Jocalyn Clark's report from the AIDS
conference in Toronto that male circumcision is not a panacea for HIV
prevention (bmj.com, news, 25 August 2006).
I would like to call attention to several aspects of the studies she
describes and the wider issues that were not remarked upon in the session
where the studies were presented. In Robert Bailey's presentation of his
study (PLoS Medicine 2005;2:e298) 35% of the circumcised men had not
recommenced having sex after 90 days, though these were men who had been
recruited because they were sexually active. The reason(s) why they had
not begun having sex again was not mentioned. Yet for adult men being
circumcised this is surely an important piece of information to have.
In another presentation, circumcised men were compared with non-
circumcised men and the results were again favourable to circumcision. Yet
the men were not examined physically to check how complete their
circumcision was. Circumcision was accepted on the basis of self-report
only, which surely makes uncertain the validity of the results.
The cost-effectiveness study showed a cost of $55 per man circumcised
in an African setting, but it did not examine the costs of training for
all the health care providers who would be needed to provide a service to
even 20% of the male population of sub-Saharan Africa. Nor did it take
account of treatment for possible complications that many men might need
if they were circumcised by a traditional healer in the absence of
trained, skilled providers. Nor did it discuss where the funds would come
from, when millions more condoms need to be promoted and provided in the
region, though condoms were said to cost only some $11 per man by
comparison, and when only 9% of pregnant women to date have had access to
antiretroviral drugs for prevention of mother-to-child transmission (and
even fewer access to drugs for themselves).
The importance of ensuring that every man circumcised does not walk
away believing he is protected from HIV and of convincing him of the need
to use condoms anyway, was also played down, not only from a cost point of
view as regards condom supplies, but also from a counselling point of
view. Bailey's study did intensive condom counselling with the men
involved for many months. That cannot be expected to be replicated if this
"project" is scaled up, and the absence of such counselling may reduce the
protection value of circumcision.
Lastly, an Ethiopian colleague asked me at a recent consultation why
no one has looked at Ethiopia as regards the protective effect of male
circumcision, since the male circumcision rate in Ethiopia is almost 100%
and the prevalence rate of HIV infection is also very high.
Male circumcision has been shown to have a number of health benefits
for men who were circumcised as infants. But the question of priority
setting as regards where to put HIV prevention efforts is becoming an
increasingly complicated one, and needs far more debate than it received
at the session on male circumcision or indeed during the AIDS conference
as a whole. That debate is long overdue.
Marge Berer
Editor, Reproductive Health Matters
RHMjournal@compuserve.com
Competing interests:
None declared
Competing interests: No competing interests
Male Circumcision : a debate going for centuries
Dear Editor,
I enjoyed reading this article by Jocalyn Clark. It is so intresting
that some topics remain in debate for centuries as this one. It has long
been debated wheter circumcision is advantageous or not, not only in
medical forums but also in religious forums. In some cultures like
Muslims, it is a religious thing to have circumcision and children as
young as four weeks have the procedure and whereas in some religions it is
totaly a negative thing to have circumcision.
I feel that it is a sensitive issue and has huge implications on varrious
peoples relegious beliefs and psychological well being.We do know so far
from evidence based studies that Circmcision is advantageous but I Feel we
need further strong evidence to justify it. It would be a good idea to
arrange for varrious relegious groups to understand the advantages and
disadvantages of this procedure so that those patients are accepted and
looked in their community as normal people neither as those who have gone
against their religon.
As far as AIDS is concerned, I feel that the biggest factor which can
control HIV Spread is safe sex and sex education to people which can de
delivered at all stages for e.g Community education, schools, GUM Clinics
etc.We might have some advantage by promting circumcision surgery but the
most important factor will still be patient education and all of us know
that patient education is the mest cost effective treatment .
As the old granny says "Prevention is better than cure". It is true for
obesity, hiv, alcholism,depression etc.
I feel we still are primarily focusing on the medical aspect of things and
not on the grass root level i.e Education and awareness in Community for
e.g one teenage pregnency management costs atleast one thousand pounds
while in the same amount we can have multiple education session for the
whole school and prevent at least three teenage pregnecies.
In summary I feel that we need to address the religious beliefs of people
and focus on awareness and community education to have the best outcome in
terms of patient safety and HIV prevention.
Kind Regards
Girish Chawla
Competing interests:
None declared
Competing interests: No competing interests