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The most persuasive article on male circumcision


A January 2008 article in a new journal Future HIV Therapy makes the most persuasive case for male circumcision being rolled out on a much, much wider scale in sub-Saharan Africa. We have blogged about the importance of male circumcision before (see here, here, and here).

This new piece is by Jeffrey D Klausner, Richard G Wamai, Kasonde Bowa, Kawango Agot, Jesse Kagimba & Daniel T Halperin. They start their paper by asking “What would the reaction of the international public health community have been if a year ago scientists had announced the discovery of a vaccine or chemical gel that, in three separate clinical trials, had reduced the risk of heterosexual HIV infection in men by at least 60%?”

They answer that question by noting that male circumcision (MC) provides that kind of risk reduction potential and also one which potentially provides an “‘African solution to African problems.”

Here are some choice quotes:

Currently, MC is the only modality for preventing sexual HIV transmission that has been proven to work by the highest standards of scientific evidence; specifically, findings from multiple randomized controlled trials. In fact, it appears that the actual protective effect of MC is probably somewhat higher than the official 60% estimate cited by WHO and UNAIDS, especially among higher-risk men.

In fact, it appears that the actual protective effect of MC is probably somewhat higher than the official 60% estimate cited by WHO and UNAIDS, especially among higher-risk men. In part, this is because some men who were randomly assigned to the circumcision arm in each trial did not show up for their appointment and, more importantly, a larger number of men who were randomly assigned to noncircumcision decided to get circumcised on their own during the trial period. Hence, the ‘as-treated’ protective effect, taking into account the actual MC status of participants, was a 76% HIV reduction in the trial in South Africa (where HIV prevalence was highest) [19]; and averaging across the three trials it was 65% [12].

The ultimate population-level impact of MC would be further amplified by a ‘herd immunity’ phenomenon if a sufficiently large proportion of men were to become circumcised in the population.

Modeling suggests that widespread circumcision in the rest of sub-Saharan Africa could avert up to 2 million new HIV cases and 300,000 deaths over the next 10 years, and 3.7 million infections and 2.7 million deaths in the following 10 years, many of those among women [27].

What about the cultural acceptability of male circumcision? Is this not cultural imperialism? This article largely puts that notion to bed.

A dozen acceptability studies conducted in different parts of Africa where MC is no longer traditionally practiced have found that the majority of uncircumcised men want the procedure performed, and generally an even higher proportion of women in those regions would prefer to have an circumcised partner.

Male circumcision was historically practiced in nearly all of Africa, but 19th century European missionaries condemned the widespread traditional initiation ceremonies, which included circumcision, as pagan practices.

In a 2006 household survey of Swazi men in both urban and rural areas, 87% said they would want the procedure if it helped reduce the risk of HIV infection. In January of that year, the media reported on a ‘circumcision riot’ when over a hundred men in the capital city were turned away because not enough physicians were available at a ‘free circumcision Saturday’ event.

The authors are incredulous that there has been a delay in rolling out male circumcision on a broader scale.

So the question must be asked: why the continuing delays in the implementation of MC? Why do some prominent officials, nongovernmental organizations, Ministries of Health and international organizations vacillate as thousands become infected every day, preferring to debate over cultural imperialism, the ‘rights’ of the foreskin, the ‘real world’ validity of randomized trials and so on?

We understand the very real operational challenges, implementation logistics, safety concerns and the enormous task of scaling-up a surgical procedure so that it is readily available for millions of impoverished people.

They make their own personal case:

Two of the authors (Wamai and Agot) are from Kenya and have witnessed first-hand the devastation in the part of the country (Nyanza Province) where the virus has flourished due in large part, we now realize, because that is the one province where MC is not a cultural norm. Another (Bowa) is a Zambian urologist who has struggled to make safe MC available at the University Teaching Hospital in Lusaka; due to funding limitations, the demand for services has far outstripped supply and the waiting list has grown up to 8 months long. Another (Kagimba) was one of the original architects of the now famous ‘Zero Grazing’ behavior change (partner reduction) strategy in Uganda, and seeks to add MC to the ‘ABC’ prevention approach.

They conclude with a call for action:

Now, 25 years after the pandemic was first identified, we have an important additional tool, the knowledge to help bring life back, to give people some hope. We need the rallying cry; above all, we need accountability. We need you – the reader, the media, the viewer, the voter, the caring man or woman on the street – to say not whether but when. When will there be widespread, safe and affordable MC services available in Africa? Every day we are counting and watching.

Immediately, the front page of every major newspaper and other broadcast media around the world – certainly those in southern Africa – should report on the great impact that implementation of MC could bring.

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6 Responses to “The most persuasive article on male circumcision”

  1. The word “persuasive” is fitting. Halperin and a small coterie of others have been trying to persuade the world to cut off baby boys’ foreskins for at least a decade, some far longer. Their strident advocacy leaks over, to say the least, into their science.

    A good example is the expession “the only modality for preventing sexual HIV transmission that has been proven to work by the highest standards of scientific evidence”. The Randomised Clinical Trials were NOT the highest standard of scientific evidence, because they were not double blinded (and probably can never be, though steps in that direction could have been taken). This is important when both experimenters and subjects passionately want circumcision to be effective. Humans are not lab rats and their mating can not be controlled. The three RCTs are subject to a number of caveats – high dropout rate (and probably differential – circumcised men with HIV being the most disillusioned), neglect of non-sexual transmission (in the face of clear evidence) differential treatment of the control and experimental groups, and curtailment as soon as significant “protection” had been achieved.

    The authors now attempt to ramp up the effectiveness of circumcision by micro-calculating the relatively small numbers of men infected. Already, unjustifiable extrapolations have been made from some tens of men over months to millions over decades.

    Circumcision is deeply embedded in culture, not only in Africa, but also the developed world, especially the US, and a century of promotion for a myriad bad reasons is not neutralised by hiding the cutting of baby boys’ genitals behind the innocuous-looking initials “MC”.

  2. My main concern with the RCTs for MC is the short time frame in which the studies took place. What, if any, effect does circumcision have on subsequent behavior? Circumcision does reduce the likelihood of transmission, but it is not a vaccine. Behavior is still going to matter.

  3. The distance between a double-blinded RCT and non-blinded RCT is much smaller than RCT to other research designs. Randomized enrollment remains the gold standard in scientific investigations because the design, if done carefully, addresses the very points that Hugh raises – i.e. unobserved unbalanced confounders. A carefully selected cohort that is homogeneous in every way but for their treatment assignment makes casual inference highly convincing as every other possible option for the observed outcome is on average present in equal amounts in both the control and treatment groups.

    The reassuring fact that not one but three RCTs concluded that circumcising the foreskin is protective against HIV infection is indeed persuasive.

  4. In most cases the consistent findings of three RCTs would represent a ‘slam dunk’. Yet we find some nitpicking going on here. Why? I suggest that anti-circumcision groups have invested so much into their ’cause’ that the die-hards just can’t consider just packing up their tent and moving off into the sunset. The anti-circumcision movement is becoming more like the Flat Earth Society with each study published finding some or other benefit through male circumcision. Like the HIV denialists they will just fade away.

  5. Its said (serbia) that evil people from Usa have build this HIV virus.This is a conspiracy theory but i am sure there is some truth in it.

    In this case those people that made HIV (or Sida ) will do everything they want to blame new HIV cure …

  6. can anyone discus why foreskins seem to propagate the virus more?