There is a lot of excitement about the possibilities circumcision holds as HIV prevention tool. We will keep you up to date on new developments.
There is also some confusion: It is important to remember that even though this is potentially a valuable prevention method, researchers do not claim that circumcision can prevent all transmission.
There are also some concerns that circumcision my have a negative influence on condom use and gender equality.
Circumcision in HIV Prevention - Resources
Tools, resources and guidance for the use of circumcision in HIV prevention:
The CDC Dives Into the Great American Circumcision Debate. 07/01/2015
Published at POZ Health, Life and HIV
Written by Benjamin Ryan
2 January 2015
Studies conducted in sub-Saharan Africa have shown that male circumcision lowers men’s risk of acquiring HIV and other sexually transmitted infections from women. Do those findings belong in U.S. health policy?
The Centers for Disease Control and Prevention (CDC) is weighing whether to make its first-ever recommendations on the sensitive and divisive subject of male circumcision. On December 2, the federal agency issued a draft proposal that, if put into effect, would advise clinicians to counsel men, boys and expectant parents that removing the penis’s foreskin reduces the risk of female-to-male transmission of HIV and other sexually transmitted infections (STIs), as well as a number of other health problems.
The proposal grew out of the findings of a trio of large, placebo-controlled randomized controlled trials (RCTs, the gold standard of medical research) conducted in sub-Saharan Africa and published between 2005 and 2007, which found that heterosexual men who were circumcised during the studies had a 50 to 60 percent reduced risk of acquiring HIV from vaginal sex. These trials have led to a massive push to circumcise men in 14 priority African nations in an attempt to stem the tide of the HIV epidemic in that part of the world, with nearly 6 million circumcisions performed between 2008 and 2013.
The African trials also found that circumcision lowered the participants’ risk of contracting herpes simplex virus-2 (HSV-2) and human papillomavirus (HPV) by about 30 percent. There was further evidence that removing the men’s foreskins lowered rates of bacterial vaginosis in women as well as genital ulcer disease in both men and women.
Additional research has shown that circumcised males are less likely than their uncircumcised counterparts to develop penile and possibly prostate cancer, and that they are less likely to experience urinary tract infections during infancy.
The CDC has proposed that clinicians weave these numerous findings into discussions with parents about whether to circumcise newborn boys, as well as with older male patients. In particular, this would include sexually active males having high-risk heterosexual sex—for example, with an HIV-positive woman, female sex workers or injection drug users, or multiple female partners. The CDC makes clear that adolescent males should be included in the decision-making process when clinicians counsel them and their parents on the subject.
The proposed recommendations underline the fact that circumcision does not eliminate the chance of contracting HIV or other STIs, and that sexually active men should still take measures to lower their risks, such as reducing their number of sexual partners and using condoms.
The proposal also addresses the fact that research has not found that circumcision protects men from contracting HIV through sex with other men—which is how nearly two-thirds of all new U.S. cases of the virus transmit. Nor has research shown that circumcision helps prevent STI transmission resulting from male-to-male sex. While the lack of a foreskin may in theory offer protection from HIV to the insertive partner (the top) during anal sex, its presence is irrelevant in the case of receptive anal intercourse, which is by far the most likely way that men who have sex with men (MSM) contract the virus. Furthermore, research suggests that MSM who are only ever the insertive partner during sex (exclusive tops) are a distinct minority.
The proposed recommendations state that adult men who are circumcised “generally report minimal or no change in sexual satisfaction or function.” Such a claim is met with derision by anti-circumcision activists, sometimes known as “intactivists,” who typically maintain that removing the foreskin significantly reduces enjoyment of sexual activity. However, the CDC’s position is backed up by the African RCTs, which included over 10,000 participants, as well as by some small U.S. studies.
The review period for the CDC’s proposed recommendations, during which the draft is open to public comments as well as clinician experts’ feedback and potential requests for more information, runs through the middle of January. At that point, the CDC will consider any possible changes and decide whether to put a finalized policy in place.
The proposal comes at a time of rising American ambivalence, and often fierce opposition, to circumcision. While about four in five adult males in the U.S. report being circumcised, newborn circumcision has become less common over the past few decades. Today perhaps a bit more than half of all American baby boys are circumcised. U.S. health policy, on the other hand, has begun to shift in the other direction. Long neutral on the topic, the American Academy of Pediatrics (AAP) stated in 2012 that the potential benefits of newborn circumcision outweigh the risks—a position that the CDC cites in its draft proposal. The AAP stopped short of an actual recommendation of the procedure, however, as does the CDC.
Groups opposed to circumcision, which typically consider the removal of a newborn’s foreskin a cruel and unnecessary act of genital mutilation, posit that the AAP, and now the CDC, is engaging in coercive attempts to buck a trend that is flagging for very good reason.
“Bottom line: Do we have the right to remove normal tissue from the body of a non-consenting minor or does that body belong to its owner?” says Marilyn Milos, founder and director of the anti-circumcision organization NOCIRC. “Parents cannot consent to amputation of normal body parts of their child.”
The CDC’s proposed recommendations state that an argument for circumcising during infancy as opposed to when a male is old enough to consent is the reduced chance of potential complications, as well as the certainty of providing the health benefits before sexual activity begins. Newborn circumcision has a 0.4 percent complication rate, compared with 9 percent among boys between the ages of 1 and 9. The most common complications include bleeding, inflammation and the need for corrective procedures. For boys older than 10, who experience a 5 percent complication rate, the potential problems also include wounds of the penis. There is no data on complications among teenagers.
The CDC looked to the three African RCTs for statistics about adult males, who, the recommendations state, experience a 2 to 4 percent complication rate, most commonly pain, bleeding, infection and lack of satisfaction with the penis’ appearance.
Meanwhile, leaders in the anti-circumcision camp have long lambasted the science supporting the health benefits of circumcision as flawed and, further, don’t accept that studies conducted among sub-Saharan Africans apply to American males.
Robert Bailey, PhD, MPH, a professor of epidemiology at the University of Illinois at Chicago, who led the African RCT that was conducted in Kenya, allows that exposure to malaria, parasites or other microbes in Africa may increase susceptibility to HIV among the cells in the foreskin that the virus targets.
“Nevertheless,” Bailey says, “the evidence that we have from the few studies in the U.S. of heterosexuals are consistent with the results in Africa. I really think the 50 to 60 percent protective effect is applicable anywhere in the world.”
The Americans studies in question aren’t RCTs, however, so they can’t offer as dependable a quality of evidence as the three African trials. Nor are researchers ever likely to conduct an RCT in the United States that is comparable to the African trials. Because American heterosexual males have such a vastly lower risk of being exposed to HIV from sex with women than African males, a U.S. RCT that could yield results with sufficient statistical heft would require an impractically enormous number of participants. Also, scientists believe it would be unethical to have a placebo group in such a trial, given what is now known about the benefits of circumcision.
Considering that only an estimated 4,100 out of 50,000 new cases of HIV in the United States transmit from women to men, skeptics also question how encouraging male circumcision would have much of a practical effect on reducing the actual number of annual new HIV cases.
One particular 2010 CDC paper, which informed the development of the draft recommendations, sheds some speculative light on that question. In the study, researchers used mathematical modeling to project the effects of newborn circumcision on U.S. HIV rates and associated health care costs—assuming that the lack of a foreskin reduces female-to-male transmission by 60 percent. Beginning with the statistic that all American males (not just heterosexuals) have a 1.87 percent lifetime chance of becoming HIV positive, the study projected that circumcision reduces this risk by 15.7 percent. Black males, who have an estimated 6.23 percent lifetime risk of contracting HIV (compared with just 0.96 percent among white males), could expect a 20.9 percent lifetime reduction in risk from circumcision at birth.
Considering that circumcision rates are lower among African-American males (as well as Latinos), encouraging the procedure among that population in particular may therefore have a more appreciable effect on the epidemic in the long run.
“It’s important to understand that there is a black epidemic that is dramatically different than the white epidemic in America,” says Phill Wilson, president and CEO of the Black AIDS Institute. “In black America, we have a generalized epidemic, and in white America, we have a concentrated epidemic.”
While the white HIV epidemic is generally concentrated among MSM, Wilson says, “In black America, for various reasons, it is a disease among gay men, among women, among injection drug users, and among heterosexual men.” Consequently, Wilson believes that both newborn and adult male circumcision “would make a huge difference to HIV transmission in black communities.
“At the end of the day, when we want to get to zero [HIV infections], this is a percentage game,” Wilson adds. “Twenty percent lifetime change is significant for this intervention when you combine it with the other [HIV prevention] tools in our toolbox.”
U.S. health officials are careful to state that the ultimate goal is not to force circumcision upon American males. Michael Brady, MD, a member of the task force on circumcision at the AAP, says, “I don’t think anybody is saying that everybody should be circumcised. I think what the CDC and the AAP are trying to say is that it’s very reasonable for people to understand what the risks and the benefits are.”
“We believe clinicians need complete information on all proven strategies in order to effectively talk to their patients about HIV and [STI] prevention options,” says Eugene McCray, director of the Division of HIV/AIDS Prevention at the CDC. “The guidance is designed to help health care providers provide accurate information to individual men, as well as to parents of male infants, to help them make informed decisions about circumcision.”
Georganne Chapin, executive director of the anti-circumcision group Intact America, counters, “There are far more effective ways to achieve a protective effect than the amputation of healthy, functional sexual tissue.”
To read a POZ feature about the debate over the findings of the African RCTs, click here.
Voluntary Medical Male Circumcision (VMMC): Demand Creation Toolkit. 18/01/2014
From The Health Compass
This toolkit provides implementing partners and organizations with the guidance and tools needed to conduct communication and outreach activities that drive demand for voluntary medical male circumcision (VMMC). The toolkit is a practical resource that enables users to create community-specific communication campaigns quickly and easily that uphold national, international, and donor-driven standards for quality, content, and sensitivity. The strategy for demand creation outlined in this toolkit addresses three broad audience groups: Married and unmarried males aged 15 to 49 years at risk of acquiring HIV infection through heterosexual (vaginal) intercourse; Married and unmarried females aged 15 to 49 years, including the sexual partners of males aged 15 to 49, who can influence males’ decisions about VMMC; and Key influencers, such as male peers, community leaders, spiritual leaders, celebrities, or others at the community, regional, and/or national levels, who can encourage males to consider VMMC. The toolkit provides specific approaches and materials for reaching these strategically important and high-priority audiences in the interest of achieving an AIDS-free generation. It is organized into three sections: the introduction, planning and implementation, and resources. The toolkit is intended for use by Ministries of Health, nongovernmental organizations (NGOs), and other implementing partners responsible for creating demand for VMMC. It provides a step-by-step process to turn communication strategies into demand creation campaigns. The guidance and tools provided will help program managers and planners, demand creation coordinators, and other staff develop communication materials and conduct demand creation activities that drive demand for VMMC services. The toolkit is designed for use at the national, regional, and local levels.
Organization that developed this resource and used with permission from:
RTI International, Population Services International (PSI), Centers for Disease Control and Prevention
Cut to Fit 10/10/2013
By Benjamin Ryan of POZ
Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?
The evidence appeared overwhelming. Dozens of smaller studies conducted from the late 1980s onward suggested that circumcised men in sub-Saharan Africa were at reduced risk of acquiring HIV.
Some of the research had conflicting results, but meta-analyses supported the hypothesis that removing the male foreskin protected against HIV transmission. Eventually, there was enough data to justify three randomized controlled trials—considered the gold standard of scientific research—of more than 10,000 HIV-negative uncircumcised men in Kenya, Uganda and South Africa.
In each of the three trials, half the men were randomly selected for circumcision while the others served as a control. Each trial was halted early on ethical grounds because it was so clear that circumcised men were acquiring HIV at significantly reduced rates when compared with the control group.
The results of the studies, one of which was published in 2005 and the other two in 2007, fell neatly in line with one another. Circumcision, the researchers concluded, reduces heterosexual men’s risk of HIV by about 60 percent.
“We very rarely have a circumstance where we have three trials that show you almost identical effects,” says Edward Mills, PhD, an associate professor at the Interdisciplinary School of Health Sciences at the University of Ottawa, who wrote a 2008 meta-analysis of the studies. “And therefore, the inferences that we can draw from these three trials are much stronger than in virtually any other circumstance.”
Jason Reed, MD, MPH, an epidemiologist in the Office of the U.S. Global AIDS Coordinator (OGAC), says of the studies’ findings: “It’s a remarkable level of consistency that I think other scientific interventions only wish that they had.”
Indeed, in 2007 the World Health Organization (WHO) put all its weight behind ramping up voluntary medical male circumcision (VMMC) in sub-Saharan Africa. The global public health agency characterized VMMC as a highly effective method of reducing female-to-male sexual transmission of HIV—“proven beyond reasonable doubt”—and as a cost-effective means of curbing the rampant epidemic in that part of the world.
WHO, along with UNAIDS, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and other global stakeholders, established 13 countries in eastern and southern regions of the continent (PEPFAR, which is the primary funder of Africa’s VMMC programs, later added the Gambela region of Ethiopia), each of which had predominantly heterosexually driven epidemics, high rates of HIV and relatively low levels of male circumcision either nationally or in specific regions. This constellation of variables invited the best bang for the buck in the scale-up of VMMC programs.
The agencies set ambitious goals for the program: to work through African ministries of health to support reaching 80 percent circumcision prevalence among 15- to 49-year-old males in the priority countries by the end of 2016. Mathematical models run in 2009 projected that 3.4 million HIV transmissions could be prevented by 2025, or a 22 percent reduction of expected new cases, as a result of such an effort.
In the search for explanations as to why the lack of a foreskin might reduce men’s risk of acquiring HIV, scientists have long theorized that Langerhans cells may play a major role. Found in abundance in the foreskin, these immune cells ordinarily would absorb and destroy a pathogen such as HIV. However, recent studies have helped hone a hypothesis that anaerobic microorganisms that thrive beneath the foreskin may give rise to inflammation, which may then cause the Langerhans cells to switch their role into that of a Trojan horse: actually carrying HIV to CD4 cells and helping establish a chronic infection. The anaerobes and inflammation may also draw CD4s to the foreskin, making them more vulnerable to direct infection.
Consequently, removing the foreskin would not only reduce the number of Langerhans cell targets, but also greatly diminish the population of inflammation-causing anaerobic microorganisms on the penis, helping protect the body against HIV.
Supporting the hypothesis that the very volume of tissue influences the foreskin’s role in HIV transmission, a 2009 paper published in the journal AIDS found that the larger the foreskin, the more likely men were to acquire HIV. The top 25 percent size-wise were 2.37 times as likely to contract the virus when compared with the bottom quartile.
Such biological explanations as to circumcision’s apparent health benefits tend to fade into the background in an ongoing ideological war waged by a small yet highly vocal group of dissidents fighting against the VMMC movement in Africa. Sometimes referred to as “intactivists” (as in “intact foreskin”), and largely hailing from the United States and Europe, these skeptics have sounded a steady drumbeat of protest against what they argue is a trio of deeply flawed randomized controlled trials that have supported a waste of precious resources on a procedure many of them view as barbaric.
Indeed, the principles of VMMC overlap and at times clash with religious traditions, social and cultural norms and deeply held personal beliefs. To the loose syndicate of dissidents, the flurry of excitement and activity over VMMC is anathema. Publishing numerous, forceful articles in medical journals, they’ve committed to an ongoing volley with the vast scientific community supporting the VMMC scale-up abroad. Over the years, VMMC backers have responded in kind, rebutting all the dissidents’ arguments and calling their attempts to discredit the science strikingly misguided, if not purposefully manipulative.
Ronald H. Gray, MD, a professor of epidemiology at Johns Hopkins Bloomberg School of Public Health, who was the lead author of the Uganda trial, says of the dissidents, “What they tend to do is cherry-pick at details in these papers.”
John Potterat, a former director of STD/AIDS programs in the El Paso County Health Department in Colorado Springs, Colorado, has spent much of his retirement years stirring skepticism toward the position that sexual activity is the main driving force behind HIV transmission in sub-Saharan Africa. He calls Gray’s accusation malicious and untrue—“calumny,” to use his exact word.
“I’ve done my homework for 40 years; believe me I really know my shit, OK?” says Potterat, who, though he lacks an advanced degree, was dubbed by Malcolm Gladwell as “one of the country’s leading epidemiologists” in the journalist and author’s 2000 best seller The Tipping Point.
“Most of what I have read coming out of Africa can be summarized as follows: first-world researchers doing second-rate science in third-world countries,” Potterat says. “Circumcising all these men in Africa is based on a useless result.”
Simon Collery, a blogger, development worker and HIV advocate with a master’s in education and international development from the University of London, says it is the VMMC advocates who are the cherry-pickers.
“They wanted to spend a lot of money circumcising people,” says Collery, who lived in Kenya but now lives in Cambodia, “and therefore they found the evidence, which is very weak evidence.”
While the dissidents may have failed to sway major players in the global public health sphere enough to change actual policy, OGAC’s Jason Reed says their voices have been heard on the ground by Africans themselves.
“I think they fuel this ongoing debate about ‘Does this really work?’” Reed says of the intactivists’ persistent attempts to chip away at the public’s perception of VMMC’s efficacy. “And in a number of countries [African stakeholders] are still looking for validation to move slowly. That definitely has an impact…sometimes hamper[ing] programs by spreading misinformation and creating skeptics among those who stand to benefit the most.”
The VMMC rollout has indeed proved relatively modest thus far, if steadily gaining in momentum now that the basic framework has been laid. According to Rachel Baggaley, MD, who coordinates innovative prevention policies in the HIV department at WHO, an estimated 3 million African males have been circumcised during the past five years. This figure is far out of pace from the 20 million global stakeholders initially set as a goal to circumcise by the end of 2016.
However, Baggaley says such public health goals are often aspirational targets set overly high in order to light a fire under programs that require a good deal of effort to get off the ground. Nevertheless, she acknowledges that WHO and its partners underestimated the complexities and social sensitivities required to successfully promote the program in certain populations. Two major challenges moving forward, she says, are an insufficient number of local health care providers and older African men’s resistance to circumcision.
In the United States, about 79 percent of adult males report being circumcised. According to a new analysis from the National Center for Health Statistics, 65 percent of newborns were circumcised in 1981. After dropping during the ‘80s and rising in the ‘90s, the circumcision rate then fell to 58 percent by 2010. In 2012, the American Academy of Pediatrics (AAP) revised its previously neutral policy on circumcision; it now states that the procedure’s potential benefits outweigh its risks, although the AAP refrains from a full-on recommendation.
The health benefits of circumcision AAP cites include a reduction in risk for sexually transmitted infections, including herpes and human papillomavirus (HPV), as well as a reduced risk of penile cancers and lesions. The group says the risks of circumcision are typically minor but may include bleeding and infections.
While many intactivists argue circumcision reduces sexual pleasure, the AAP’s position is that research does not support such a claim. A 2008 study of the members of the Uganda VMMC trial found no differences in sexual satisfaction or function between the circumcision and control arms of the study, with more than 98 percent reporting no problems in those realms.
The AAP also has declared that circumcision can reduce the risk of acquiring HIV among heterosexual men in the United States. In fact, scientists believe that the 60 percent reduction in risk found in the three African VMMC trials applies to all heterosexual men globally.
For men who have sex with men (MSM), studies have not shown that circumcision offers noticeable protection against the virus. This is likely because few MSM who engage in anal intercourse exclusively play the insertive, or top, role. Only 100-percent tops might significantly benefit from circumcision, and one recent research study estimated that only about one in five HIV cases among gay men in the United States results from a receptive partner, or bottom, transmitting to a top.
Three quarters of all new infections in the United States are among MSM or injection drug users, while just 8.5 percent occur in the heterosexual male population. So the presence or absence of a foreskin in the male population at large is unlikely to lower HIV rates anywhere near to the extent it would in sub-Saharan Africa, where the epidemic is predominantly driven by heterosexual intercourse and where adult prevalence rates in the VMMC scale-up countries are as high as 23.6 percent in Lesotho and 26.4 percent in Swaziland, compared with the overall U.S. prevalence of 0.45 percent.
The skeptics, however claim that the assertion that sub-Saharan Africa’s epidemic is largely fueled by sexual practices is a far from settled matter. Their primary opposing theory is that unsafe medical, dental or cosmetic practices, or other puncturing exposures, may in fact be the main drivers of the HIV epidemic in that part of the world.
A particularly vocal VMMC dissident, David Gisselquist, PhD, who received his doctorate in economics from Yale and who has spent more than a decade arguing his case, says the unsafe medical practice theory of HIV transmission in Africa is supported by “outstanding evidence.” He has accused WHO of enacting a “continuing cover-up of hospitals’ and clinics’ contribution to Africa’s epidemics.”
However, a 2006 epidemiological analysis published in the journal Sexually Transmitted Diseases calculated that the per-injection risk factor and the number of unsafe injections sub-Saharan Africans would need to receive each year to reach the HIV prevalence rates found in that part of the world are “unfeasibly high.”
Also, a series of analyses reported in a 2011 Journal of the International AIDS Society (JIAS) paper found that, between Uganda, Kenya, Zambia, Swaziland and Lesotho, injections or blood transfusions had a negligible effect on the countries’ HIV epidemics, while sexual behavior accounted for between 94.1 and 99.8 percent of transmissions. Transmission among MSM, the paper stated, makes up an estimated 15.7 percent of new HIV infections in sub-Saharan Africa.
Gisselquist dismisses the models on which such estimates are based as deriving from “made-up parameters.”
Rupert Kaul, PhD, a professor in the departments of medicine and immunology at the University of Toronto, disagrees vehemently. “If we’re talking about sub-
Saharan Africa,” he says, “there’s absolutely no question that what we’re talking about is sexual transmission.”
Of the dissidents’ long-running unsafe medical practices line of argument, he says, “This is just sort of their high horse.”
The 2011 JIAS paper examined the evidence to support VMMC in sub-Saharan Africa and pointed out that only about 10 percent of the region’s HIV cases are among those younger than 15, and that prevalence jumps dramatically in those 15 and older. This correlation is “clearly consistent with sexual behavior as the main mode of transmission,” the authors wrote.
Gisselquist, along with Potterat and others, criticize epidemiologists for not tracing the source of individual infections when Africans test positive—in other words, for not doing the legwork in the field to see if something other than sex might have been at play. They point out that in three circumcision trials a significant proportion of men who acquired HIV did so while reporting either no sex or consistent condom usage, including 23 of the 69 transmissions in the South Africa study and 16 of the 67 new infections in the Uganda trial. (The Kenya trial did not publish such specific data.)
“I’d say, ‘Look at the evidence,’” Gisselquist says, addressing the authors of those studies. “‘This is the evidence you reported.’ But these guys are sitting under a tree in Baltimore and saying, ‘Well, we know it’s all from sex in Africa anyways.’”
Ronald Gray, who headed up the Uganda trial, says that all six of the men in the study who did not report intercourse during the period when they were infected did report sex both before and after that period. He theorizes they “likely misreported their sexual behaviors.”
“We know that self-reporting on sexual behavior is not good,” says OGAC’s Jason Reed. Stating a common point, he argues: “The fact that male circumcision was the only difference between these two groups of people across three studies, and that it still reduced their HIV incidence by the same proportion [in all three studies], would suggest that male circumcision is protecting them against whatever is putting them at risk.”
In 2011, Gregory J. Boyle, PhD, a consultant from Queens-land, Australia, and George Hill, vice president for bioethics and medical science at Doctors Opposing Circumcision in Seattle, published a lengthy criticism of the randomized controlled trials of VMMC in the Journal of Law and Medicine (JLM). The next year, the same journal published a 30-page rebuttal whose nine authors, including Robert Bailey, lambasted Boyle and Hill for recycling discredited theories and relying on “outmoded evidence, outlier studies and flawed statistical analyses.”
Like many dissidents, Boyle and Hill highlighted the observational studies of circumcision, some of which showed a correlation between lacking a foreskin and raised HIV risk, not the other way around. Potterat calls the overall findings of those earlier studies “a toss-up.”
The JLM rebuttal, which sneered at the dissidents’ “highly selective literature review,” pointed to one particular meta-analysis of observational studies that found circumcision had a 61 percent protective effect, thus negating any apparent inconsistencies in the study findings.
Skeptics have expressed concern that the early termination of the controlled trials over-estimated circumcision’s protective effect—a common statistical result of ending a trail prematurely. But the JLM rebuttal cited the fact that nearly five years of follow-up in two of the trials found that the reduction in risk only increased over time: to 67 percent risk reduction in the Kenyan study and 73 percent in the Uganda trial.
Recent research also is beginning to show that widespread circumcision is already having an appreciable effect on specific African communities. In Orange Farm, South Africa, the site of that country’s VMMC trial, the subsequent large-scale roll-out of the program has seen an estimated 57 to 61 percent reduced HIV incidence among circumcised men as compared with uncircumcised men. And in Rakai, Uganda, VMMC rates among non-Muslim men between 15 and 49 years old jumped from 5.6 percent between 2000 and 2003 to 25.3 percent in 2009. During that time, HIV incidence among all non-Muslim men dropped 22 percent, and researchers have calculated that 37 percent of that drop can be attributed to the scale-up of circumcision.
Another argument posed by the skeptics is the notion that recently circumcised men are likely to put themselves at increased risk of infection should they engage in unprotected sex before their wounds heal.
Robert Bailey, PhD, MPH, a professor of epidemiology at the University of Illinois at Chicago, who was the principal investigator for the Kenyan VMMC trial, has completed a study showing that 35 percent of men do start having sex again before the WHO-recommended six-week waiting period, but that only 7 percent do so before the wounds heal. He argues that an approximate two-week period of increased risk for these men, when compared with the permanent risk reduction of circumcision, is relatively insignificant.
A further area of concern is the phenomenon known as “risk compensation”—the notion is that if a man believes he is more invincible with a circumcised penis, he may be more likely to have unprotected sex or increase his number of partners. Research has been mixed in this area. Time will tell how men’s behavior plays out.
In the meantime, Seth Kalichman, PhD, a professor of psychology at the University of Connecticut, who published a 2007 article in PLOS Medicine questioning the VMMC trials for improperly accounting for risk compensation, says that a major challenge posed to circumcision efforts is how to communicate the practical implications of a “60 percent risk reduction” to African men without giving a false sense of security.
All the back and forth between the VMMC supporters and the dissidents aside, the march toward widespread circumcision in sub-Saharan Africa remains a major priority in global public health, and its detractors are few in number.
Ronald Gray of Johns Hopkins says, “I’ve given up trying to respond to their many publications.”
“It’s a circular discussion that on some levels probably won’t ever be satisfied,” says Reed of OGAC. Regarding the dissidents, he says, “It’s a group of people that largely argue, I think, from an emotional place. I think our position is that no amount of scientific data is going to satisfy the very real issues that they have with the intervention. I think they try to make the case that it’s not valuable from a scientific standpoint, when in fact the problems that they have with it aren’t the science.”
Potterat, who explains that “skepticism is part of the fabric of my mind,” says he’s open to suggestion that circumcision is a worthwhile intervention, but is still waiting for what he considers solid evidence.
“We’re not saying we know,” Potterat says. “We’re saying there’s something wrong with this picture and we don’t know what’s going on, but neither do you. And I guess that really has stepped on people’s ideological, political, academic or other agendas that they just don’t want to see.”
Rachel Baggaley at the WHO sees the argument from a different perspective: that of Africans at high risk for HIV. “The denialists are often coming from places where HIV is not a massive threat to them. Whereas, if you’re a young man in South Africa, you’ve got such a high lifetime chance of acquiring HIV, that, frankly, to deny that opportunity to something that reduces that chance by 60 percent is rather paternalistic.”
The print edition of this story incorrectly stated that there were two different 2011 Journal of the International AIDS Society papers that, respectively, referenced information about HIV transmissions through injections in Africa and HIV incidence by age group in Africa. Both citations actually come from the same paper.
Also, the print edition stated that the VMMC scale-up in Orange Farm, South Africa, yielded a 76 percent protective effect. A journal article released since the print edition went to press found that circumcision in Orange Farm was linked to an estimated reduction in HIV incidence among men of 57 to 61 percent.
WHO/UNAIDS - Conclusions and Recommendations
WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming Montreux, 6- 8 March 2007 . Conclusions and Recommendations
Download the new recommendations here (PDF; 10p.; 127.84KB).
Neo-natal Circumcision Not in Conflict with Children's Act of 2005. 12/8/10
Much confusion over legality of male circumcision on boys younger than 16
12 August 2010
Much confusion has been generated recently regarding the legality of performing medical male circumcision on boys below the age of 16 in South Africa. This confusion seems to be based on a poor reading of the Children’s Act 38 of 2005. This confusion has caused some providers to be hesitant to perform circumcisions on infant boys, even where the parents have provided consent and slowed down the implementation of programmes ultimately aimed at preventing new HIV infections in the future.
SECTION27 has prepared a legal memo analysing the issue and has concluded that the Children’s Act contains no legal limitation – beyond current informed consent requirements – that prohibits medical practitioners from recommending and providing neo-natal male circumcisions to infants boys of consenting parents.
The full memo is reproduced below and is also available here (PDF, 637.23KB, 3pg)
Voluntary Male Medical Circumcision is Safe and Effective: But Beware of Unsafe Devices. 8/7/10
Joint statement by the Treatment Action Campaign (TAC), SECTION27 and the Southern African HIV Clinicians Society
8 July 2010
The Southern African HIV Clinicians Society and the Treatment Action Campaign support the implementation of a country-wide voluntary male medical circumcision (VMMC) programme. Male medical circumcision reduces the risk of heterosexual men contracting HIV and the Human Papilloma Virus (HPV). Despite the effectiveness of VMMC, it is essential that circumcised men are encouraged to continue using condoms during sexual intercourse.
We welcome the steps the South African government is taking to implement VMMC. Kwazulu-Natal has run several events encouraging youth to have medical circumcisions and the Department of Health together with the South African National AIDS Council is developing circumcision guidelines. The continuous disturbing reports of traditional circumcisions that have resulted in deaths and penile mutilations show how important it is to implement a medical circumcision programme that is safe and in which adverse events are kept to an absolute minimum. The success of VMMC is dependent on public confidence in the programme's safety.
We are therefore deeply concerned that a Malaysian company, Taramedic Corporation, and its South African partner, Carpe Diem Enterprises, are aggressively marketing a circumcision device called the Tara KLamp (TK) to several sub-Saharan African countries, including South Africa, Lesotho, Kenya, Botswana and Zimbabwe. A randomised controlled trial in adolescents and adults found a very high rate of adverse events and much greater pain associated with this device compared to the standard forceps-guided circumcision technique.
The TK must be withdrawn from sale and distribution for adolescent and adult circumcision throughout sub-Saharan Africa until the device's safety concerns are addressed.
A review of the Tara KLamp (TK)
The TK is a circumcision device that is clamped onto the foreskin with the purpose of necrotising it. After approximately seven days the device, along with the foreskin, usually falls off. In some cases the device does not fall off forcing the patient to have the TK removed surgically.
The Orange Farm clinical trial showed that VMMC can reduce a heterosexual male’s risk of contracting HIV by 60%. In 2005 the Orange Farm researchers performed a randomised controlled trial to see if the TK could be used as an alternative method of circumcision. 35 men were circumcised with the TK and 34 with the standard forceps-guided technique that was used during the original trial.
Adverse events from use of the TK were far higher: 37% compared to 3.4% for the forceps-guided method. This was a statistically significant result (p=0.004). Men circumcised using the TK also reported worse pain than men circumcised using the forceps-guided method. Furthermore, the device clearly causes consternation: 97 men refused to participate in the trial, 94 of them giving the reason that they did not wish to use the TK.
The TK trial was stopped early due to the unacceptably high rate of adverse events. The researchers concluded, “Given the high rates of adverse events in this study and the low number of available studies, we strongly caution against the use of the TK for young adults, and we recommend careful evaluation of the procedure when performed on children.”
Safety must be proven before any new medical intervention is implemented. Currently, the balance of evidence shows that the TK is unsafe for use on adolescents and adults. We cannot find any published studies of the TK being shown to be safe for adolescents and adults. Two studies, neither of them randomised and consequently of questionable quality, indicate that the device might be safe for young children.
The marketing practices of Carpe Diem Enterprises
Carpe Diem Enterprises is the distributor of the TK in South Africa. The company has disregarded the safety concerns raised in the Orange Farm study. The device's website states, “This invention enables circumcisions to be performed not only safely and easily but also ----- for the first time in surgical history ----- enables circumcisions to be performed just as aseptically, at home, on the roadsides or out there in the bush, as in an operating theater. ”
The device is marketed as a faster method of performing circumcisions, as it can be carried out in less than 10 minutes. This is not much faster than the medical forceps-guided method of circumcision and certainly does not outweigh safety concerns. It also does not take into account the additional time needed to surgically remove the device from some patients.
The TK is also more expensive than the forceps-guided method of circumcision. According to our discussions with the manufacturer, the TK is being sold to general practitioners for R160 excluding VAT. However the device only slightly reduces the number of surgical instruments needed in a circumcision. Consequently we estimate that using the TK adds significant cost, even without considering the extremely large additional cost that would be incurred from hospitalisations due to increased adverse events.
The attitude of the company towards critical research of its device is exemplified by Dr. G. Singh, the inventor of the TK, who made the following threat in an email exchange with one of the authors of the Orange Farm study, “All it needs is a simple withdrawal of your manuscript and gracefully accept the reality. I am even not asking for an apology, for I am a very forgiving man..... but there is a limit!”1
The TK has also been used throughout the region as a part of the evangelical mission of the marketers of the device, Tony Lawrence and Magda Van Der Walt. A book promoting the device and the work of Tony Lawrence states the following:
“Twice per year... young male initiates in South Africa alone take an important step toward manhood by undergoing circumcision during a time of initiation … But what should be a glorious occasion for these teenagers often turns out to be a nightmare. One out of five boys end up with their genitals partially or fully amputated.... The Seize the Day foundation is rescuing these children in a holistic way. Among other things, Tony Lawrence and the seize the day volunteer distribute a pack to each initiate. (The pack contains a TK and a bible) ... The solution is to circumcise and evangelize.”2
The TK is being aggressively marketed and, at times, with an inappropriate religious agenda. The marketers of the device make unsubstantiated claims and disregard safety concerns. They have threatened researchers who published data critical of the TK. The TK must be withdrawn from use throughout sub-Saharan Africa for adults and adolescents until its safety concerns are addressed.
1 This correspondence was forwarded to TAC by Carpe Diem Enterprises
2 W Cambell et al., ‘Be a hero: The battle for mercy and social justice.’ 2004. Pg. 204
Male Circumcision: Progress and Problems with Implementing this Prevention Tool. 18/1/10
This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period
By Christine Lubinski
18 February 2010
It’s been almost 3 years since the World Health Organization developed its recommendations and goals for male circumcision. As Kim Dickson, MD, an AIDS expert with the WHO, outlined in a presentation at CROI today, scale-up has not been speedy or simple.
In her talk, Dickson noted that the WHO identified 13 priority countries for scale up, especially those with high prevalence, generalized heterosexual epidemics, and low levels of circumcision. All of the countries are in eastern and southern Africa. The goal: reach 80 percent of adult males and newborns by 2015 in the target countries.
This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period. The approximate cost of the procedure in these settings is $50.
Advocacy has been vibrant at all levels, and there have been multi-stakeholder consultations in all countries including various groups. A number of funding agencies have made money available for male circumcision-related activities, including PEPFAR, the Global Fund, and the Bill & Melinda Gates Foundation. Male circumcision policies have been developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe. Kenya has developed actual guidelines. Most countries are focused on so-called “catch-up” strategies to reach adult men, but longer term neonatal strategies are under consideration in Botswana, Swaziland and Zambia. Provider training programs have been implemented in almost all 13 countries.
The bottom line question, however, is how many circumcisions have been done?
Only Kenya has scaled up male circumcision in any significant way. Using teams of providers, Kenya did 36,000 circumcisions in 30 days in 11 districts at an approximate cost of $30 per procedure. Almost 100,000 procedures have been performed to date. Kenya’s success is in part related to a successful partnership between government and NGOs.
There are many challenges and constraints. Human resource issues loom large, not only to do the procedure but even to identify dedicated staff to focus on developing and launching this intervention in resource-poor settings. Task shifting is not permitted in some countries, and the number of available doctors and nurses are simply inadequate. It is difficult in some cases to get the necessary political support. In addition, it appears that country health leaders are not always aware that specific funding for MC is available or don’t know how to access it.
Most of these countries have traditional providers of male circumcision, and there is no clear guidance on how to involve them. Service delivery sites also need guidance on how to deal with HIV-positive men who may present. While circumcision is not generally recommended for this group in this context, it is important that they be dealt with in an appropriate and non-discriminatory way.
We need strategies for demand creation. We also need effective communication strategies to convey messages about the partial protection provided by MC and messages to reduce risk compensation. We already know that political commitment accelerates programs and that early engagement and consultations with stakeholders prevent setbacks. We need innovation to scale up service delivery and new devices to accelerate delivery and reduce adverse events.
More information is available here
Money from Mutilation: The Tara Klamp Story
A massive unethical medical intervention
Treatment Action Campaign
2 November 2010
A massive unethical medical intervention is unfolding in Kwazulu-Natal (KZN). It could harm many men. At the root of it is greed and also cowardice. We tell the story of the Tara KLamp in four parts. Beyond the details it is ultimately a simple story. The Kwazulu-Natal government is using an unsafe circumcision device that will injure thousands of men. The device has been sold to the state by unscrupulous business people with shady pasts. At the end of our story one question will remain unanswered, what motivated the KZN government to do this?
-Part one: Introducing the Tara KLamp
-Part two: The dubious people selling the Tara KLamp
-Part three: Where's the money: The role of the Kwazulu-Natal Government
-Part four: How not to be brave: The World Health Organisation
-Appendix: Cost of Tara KLamp versus forceps-guided circumcision techniques
Read this articel here
TAC Electronic Newsletter - Reporting on the Tara KLamp
1 November 2010
Money from mutilation: The Tara KLamp Story1
Part one: Introducing the Tara KLamp
Part two: The dubious people selling the Tara KLamp
Part three: Where's the money: The role of the Kwazulu-Natal Government
Part four: How not to be brave: The World Health Organisation
Appendix: Cost of Tara KLamp versus forceps-guided circumcision techniques
A massive unethical medical intervention is unfolding in Kwazulu-Natal (KZN). It could harm many men. At the root of it is greed and also cowardice. We tell the story of the Tara KLamp in four parts.2 Beyond the details it is ultimately a simple story. The Kwazulu-Natal government is using an unsafe circumcision device that will injure thousands of men. The device has been sold to the state by unscrupulous business people with shady pasts. At the end of our story one question will remain unanswered, what motivated the KZN government to do this? Perhaps by following the money we will find out.
Part One: Introducing the Tara KLamp
Medical male circumcision reduces the risk of heterosexual men acquiring HIV infection. This has been shown in three clinical trials in sub-Saharan Africa.3,4,5 Circumcision also has other health benefits. It puts an end to the painful condition, suffered by some men, of swelling foreskin. It reduces the risk of men contracting human papilloma virus which can cause throat cancer as well as cervical cancer in women. There is some evidence that circumcised men also have a lower risk of penile cancer and urinary tract infections. On the other hand, the risks with having a medical circumcision are small. There is about a 1 to 3% complication rate and these resolve nearly 100% of the time.
So it was greeted with great excitement when after years of foot-dragging the Department of Health began backing voluntary medical male circumcision. The KZN government led the way following an announcement by King Goodwill Zwelithini that circumcision should be revived amongst Zulu men.6
Unfortunately, this initial enthusiasm has turned sour. Instead of using only standard surgical techniques, such as the forceps guided one, for all circumcisions conducted in the province's public sector facilities, the provincial government has also rolled out a dangerous plastic circumcision device called the Tara KLamp. It works by clamping shut on the foreskin so that the blood supply to it is cut off. Over a period of 7 to 10 days the foreskin is supposed to die and fall off with the clamp, but sometimes the clamp must be surgically removed.7
The device was invented by Dr. Gurcharan Singh and is manufactured by a Malaysian company, Taramedic Corporation. It is sold in South Africa by two companies, Intratrek Properties and Carpe Diem Enterprises.
Researchers at one of the circumcision trial sites, Orange Farm in Gauteng, invested great effort to find the optimal way to carry out circumcisions. As part of that effort, back in 2005, they decided to test the Tara KLamp. They were genuinely excited by it, hoping that it would be quicker than the standard forceps guided technique but without compromising safety. They had reason to believe it would be successful. Two previous Tara KLamp studies had been conducted in children without serious problems.8
Unfortunately, the Tara KLamp was a disaster. 166 men were asked to participate in the trial but 97 declined, of whom 94 gave the reason that they did not wish to use the clamp.9 The remaining participants were randomly selected (with their permission) to either receive clamp or forceps guided circumcision. On every important measure the clamp was worse.10
Here are the results of the TaraKLamp versus forceps-guided techniques:
Complication rate: 37% versus 3%.
Delayed wound healing: 21% versus 3%
Problems with penis appearance: 31% versus 3%.
Participants more likely to report bleeding: 21% versus 0%
Injury to the penis: 21% versus 0%
Infection: 32% versus 0%
Swelling: 83% versus 0%
Problems with urinating: 16% versus 0%
The participants were also asked to estimate pain using a standard well developed methodology. The clamp caused much greater pain. In fact, this is probably its biggest problem.
The doctors involved in the trial noticed these problems. They requested the trial to be interrupted. Medical trials should have a Data Safety Monitoring Board. One of this board's jobs is to stop a trial if it becomes unethical to continue it. And indeed, after reviewing the data and seeing the shockingly bad results of the clamp, this is exactly what the board did.
The results of this trial were published in the South African Medical Journal last year.11 That should have put an end to the Tara KLamp being used in adults. Unfortunately it was not to be. As we shall see, the sellers of the Tara KLamp and the KZN government were intent on using the clamp.
Part two: The dubious people selling the Tara KLamp
The Tara KLamp is being marketed in South Africa, Lesotho, Mozambique, Kenya, Botswana and perhaps elsewhere. The KZN government has purchased tens of thousands of Tara KLamps. Without aggressive marketing, the clamp would have been a forgotten, failed adult circumcision device.
Much of the marketing is carried out by Tony Lawrence. It is Lawrence who is usually quoted defending the clamp in articles published in the South African media. Lawrence is a motivational speaker with various business interests. Together with Magda van der Walt, he runs a company that sells the clamp, Carpe Diem Enterprises.
Van der Walt is a former Miss United Nations South Africa runner up – something she claims opened many doors for her in the political world. She also claims to have invested large amounts of her own money in Carpe Diem. Both Van der Walt and Lawrence are listed as non-voting members of the Haggai Institute South Africa, the South African branch of an international evangelical organisation.
Evangelism is part of their marketing strategy. A book promoting the device and the work of Lawrence states, “Twice per year... young male initiates in South Africa alone take an important step toward manhood by undergoing circumcision during a time of initiation … But what should be a glorious occasion for these teenagers often turns out to be a nightmare. One out of five boys end up with their genitals partially or fully amputated.... The Seize the Day foundation is rescuing these children in a holistic way. Among other things, Tony Lawrence and the seize the day volunteers distribute a pack to each initiate … The solution is to circumcise and evangelize.”12
It appears that as it became clear that South Africa would implement circumcision, Carpe Diem toned down the religious aspects of their messaging in the hope of selling the Tara KLamp to the public health system.
Their marketing strategy is now focussed on discrediting the safety concerns raised by the Orange Farm study. Their website states, “This invention enables circumcisions to be performed not only safely and easily but also --for the first time in surgical history-- enables circumcisions to be performed just as aseptically, … on the roadsides or out there in the bush ...”.13 This statement is contradicted by the available evidence from the Orange Farm trial and reports of penile injuries in some patients in KZN.
The device's marketers, as well as KZN health officials, have also claimed that the device had bad results in Orange Farm because the trial doctors were insufficiently trained to use it. This is false. The doctors on the Orange Farm trial were highly experienced circumcision surgeons. They were provided with training on how to use the clamp at the outset. When they experienced a high rate of adverse events, Lawrence went to Orange Farm with an expert to train the doctors further. But the adverse events continued and the trial was then stopped. That expert circumcision doctors experienced problems with it despite training is not compatible with the claim that the Tara KLamp enables circumcisions to be performed safely and easily and even in the bush.
The clamp, which must be disposed after a circumcision, is usually sold for about R160 by Carpe Diem, although the KZN government has paid much more for it. Carpe Diem claims that circumcisions are cheaper with the clamp than the standard forceps guided technique. However, we consulted circumcision experts and calculated that the cost of the standard forceps circumcision is cheaper than the Tara KLamp, even without taking into account the cost of the additional complications that the clamp causes.14
The device is also marketed as a faster method of performing circumcisions, as it can be carried out in less than 10 minutes. This is not much faster than it takes to do a forceps-guided circumcision and certainly does not outweigh safety concerns. It also does not take into account the additional time needed to surgically remove the device from some patients, or the time health workers have to spend on the additional complications caused by the Tara KLamp.
In a letter circulated to the media Lawrence writes, “A number of key professionals (including urologists) have confirmed the efficacy of Tara KLamp and amongst these, is Professor Segone, previous Head of Urology at MEDUNSA.” We spoke to Professor Segone and he denied ever endorsing the Tara KLamp.
The attitude of the company to research critical of its device is exemplified by Dr. Gurcharan Singh, the Tara KLamp inventor. In an email exchange with an author of the Orange Farm study Singh wrote, “All it needs is a simple withdrawal of your manuscript and gracefully accept the reality. I am even not asking for an apology, for I am a very forgiving man..... but there is a limit!”
However it was not Carpe Diem, but Intratrek Properties, directed by Ibrahim Yusuf, that got the lucrative KZN contract for the device, amidst some controversy.15 The Mail and Guardian (M&G) published a story about Yusuf and his murky past, which quotes sources alleging that he was involved in Mandrax smuggling in Zambia in the 1980s. The M&G also described a 2002 newspaper report that alleged that the Zambian Drug Enforcement Commission (DEC) was looking for Yusuf to help with an investigation into US$29,000 obtained from the Zambian National Assembly. Yusuf denied all the allegations against him to the M&G.16 The M&G subsequently published a further story alleging that Zambia's Drug Enforcement Commission was seeking Interpol's assistan ce to find Yusuf to “answer criminal charges.” Yusuf denied this too.17
Intratrek is also registered in Mozambique. Yusuf has 49% of the company's shares. His co-directors are former ANC intelligence operative Lawrence Pietersen with 26% of the shares and ex-Mozambican general Joao Americo Mpfumo who holds 25%. We have learned that the general is promoting the clamp in Mozambique.
As far as we can tell, none of Lawrence, Van der Walt, Yusuf, Pietersen or Mpfumo has medical backgrounds or expertise in circumcision. The obvious question that surely follows is why has the KZN government bought their device?
Part 3 will be published tomorrow. Part 4 will be published on Wednesday.
1 Written by Nathan Geffen and Marcus Low with assistance from Catherine Tomlinson, Kiu Kim, Jonathan Berger, Ntombizonke Ndlovu, Richard Shandu and Lihle Dlamini. Several other people assisted but wish to remain anonymous.
2 The manufacturers of the Tara KLamp capitalise the L in KLamp.
3 Auvert et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Epub Oct 25. http://www.ncbi.nlm.nih.gov/pubmed/16231970
4 Bailey et al. 2007. Lancet. Feb 24;369(9562):643-56. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/17321310
5 Gray et al. 2007. Lancet. Feb 24;369(9562):657-66. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. http://www.ncbi.nlm.nih.gov/pubmed/17321311
6 Mthembu B. 2010, 19 January. KZN backs circumcision programme to combat HIV. Mail & Guardian. http://www.mg.co.za/article/2010-01-19-kzn-backs-circumcision-programme-to-combat-hiv
7 See also: TAC and Southern African HIV Clinicians Society. 2010. Voluntary Medical Male Circumcision is Safe and Effective: But beware of unsafe devices. http://www.tac.org.za/community/node/2905
8 These studies were of questionable quality because neither were randomised and one did not have a control group, but they were sufficient basis for proceeding with a trial in adolescents and adults.
9 This trial was a separate one to the Orange Farm trial that showed that medical male circumcision reduces the risk of heterosexual men contracting HIV. Both trials were carried out by the same investigators.
10 All these differences were statistically significant.
11 Lagarde E et al. 2009. High rate of adverse events following circumcision of young male adults with the Tara KLamp technique: a randomised trial in South Africa. S Afr Med J. Mar;99(3):163-9. http://www.ncbi.nlm.nih.gov/pubmed/19563093
12 Cambell, W et al., ‘Be a hero: The battle for mercy and social justice.’ 2004. Pg. 204. http://books.google.co.za/books?id=mpG77eCDCREC&pg=PA203
13 Tara KLamp marketing brochure. www.taraklampsa.co.za/Tara%20KLamp%20Booklet.doc
14 The appendix to this series of articles explains the difference in cost between the two techniques.
15 Faull L. 2010. Tender details get the KLamp. Mail & Guardian. http://www.mg.co.za/article/2010-09-03-tender-details-get-the-klamp. Many of the details for the M&G article were discovered by TAC intern Kiu Kim.
16 Faull L. 2010. Cloud over clamp man. Mail & Guardian. http://www.mg.co.za/article/2010-10-01-cloud-over-clamp-man
17 Faull L. Tara KLamp director faces extradition. M&G October 23 to 28 2010.
This is part three in our four-part series on the Tara KLamp. Part one and two can be read here:
Part four will be published tomorrow.
Part three: Where's the money: The role of the KZN Government
The Tara Klamp is unsafe, more expensive, and only marginally faster to use than standard methods of circumcision. Also, standard surgical techniques work very well in mass circumcision programmes. For example, a Zimbabwean programme, with a team of two doctors and three nurses, has been optimised to do ten surgical circumcisions an hour.1 Why then did the Kwazulu-Natal (KZN) health department start using the clamp?
On 12 July 2010 the Treatment Action Campaign (TAC) sent a letter outlining our concerns to KZN MEC for Health Sibongiseni Dhlomo. His reply was astonishing, “What we have explained to the Minister and now indirectly to you is that we are committed to massive Medical Male Circumcision in KZN as directed by His Majesty our King. We will do it medically as the Majesty instructed us. The king has instructed us that no one should die as a result of our MMC intervention but he did not instruct us that no one should have pain.” This is the only response we have had from Dhlomo. Various attempts to meet with him and Premier Mkhize to discuss the Tara KLamp have so far failed to materialise.
On 3 August we asked the department for details on the contracts relating to the purchase of the Tara KLamp. We did not receive a reply. On 3 September the Mail & Guardian ran an article titled “Tender details get the klamp”.2 It outlined how they too failed to obtain financial details on the purchase of the clamp.
In October, in reply to questions asked in Parliament, the national Minister of Health wrote that the KZN government had purchased 22,500 Tara KLamps from Intratrek as of 30 September at a total of R4.4 million excluding VAT.3 KZN paid R188 (ex. VAT) per device for the first 2,500 but then started paying R195, much higher than the Carpe Diem price of R160. A KZN official explained in a telephone conversation with TAC that the province did not need to call for a tender for the clamp because there was only a single supplier. This is confirmed in the national Minister of Health's Parliamentary answer. Either Carpe Diem has been abandoned by the Malaysian manufacturer or the claim of a single-supplier is false. Even if Intratrek is the only supplier, a motivation for the purchase must still be made public.
As part of the circumcision drive in KZN, the province has held several circumcision camps, where young men gather at a hospital venue and are circumcised. Most of these camps have used forceps-guided circumcision, but the Tara KLamp is also being used.4 Apparently to compensate for the increased pain caused by the clamp, health workers in at least one of these camps were instructed to administer a higher dose of a strong pain killer, bupivacaine. Although this would relieve the worst pain experienced from the clamp, which usually occurs in the first 24 hours, it adds to the cost. The health workers were also instructed to prescribe antibiotics to offset the device's risk of infection. The KZN government intends to do millions of circumcisions over the next few years. If it gives antibiotics routinely to men circumcised with the clamp it will risk creating antibi otic resistance for no good reason.
Following a letter from TAC to Health Minister Aaron Motsoaledi describing our problems with the device, Motsoaledi met with TAC and the Southern African HIV Clinicians Society. In response to our concerns, he established the Medical Male Circumcision Steering Committee.
As a compromise, the committee, which includes people from the WHO, HIV Clinicians Society, KZN and national government, is trying to do a rapid assessment of the clinical outcomes of patients who were circumcised with the clamp in KZN. But this should have been a secondary objective; stopping the use of the device should have been the first priority. Even so, the committee, which has met a few times, has missed its deadlines for conducting the assessment. Furthermore, we have learned that the record keeping of the Tara KLamp circumcisions conducted in KZN over the last few months has been poor so it is unlikely that the rapid assessment can be done properly.
Sandile Tshabalala of the KZN Health Department was quoted by SAPA claiming that “More than 5000 people have been circumcised by this clamp and not even a single person has died. … No-one has complained that his penis has been cut."5
Meanwhile, TAC has received reports, including cell phone video clips, of people injured by the Tara KLamp. We also have a first-hand account of the immense pain a man experienced. We release photos of Tara KLamp caused injuries in KZN over the last few months. Please note these are very disturbing:
It has also been reported that the KZN Health MEC has committed to rolling out the Tara KLamp in prisons and that 148 such circumcisions have already been carried out in Qalakabusha Prison.6 But the reasoning behind this decision is difficult to understand. Medical male circumcision has been shown to reduce the risk of HIV-positive women transmitting the virus to men. No prevention benefit has been shown in populations of men who have sex with men.
This is a terrible situation. Companies selling the Tara KLamp are making money by inflicting injuries and suffering. The KZN government's adoption of the clamp is, in the best case scenario, deeply suspicious and unscientific.7
Part four will be published tomorrow.
1 Hatzold K et al. 2010. Models to increase volumes and efficiency (MOVE) in Zimbabwe's male circumcision program. XVIII International AIDS Conference. http://pag.aids2010.org/Abstracts.aspx?SID=433&AID=11622
2 Faull L. 2010. Tender details get the KLamp. http://www.mg.co.za/article/2010-09-03-tender-details-get-the-klamp
3 National Assembly. Question No. 2523. http://www.tac.org.za/userfiles/QuestionsAndAnswersInParliamentAboutTaraKLamp20100913.doc See also National Assembly. Question No. 2461.
4 We have learned that approximately 7,000 forceps-guided circumcisions have been carried out since the programme was launched. The KZN Health Department released a statement claiming that a total of 10,229 circumcisions have been conducted since April 2010 and the target for 2010/11 is 372,754. http://www.info.gov.za/speech/DynamicAction?pageid=461&sid=13648&tid=22281
5 SAPA. 26 October 2010. KZN defends Tara Klamp. http://www.aegis.org/news/sapa/2010/SA101003.html
6 SAPA. 29 October 2010. KZN government to circumcise prisoners. http://www.timeslive.co.za/local/article733337.ece/KZN-government-to-circumcise-prisoners
7 In a statement published On 14 October a group of over 20 civil society organisations, including MSF, the World AIDS Campaign, Black Sash, SECTION27 and TAC demanded that the Deputy President and the Minister of Health intervene with utmost urgency to halt the use (and purchase) of the Tara KLamp until a Voluntary Medical Male Circumcision policy based on sound medically proven procedures can be adopted nationally. See http://www.section27.org.za/2010/10/14/meeting-the-challenges-of-hiv-treatment-and-prevention-through-independent-mobilisation-and-work-through-the-sa-national-aids-council-sanac/
Progress in Scale-up of Male Circumcision for HIV Prevention in Eastern and Southern Africa
Subtitle: Focus on service delivery
Published by the World Health Organisation 2011
ISBN 978 92 4 150251 1
Abstract: WHO and UNAIDS are monitoring progress in scale-up and impact in these priority countries. As most countries have the key elements of programmes in place, the present report provides an overview of progress by the end of 2010 with a focus on the numbers of MCs performed for HIV prevention. In support of monitoring and evaluation (M&E), WHO and UNAIDS, in collaboration with PEPFAR, developed A guide to indicators for male circumcision programmes in the formal health care system3 in 2009, suggesting indicators that should be used by countries. Key indicators from the guide for which data were reported from at least some countries for 2010 and which are presented in this report include:
-number of MCs performed for HIV prevention;
-number and percentage of persons seeking MC services who were tested for HIV.
-Section 1. Introduction and overview
-Section 2. Progress in service delivery of male circumcision for HIV prevention in priority countries
-Section 3. Innovations to accelerate and sustain delivery of services
-Section 4. Key lessons, challenges and summary
Download this document here (PDF, 1.43 MB, 32 pg)
A New Way To Protect Against HIV? Understanding the Results of Male Circumcision Studies for HIV Prevention. UNAIDS Documents and Guidelines
This brochure is designed to help prevention advocates understand the ramifications of findings from studies of male circumcision for HIV prevention, and to explore the opportunities and challenges associated with implementation. It is part of AVAC’s “Anticipating and Understanding Results” series, which provides timely analysis of trials of AIDS vaccines and other new prevention
technologies. For other publications in this series, visit avac.org/publications.htm#series. Download PDF (268.11 KB)
TAC Policy Brief on Voluntary Male Medical Circumcision (VMMC). 25/11/09
It is two and a half years since TAC published its briefing on VMMC.  Since then, in Southern Africa, over 3,000 VMMCs have been carried out by the Family Life Association of Swaziland. Zambia has performed nearly 8,000 and Zimbabwe just under 1,300. Yet comparatively little progress has been made making this affordable intervention (about R300 per VMMC) available beyond Orange Farm in South Africa, where several thousand circumcisions have been performed in an ANRS sponsored research project. PEPFAR, the Global Fund and the Gates Foundation have committed to funding VMMC, but South Africa has not made use of this opportunity. 
The key recommendation of this brief is that the South African National AIDS Council (SANAC) needs to move quickly to adopt a policy that promotes the scaling up of VMMC and that the Department of Health must ensure this policy is implemented. It is at over four years since the results of the first circumcision trial were published; South Africa should have scaled up beyond Orange Farm by now.
Evidence for the benefts of VMMC
The evidence that circumcised heterosexual males have less risk of contracting HIV is compelling. Three randomised controlled clinical trials conducted in high-prevalence areas in sub-Saharan Africa, whose resuts have been published in reputable medical journals, have found that the risk of HIV-negative males contracting HIV is reduced by 50 to 60% when they are circumcised. , ,  Evidence from two of these trial settings, Orange Farm and Rakai, Uganda, shows that VMMC also reduces the risk of men contracting Human Pappiloma Virus (HPV). ,  A trial in Rakai also found that VMCC reduces the risk of men contracting Herpes Simplex Virus-2 (HSV-2). 
The benefits of VMMC for the female partners of circumcised men have also been shown. Women partners of circumcised men are less likely to contract trichomoniasis and bacterial vaginosis. VMMC also reduces the risk of symptomatic ulceration in HIV-negative men and women and HIV-positive men. , 
A UNAIDS/WHO/SACEMA expert review of mathematical models of VMMC found:
* There would be large benefits of male circumcision among heterosexual men in low male circumcision, high HIV prevalence settings. The review found that one HIV infection would be averted for every five to 15 male circumcisions performed
* They found that the cost of averting one HIV infection ranges from R1,125 (US$150) to R6,750 (US$900) using a 10 year time horizon.
* Critically they found that women benefit indirectly from reduced HIV prevalence in circumcised male partners and that VMMC service scale-up "acts synergistically with other strategies to reduce HIV disease burden." 
A review of the risks and benefits of circumcision for women, published in The Lancet in July, states:
Although circumcision of HIV-infected men does not seem to directly reduce HIV risk for their female partners in the short term, women will benefit from male circumcision programmes. Wide-scale roll-out of male circumcision is expected to lead to decreasing HIV prevalence in communities over 10—20 years, in both men and women, by averting new infections in men and onward transmission to their partners.8 On a shorter timescale, a woman's HIV risk would be substantially reduced if circumcision prevents her male partner from acquiring HIV. Indeed, anecdotal reports suggest that interest in circumcision in young men in the first roll-out programmes in Africa is in part being driven by women's preference for circumcised partners. Finally, women with circumcised partners, irrespective of HIV serostatus, face decreased risk of sexually transmitted infections such as Trichomonas vaginalis, bacterial vaginosis, herpes simplex virus type 2, and human papillomavirus. 
Circumstances where VMMC has no proven benefits for HIV
There are circumstances where VMMC appears to have no proven benefits for HIV:
* Circumcised HIV-positive men do not have a lower risk of passing HIV to their female partners. A trial testing this was ended early by its Data Safety Monitoring Board because of futility. (NB: The 2007 TAC briefing indicated that there was some evidence this was benefit of circumcision. This was based on the best evidence at the time, but is now not supported by the evidence.) 
* There is no compelling evidence that VMMC reduces the risk of transmission in homosexual sex.
Evidence for the safety of VMMC
No surgical procedure is risk-free, but the evidence for the safety of VMMC is considerable:
* Over 50,000 VMMCs have been performed in sub-Saharan Africa as part of trials and projects to reduce the risk of transmission from HIV. There are no reported cases of serious permanent adverse events.
* The balance of evidence indicates that VMMC does not cause sexual dissatisfaction or dysfunction. 
No evidence for risk compensation
An argument offered against VMMC is that it will result in risk compensation behaviour, i.e. that men would take sexual risks in the belief that they are protected from HIV transmission. Furthermore, that this risk-taking would have negative effects on women's rights.
No evidence has been offered for this view. It is often simply asserted. But a study of risk compensation behaviour in one of the three trials found that it did not occur.  In a real world setting in Kenya, i.e. outside of a trial, no evidence was found of risk compensation behaviour. 
It is important that counselling at VMMC sites and public messaging on VMMC emphasises that VMMC is not completely protective against HIV transmission and using condoms for sex remains necessary to reduce the risk of contracting HIV.
Other arguments against circumcision are dealt with by Halperin et al. (2008). 
Promoting VMMC is consistent with human rights
VMMC is consistent with a human rights approach to health-care. It should always be implemented in accordance with these principles:
* It must be voluntary or, in the case of infants, must be done with parental or guardian consent.
* It must be accompanied by proper counselling on the need for practising safer sex, the offer of HIV testing and referral to treatment facilities for people who are HIV-positive.
* It must not undermine women's health.
There are several projects in Sub-Saharan Africa that already meet these criteria, including the Orange Farm project in South Africa. They should be used as models for scaling up VMMC.
The slow progress in rolling out VMMC means we are losing an important opportunity. The delay in making this essential health intervention available is inconsistent with human rights, for both men and women, as well as sound public health care.
 TAC. 2007. Male circumcision and HIV prevention : A TAC Briefing. http://www.tac.org.za/community/node/2160.
 Swaziland data was obtained via personal communication with the programme co-ordinator of the Family Life Association, Dr Ladislous Chonzi. The data for Zambia and Zimbabwe was obtained via personal communication with Scott Billy of the Society for Family Health. Also personal communication with Emmanuel Njeuhmeli of PEPFAR.
 Auvert et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25. http://www.ncbi.nlm.nih.gov/pubmed/16231970
 Bailey et al. 2007. Lancet. Feb 24;369(9562):643-56. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/17321310
 Gray et al. 2007. Lancet. Feb 24;369(9562):657-66. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. http://www.ncbi.nlm.nih.gov/pubmed/17321311
 Auvert et al. 2009. J Infect Dis. 2009 Jan 1;199(1):14-9. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. http://www.ncbi.nlm.nih.gov/pubmed/19086814
 (1, 2, 3) Aaron et al. 2009. NEJM. Volume 360:1298-1309. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis. http://content.nejm.org/cgi/content/full/360/13/1298
 Gray et al. 2009. Am J Obstet Gynecol. 2009 Jan;200(1):42.e1-7. The effects of male circumcision on female partners' genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. http://www.ncbi.nlm.nih.gov/pubmed/18976733
 UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. 2009. Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision Making? PLoS Med 6(9): e1000109. doi:10.1371/journal.pmed.1000109
 Baeten et al. 2009. The Lancet, Volume 374, Issue 9685, Pages 182 - 184, 18. Male circumcision and HIV risks and benefits for women.
 Wawer et al. 2009. Lancet. 2009 Jul 18;374(9685):229-37. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. http://www.ncbi.nlm.nih.gov/pubmed/19616720
 Doyle et al. The Impact of Male Circumcision on HIV Transmission. J Urol. 2009 Nov 12. http://www.ncbi.nlm.nih.gov/pubmed/19913816
 Mattson et al. 2009. PLoS ONE. 2008; 3(6): e2443. Risk Compensation Is Not Associated with Male Circumcision in Kisumu, Kenya: A Multi-Faceted Assessment of Men Enrolled in a Randomized Controlled Trial. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409966
 Agot et al. 2007. J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):66-70. Male circumcision in Siaya and Bondo Districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision. http://www.ncbi.nlm.nih.gov/pubmed/17019365
 Halperin et al. 2008. Future HIV Therapy September 2008, Vol. 2, No. 5, Pages 399-405. Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics. http://www.futuremedicine.com/doi/full/10.2217/17469600.2.5.399n/a
Thanks to Dirk Taljaard and Bertran Auvert for feedback.
Snipping Away at HIV: Male Circumcision and HIV Prevention. 16/03/09
In this opinion piece Nathan Geffen and Paul Booth make the case for the male circumcision debate to put to rest and for the urgent development of an ethical national voluntary male medical circumcision policy.
The HIV epidemic has taken over two and a half million lives in South Africa. Another five million people live with the virus. We are making progress and probably over half-a-million people are on ARV treatment. It is still far too few; the National Strategic Plan (NSP) target is to have over 1.5 million people on treatment by 2011, a big challenge.
But the area where we have fallen furthest behind is preventing new infections. We know of a few things that can change this. The mother-to-child transmission prevention programme has to improve. Condom promotion must be more explicit, frequent and clever. ARVs for rape survivors, as well as for when the “condom broke” must be widely advertised. Every school should have a life-skills programme that addresses HIV, sex and condoms properly. Getting a lot more people on ARVs will also help reduce new infections, because they reduce the amount of HIV in your body making you less infectious (but you still should use a condom).
Yet one of the interventions that would have a significant effect on prevention gets a hard time: circumcision. Three huge clinical trials as well as many studies comparing circumcised groups of people to uncircumcised ones have shown unequivocally that carrying out this simple 20 minute operation on a young man under local anaesthetic reduces his risk of contracting HIV substantially.
Understandably many people feel uncomfortable with a large public health intervention that involves amputating a body part, a particularly sensitive one at that. But consider this: Several thousand medical circumcisions have been carried out in these clinical trials without a single report of life-threatening or serious permanent damage. On the contrary, dozens of HIV infections were prevented. Also, we are a society in which other forms of voluntary bodily mutilation, piercings and tattoos, are acceptable. Surveys of men circumcised as adults generally show that they were happy they did it. Voluntary male medical circumcision needs to become part of our arsenal to reduce new HIV infections. And of course it should go without saying that no one should ever be compelled to have a circumcision.
The thought of loping off the end of a man's penis as a measure to protect against HIV seemed an absurd one when we first encountered it. But there's a biological explanation for why it works. The foreskin, which is very sensitive, is easily abraded during sex. It also contains a high number of HIV target cells and absorbs HIV more easily than other parts of the genitals.
From South Africa's experience of behaviour change interventions we have learnt that knowledge of how HIV is transmitted seldom changes the sexual risks people take. So what makes us believe that any adult man would willingly undergo circumcision, especially in light of the need to abstain from sex for six weeks following the procedure?
The answer lies in Orange Farm, a township of a few hundred thousand people south of Johannesburg. The largest medical circumcision trial took place there, at the Bophelo Pele male circumcision centre. Bophelo Pele continues to conduct circumcisions and has so far circumcised nearly 5000 adult men. We visited the centre and found the knowledge and HIV literacy of the young men waiting to be circumcised surprisingly good. All but one of them were getting circumcised primarily as an HIV prevention measure. However, every man was fully aware that male circumcision is only partially effective and that they still needed to use condoms.
Circumcision is part of our cultural landscape, practised traditionally by Xhosas, Jews, Muslims and others. An early finding of the medical trials was that African traditional circumcision often merely involves an incision into the foreskin and seldom removes the entire foreskin. Often traditional circumcisions are carried out with unsterilised equipment. Sometimes they go horribly wrong because of the poor training of the person carrying it out. This raises the possibility that initiation procedures can be teemed up with medical facilities offering circumcision, making them safer. There are already discussions about this between circumcision doctors and some traditional leaders.
Men have proven to be a hard target group to reach with HIV prevention messages. The Bophelo Pele project shows that offering circumcision brings men into clinics where they can be reached with a range of health interventions, such as HIV testing, treatment for HIV and other sexually sexually transmitted infections and counselling on safer sex.
One fear is that men will get circumcised and then use it as an excuse to have risky sex sans condoms. Besides suggesting a rather bitter view of the male section of the human race, it is actually not supported by the evidence. On the contrary, at the site of the trial that took place in Kenya, a survey showed that men who participated reduced their risk-taking. You could retort that this was not circumcision but probably the counselling and other support they received. But that is the point: it is a benefit of offering circumcision that men will then go to a clinic and be counselled so that they will be more likely to use condoms.
The World Health Organisation recommends circumcision. The South African National AIDS Council (SANAC) recognises the evidence that it is effective at reducing the risk of HIV transmission. Unless new evidence comes to light, the science part of the debate is settled. The only honest basis for being opposed to circumcision is if you have moral objections. In that case we must agree to disagree. In our view, given that circumcision has been shown to be effective and relatively safe, the state has a moral duty to offer it more widely.
We now need to develop an ethical national voluntary male medical circumcision policy. This policy must acknowledge that male circumcision is nowhere near 100% effective in preventing HIV but it must also acknowledge that circumcision is one of the most effective interventions we have for preventing HIV. It must be integrated with our other HIV prevention and treatment interventions.
World AIDS Day 2008 was a political breakthrough. There was unprecedented unity and energy from the Ministry of Health, business, labour and activists. We must not lose this momentum as we translate our refreshing new leadership into actions that save lives. Yet the only way that we can make serious headway against the epidemic and meet the NSP target to reduce HIV incidence by half by 2011 is to use all the proven interventions available, including circumcision.
Geffen is with the Treatment Action Campaign. Booth writes in his personal capacity
Male Circumcision: Context, Criteria and Culture (Part 1). 22/06/07
With male circumcision and its links to HIV acquisition hitting the headlines and sparking debates around the world, in the first of a special three-part series on the issue, UNAIDS takes a closer look at the historical, traditional and increasingly social reasons behind the practice of male circumcision across the world.
- Religious Practice
- Circumcision as a social statement
- Perceived health and sexual benefits
- Expected increase in demand
Read the document online
Moving Forwards: UN Policy and Action on Male Circumcision (Part 3). 02/03/07
In the final part of a special series on the issue of male circumcision and its links to the reduction of HIV acquisition, www.unaids.org discusses expected upcoming action and developments from the United Nations on male circumcision through a special interview with UNAIDS Chief Scientist, Dr Catherine Hankins.
Read the interview.
Male Circumcision and HIV: The Here and Now (Part 2). 28/02/07
In the second of a special three-part series on the issue of male circumcision and its links to the reduction of HIV acquisition, unaids.org considers current research findings. It’s a subject that hits headlines, fuels discussions, sparks debate and causes some of the men in the room to wince and cross their legs. Male circumcision and its links to HIV is one of the most talked about issues within the AIDS response over the last years, with latest research findings driving potential change in the way male circumcision is practiced and implemented for the future in relation to HIV prevention.
- Research findings
- The biology
- No ‘magic bullet’
- Safety, sanitation and communication
Circumcision in the News
News reports on the role of circumcision in HIV prevention:
Women with Circumcised Partners Less Likely to have HIV, no Less Likely to Use Condoms. 19/03/2014
Gus Cairns, AIDSMap
A study from Orange Farm near Johannesburg in South Africa, the area that hosted the first-ever randomised controlled trial of male circumcision for HIV prevention, which concluded in 2005, has found evidence that women who are partners of circumcised men are less likely to have HIV themselves.
A 2009 meta-analysis (Weiss) of the benefits to women of circumcising men found no evidence that having sex with a circumcised, rather than an uncircumcised, man reduced the risk of HIV infection to women, though there have been studies that show that male circumcision reduces the risk of human papillomavirus (HPV) and genital herpes (HSV2) in women.
But this is the first study to provide convincing evidence that male circumcision offers a degree of protection to their female partners too – although the benefit is quite small, in the order of a 15% reduction in prevalence in women who only have sex with circumcised men.
A voluntary medical male circumcision (VMMC) centre called Bophelo Pele was set up in 2008, funded by the Bill and Melinda Gates Foundation, after the results from the Orange Farm randomised controlled trial were confirmed by two other large trials in Uganda and Kenya.
Since Bophelo Pele started, the proportion of local men who are circumcised has risen from 15% to 53% and a recent survey found that HIV prevalence in the area was 50% lower in circumcised than uncircumcised men.
Mathematical models show that circumcision will eventually benefit women through the general fall in HIV prevalence in the population, but a direct benefit has been hard to prove.
This is especially the case in an area like Orange Farm, where prevalence is very high in women. Although the survey of men last year found that HIV prevalence in uncircumcised men was 19% and circumcised men 7% (average was 12%), in women prevalence is 30%, and in the peak age of 30-34 rises to 38%.
Among women who report ever having had sex, 30.0% in the present study reported having had only circumcised partners.
HIV prevalence among these women was lower than among other sexually active women: it was 22.4% in the partners of circumcised men and 36.6% in women who said some or all of their partners were uncircumcised. This represents an unadjusted reduction in risk of 28%, but after adjusting for confounders (such as the fact that the partners of circumcised men tend to be younger, as indeed are circumcised men), the reduction in risk was 15%. This was still statistically significant (p = 0.004).
Circumcision appears to make no difference to the rate of condom use in what the researchers called ‘non-spousal’ sex. In extramarital sex, women reported using condoms 37.5% of the time with circumcised partners and 38.6% of the time with uncircumcised ones. Fifty-five per cent of women thought condom use was easier for circumcised men.
Of women who had had sex with both, 74.4% said they preferred circumcised men, precisely because they were seen to be less likely to have HIV, but a relatively low 9.6% thought that if they had sex with a man who did have HIV they would be fully or partly protected from HIV if he was circumcised. Nine out of ten women did understand that if a man was circumcised, he could still acquire HIV.
Between 2008 and 2012, the proportion of women willing to have their male children circumcised rose from 83.0% to 96.0%.
"This study is encouraging for the current roll-out of voluntary medical male circumcision," comment the researchers.
They believe, however, that rather than there being a direct protection for the woman, the findings on the association of women’s HIV prevalence with their sexual partners’ circumcision status are probably due to the lower HIV prevalence rate among circumcised men.
A longitudinal incidence study is needed to settle the question, they add.
Auvert B et al. Male circumcision: association with HIV prevalence, knowledge and attitudes among women: findings from the ANRS 12126 study. 21st Conference on Retroviruses and Opportunistic Infections (CROI), Boston, abstract 962, 2014.
Weiss HA, Hankins CA, Dickson K Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis. 9:669-77, 2009.
Study finds medical circumcision scale up reduces HIV incidence in the community 13/09/2013
The roll out of voluntary medical male circumcision (VMMC) programs in highly affected areas not only reduces HIV/AIDS acquisition among heterosexual men, but also significantly reduces HIV levels in the community, according to a study
by researchers from the University of Versailles published in PLOS Medicine this week. The study also found that VMMC is not associated with changes in sexual behavior that may affect HIV infection rates.
Writes Rabita Aziz on Science Speaks: HIV & TB News
VMMC poster in Durban, South Africa
In 2007 and 2008 in Orange Farm, South Africa, – the site of one of three randomized controlled trials that proved that VMMC can reduce the heterosexual acquisition of HIV in men by 50-60 percent – researchers conducted a baseline biomedical survey of nearly 2,000 men aged 15 to 49 about their sexual behavior and their intention to become circumcised. At baseline, 12 percent of men had been circumcised.
A follow up survey was conducted in 2010-2011, in which more than 3,000 men were invited to participate, and it was found that 53 percent of those surveyed had been circumcised, thanks to the roll out of the Bophelo Pele Project, a community-based campaign against HIV launched in 2008, which included free VMMC. Due to the uptake in VMMC, researchers found a reduction of HIV incidence rate ranging from 57-61 percent among circumcised men, compared to uncircumcised men.
The overall HIV prevalence rate in the community at the time of follow up was 12 percent, and researchers estimated that without the circumcisions performed during the Bophelo Pele project and the preceding randomized control trial, the prevalence of HIV among men would have been 15 percent in 2011, and 19 percent in the community at large.
Researchers also found no evidence of an association between circumcision status and risky sexual behavior.
Study writers conclude that the roll-out of VMMC among adults in sub-Saharan Africa should be an international priority and needs to be accelerated to combat the spread of HIV, and further studies need to be done to show if VMMC roll-out also reduces HIV infections among women and uncircumcised men.
Circumcised Men aren’t More Promiscuous. 4/9/2013
Image courtesy stock.xchnge
The medical circumcision of men to lower their chances of contracting HIV will not make them more promiscuous.
This is the finding of a study done by South African and French researchers, published yesterday in the journal PLOS Medicine. The study was carried out at the Bophelo Pele project in Orange Farm, a community-based campaign that offers free, voluntary male circumcision. It also confirms the findings of previous trials that circumcision has a 60% protective effect against female to male HIV transmission.
In 2010 the department of health began implementing medical male circumcision across the country in an effort to reduce HIV rates.
“This is the first real life study to see what happens in a community when we are able to circumcise substantial numbers of men,” said researcher Dr Dirk Taljaard.
Comparing a random sample of circumcised and uncircumcised men from the community, the researchers found there was no increase in risky sexual behaviour in circumcised men. “This was obviously one of the concerns, that men would see this as a permanent condom,” said Taljaard.
Researcher Marcus Low of the Treatment Action Campaign said this finding was important as there had been a fear that circumcision might change sexual behaviour because men might think they were completely protected.
At the time of the study, the number of circumcised men in the community had increased from 12% to 53%. The overall HIV rate at follow-up visits was 12% and the researchers estimated that without the circumcisions, the rate of HIV-positive men would have been 15% in 2011.
Circumcision: Clear-Cut Rites Shape Stronger Men 12/08/2013
From Mail and Guardian
The best traditional schools uphold cultural values, but rely on good management and high standards.
Indistinguishable from one another, initiates celebrate the completion of their four-week rite of passage. (Delwyn Verasamy, M&G)
'We are Pedi [Northern Sotho]. My son always knew that the day would come that he would have to go to initiation school. It is our culture. I went there myself when I was 12 years old and the lessons we learned I still remember. We were taught respect," says 44- year-old Motladi Phala, beaming with pride.
Phala fights back the tears as he looks towards his son, who is huddled together with the other initiates in the courtyard of the royal palace of Chief Robert Mampuru in Etwatwa, a township near Daveyton on the East Rand.
The Benoni-based attorney can hardly restrain his tears of excitement, saying: "I am very happy."
His 13-year-old son has just completed the traditional rite of passage into manhood.
Phala's elation is reflected by the 22 other mothers and fathers who struggle to tell their children apart from the rest of the initiates, who look identical, with their bodies covered in a reddish-brown muddy substance and a loin cloth their only attire.
Outside the tent pitched next to the chief's home, the community has gathered to welcome them back after their four weeks away from their families, learning the lessons of being a man.
Representatives from the departments of health and justice, the ward councillor and other traditional courts have come to celebrate the occasion.
There is excited chatter as community members shuffle to get a glance of the initiates. Little children peep curiously out from behind their mothers' skirts. Shirtless young men whip one another with wet tree branches in a battle of endurance that provides a sideshow to the ceremonials inside the tent.
For Phala, the graduation ceremony is affirmation that he made the right decision.
"Sending your child to koma [initiation school] is a tough decision for any parent to make," he says, looking at a certificate given as proof that his son has completed the ritual. "But it was important for my wife and me that he [would] know his culture.
"He has learned that life is full of challenges and that he must appreciate what he has. Those experiences are good for him."
However, Phala's sentiments are not shared by all community members: Gift Mtshali shakes his head in disapproval as he looks on.
"I don't have a problem with initiation, but these boys are too young. How do you tell an eleven-year-old that he is a man?" he asks incredulously. "I have a son around that age. I won't let him do that."
According to the Gauteng health department, boys in the province who are younger than 18 can be circumcised, provided they get parental consent. "To just cut something from your body and then, all of a sudden, you think you are a man is lame," he scoffs.
"I respect their culture totally," says Mtshali. He is Zulu, and initiation hasn't been practised in his culture for centuries. "But this scares me. Really, it gives me goose bumps."
The custom has been heavily criticised in recent years and has even been referred to as a public health crisis: scores of boys die and hundreds more are hospitalised during the initiation season every year owing to botched circumcisions.
A 2010 report by the Commission for the Promotion and Protection of the Rights of Cultural, Religious and Linguistic Communities notes that circumcision has been singled out "as the major cause of amputations and initiates' deaths".
If the removal of the foreskin, which forms part of the initiation ritual, is not done correctly, it can lead to amputation of all or part of the penis and, in some cases, death. According to government reports, more than 60 initiates died because of bungled circumcisions in Mpumalanga, Limpopo and the Eastern Cape between May and July this year.
But Phala says the reports did not deter him from sending his son to initiation school. For him, it is an integral part of his identity.
"Koma is a school like any other. Before you send your child to school, you have to do your research. You do your homework and find out as much as you can about the place."
Mampuru's school came highly recommended by the local chief in Sekhukhune, where Phala grew up.
"It was sad to hear about the death of initiates, but I didn't have doubts about my son going to initiation school. I did my homework and I was comfortable with my choice. The outcome of koma depends on who the school is run by," he says.
In fact, says Mampuru, none of his initiates withdrew because of the reported deaths.
"This is our fifth time hosting an initiation school in the East Rand [it was held in 2002, 2003, 2006, 2011 and 2013]. We've never faced a problem such as this [deaths]. The number of kids that we take for initiation is the same number that comes back."
Mampuru says initiation is an inevitable part of cultural practice and that chiefs who run initiation schools must take responsibility for them. Part of the belief is that kings and chiefs are custodians of initiation schools.
"As a chief, you know that starting an initiation school is a big responsibility because parents are entrusting their children to you," he says.
"When my initiates go to koma, I go with them and stay with them until the process is complete. I'm the one who has to ensure that they are well taken care of. I can't just send somebody else, because this is my responsibility. Koma must be taken care of diligently.
"Nowadays, chiefs sit back thinking: 'I've appointed somebody to do the work for me. I can sit at home'.This is how problems like those in Mpumalanga arise. I take care of my own school because it is my name at stake," says Mampuru.
The chief says he saw a need for an initiation school in the East Rand after many families moved away from their villages to Gauteng for better opportunities.
Mampuru says he runs a tight ship: prospective initiates need written parental consent to be allowed into his school. And a partnership between the HIV prevention organisation Society for Family Health (SFH), the chief and the provincial health department means that initiates get full medical screening, including HIV testing and counselling, before going to initiation.
Cynthia Nhlapo, the senior programme manager responsible for medical male circumcision at SFH, says the screening before circumcision and subsequent check-ups ensure "that none of the boys die from bleeding or dehydration or any other condition that is medically related".
Such collaboration also occurs in Orange Farm, west of Johannesburg, where initial research conducted by the Centre for HIV and Aids Prevention (Chaps) in Johannesburg in 2005 showed that medical male circumcision – that is, the surgical removal of the entire foreskin of the penis, reduces the risk of HIV transmission and infection by up to 60%.
The Bophelo Pele circumcision centre in Orange Farm, a Chaps project, was the first site to prove medical male circumcision, sometimes also provided by doctors to initiates attending traditional initiation schools, as a measure to prevent HIV infection. The project works with traditional leaders in the area to improve the safety of initiates.
In traditional circumcision, no anaesthesia is provided, clinical hygiene practices are often not adhered to and, in some cases, only part of the foreskin is removed. Traditional circumcision forms part of a larger rite of passage that is performed in outdoor camps.
The effect of partial circumcision on HIV prevention is unknown, because findings that male circumcision reduces men's risk of infection with HIV are based on studies in which all participants' entire foreskin were taken off.
Mlungisi Nazo, a counsellor at the New Start Medical Male Circumcision clinic in Tsakane near Brakpan, was part of the Orange Farm project.
"In Orange Farm, we would talk to the initiation school 'teachers' who would agree to us doing the medical circumcision. Because we were not competing with the culture, we gave them space to handle the traditional stuff their own way," he says.
However, he says their reception on the East Rand has been lukewarm. "People in Tsakane are not responsive to medical circumcision because there are a number of traditional initiation schools in the area, so some people prefer to go there. Some think getting circumcised medically is a betrayal of their culture."
Nazo says it is important that people understand that what he does is purely medical and has no bearing on a person's religious or cultural beliefs. "Medical circumcision is not here to compete with the culture, but [to] complement it."
Thamaga Mathole, the chief's assistant, says there is plenty of room for co-operation within the boundaries of the set tradition because "koma is secret and sacred".
"We are developing, society is dynamic. Culture is dynamic. It's not a statue. We're not permanently in dust. There are doctors who have gone to initiation schools and they understand exactly what the tradition contains," he says.
The chief used to have a medical doctor permanently stationed at the previous initiation schools he hosted, but the doctor has since relocated.
But, Mathole warns: "You cannot have a person who has not been to initiation school coming into an initiation school."
The custom is jealously guarded and is "not for public consumption". It has a strong sense of exclusivity and secrecy, a fraternity that allows little, if any, outside interference.
"Even if you have been to hospital [and have been circumcised medically], you can't enter koma. If you go there [initiation school], you will have to stay on and finish the ritual. Hospital is hospital. Koma is koma. They differ in many ways. Why would you go to hospital and then go to initiation school?
Safe and sound
"There is no competition. Medical circumcision is not a new thing. It's been around for years and years. So has koma," says Mampuru. "The hospital and koma do not go together."
Mathole says initiation is a custom that has been passed on from generation to generation and it was where the king's or chief's legions were trained. This element, he says, has remained in the custom.
"There is this concept of power within. This is a [warrior] regiment. Mampuru is preparing them. He initiates them, he ensures that they come out [as] fit and fresh as they are now – ready to protect.
"The initiates graduate as soldiers. If you go to hospital, what do you learn about combat?"
The ceremonials are now over for Phala's son and his fellow initiates: they will return to school with their peers.
Mathole says they have an important role to play in the chieftaincy. They are now the messengers of the royal court, charged with delivering summonses for the chief.
More importantly, they will assist the chief with the next initiation school, which will be hosted in the next two to five years.
Until then, Phala and the other parents are happy to have their children back home safe and sound.
"It is such a relief for us as parents in the urban area to have a place where our children can safely practice their culture," he said.
A round of applause breaks out in the crowded tent as the initiates make their way down the red carpet laid over the gravel road to the royal court where food will be served.
The formalities give way to the festive dancing of old women in traditional dresses, who proudly ululate and sing: "Our sons have become men. They can go on with their lives now."
Traditional Leader: Circumcision Preserves Culture by Saving Lives. 24/7/12
To understand what Chief Mumena is doing, you have to understand first how strong the bonds of tradition have been to tribal culture.
By Antigone Barton
24 July 2012
To understand what Chief Mumena is doing, you have to understand first how strong the bonds of tradition have been to tribal culture.
It passed from generation to generation without pen and paper, with ceremonies and stories holding it together.
“People are custodians of their culture; that is why it has survived,” Chief Mumena says. “If they did not believe in it, it would have been wiped out under colonial rule.”
Chief Mumena is the eleventh chief of the Mumena Royal Establishment, a kingdom of the Kaonde people in Zambia. He is in Washington this week attending the AIDS conference, and was on his way to talk about his work to promote circumcision, first among men of his tribal kingdom, then across his country, and now, that he is in Washington, across the world.
His journey here has been complicated through, because circumcision was not part of Kaonde culture. Making the cultural relevance of that clearer are the fact that two tribes that neighbor Chief Mumema’s kingdom in Zambia’s Northwestern Province circumcize young men as a part of a rite of passage into adulthood.
So when Chief Mumena’s 18-year-old son came to him in February 2011 to say he wanted to be circumcized, the Chief was unsettled.
“It was an invasion of our culture,” he said. “We looked down on male circumcision as barbaric, as primitive.”
He also was afraid for his son, as he had no information on the procedure at all.
“That was the beginning of my journey,” he said.
He called a physician friend in Lusaka, Manassveh Phiri. Phiri, a longtime AIDS activist explained the science, recounted the research — the procedure lessened a man’s chance of acquiring AIDS by 60 percent, reduced chances of cervical cancer among their female partners even more.
“It wasn’t about turning my back on being Kaonde, it was about survival,” Chief Mumena says now. “Without it, we would be wiped out.”
HIV prevalence in Zambia hovers around 14 percent of the population and cervical cancer, an opportunistic HIV infection, is the number one cancer killer of women there.
“We needed real protection,” the chief says now. “We had condoms and abstinence, and you realize people do not abstain, anyway. It was more of an attitude.”
He shakes his head now, and smiles when he said he was converted by his son. “The young were ahead of us. They were setting a trend.”
On June 2 last year the Chief got himself circumcised. The annual Kaonde traditional ceremony came three weeks later, and he invited representatives of a medical nonprofit. Thirty men walked down the road to the clinic to get circumcised that day.
For his part, he redefined cultural adherence. “I love the Kaonde culture and I want to enjoy it to the fullest,” he said. “They need to be alive, to enjoy their culture.”
TAC Briefing on Adult and Adolescent Voluntary Medical Male Circumcision (VMMC). 31/10/11
Department of Health must set ambitious targets for the roll-out of circumcision in the new National Strategic Plan
31 October 2011
The evidence that voluntary medical male circumcision (VMMC) reduces the risk of HIV infection in heterosexual men is clear. Therefore the Department of Health must set ambitious targets for the roll-out of circumcision in the new National Strategic Plan.
The roll-out of circumcision must be respectful of human rights and consistent with the South African Constitution. Circumcision must be voluntary and only carried out with informed consent.
Government must ensure that legislation allows infants to be circumcised with parental consent.
Guidelines and policies for VMMC must be finalised and widely circulated.
VMMC targets must be properly costed and budgeted for, and expenditure must be monitored.
Traditional circumcision that is funded through the national HIV budget must be safe and provide the same level of protection as medical circumcision. It must also provide the same package of services, including counselling, education, HIV testing and condom distribution.
Government should halt the use of any devices that have not been approved by the World Health Organisation including the Tara KLamp and the AlisKlamp. The suspicious procurement of the Tara KLamp by the KwaZulu-Natal government must be investigated.
We are concerned about the quality of informed consent at mass circumcision camps. We believe these camps should be halted. VMMC must be carried out methodically and properly without shortcuts to boost numbers.
Systems for reviewing VMMC sites should be established. These reviews must be carried out by an independent team and all sites providing VMMC should receive visits twice annually.
TAC supports voluntary medical male circumcision (VMMC) because of the clear evidence that it reduces a heterosexual man’s risk of contracting HIV. TAC’s previous briefings on VMMC explain this evidence in detail and remain largely correct. This briefing highlights the evidence that has emerged from follow up trials.
After the closure of the randomised control trial in Orange Farm that demonstrated a 60% reduction in risk of contracting HIV for circumcised heterosexual men, a follow up trial was carried out to research the uptake of VMMC and the effect of VMMC on sexual behaviour and HIV incidence. Between 2007 and 2010, VMMC was provided freely in the Orange Farm community, along with HIV counselling, testing and condom distribution. The intervention was supported with community education.
The follow up trial showed that a large VMMC programme can be provided safely with very few adverse events. Of the 25,000 circumcisions carried out only 10 hospitalisations occurred, all of which were resolved with no permanent injuries.
The follow up study also found high take-up of VMMC by adolescent and adult men. Between 2007 and 2010, the proportion of men circumcised in Orange Farm rose from 16% to 50%. For males between 20 and 24, this figure rose to 59%.
Some people are worried that circumcised men will have less safe sex in the knowledge that they are less likely to contract HIV. This is called risk compensation. An important finding of the study was that there was no risk compensation effect.
Finally, in comparing HIV incidence and prevalence in men that were circumcised versus men that were uncircumcised, the researchers concluded that HIV prevalence would have been 25% higher and incidence 58% higher if VMMC was not available in Orange Farm.
Another follow up study was carried out in Kenya after the closure of a randomised control trial in 2006. All men who participated in the control arm of the trial were offered VMMC. Follow up at 54 months found that circumcised men reduced their risk of contracting HIV by 63%, demonstrating that the benefit of circumcision is durable.
These trials show that a large scale roll-out will likely reduce new HIV infections. If properly planned it can be provided safely many men will chose to be circumcised.
Government’s commitment to expanding VMMC
The roll-out of VMMC in South Africa’s public health system started in April 2010. By July 2011, the Department of Health (DoH) reported that more than 140 000 men were medically circumcised as a result of the initiative. The DoH has developed implementation guidelines for medical practitioners. However, these guidelines have not been widely circulated, as the current format of the electronic document is too large and consequently difficult to email or upload. The DoH should resolve this simple technical issue in order to make the document easy to distribute or download from the DoH’s website. The full document can be accessed here [INSERT LINK: http://www.tac.org.za/community/node/3187]. A draft national policy for VMMC has also been developed through the South African National AIDS Council. However this draft policy must first be approved by the Minister of Health before it is adopted.
Targets for expanding VMMC access and uptake will be set in South Africa’s next national HIV treatment and prevention policy for HIV - the National Strategic Plan (2012 - 2016). In June 2011 it was reported in the media that government aims to circumcise 5.7 million people, or 80% of men aged 15 – 49, over the next 5 years.
While government aims to provide circumcision to male infants, with the consent of parents, this is not yet available in the public sector because of confused interpretations of the Children’s Act of 2005. Infant circumcision is therefore only currently available in the private sector.
Budgets and expenditure
R260 million has been budgeted for the roll-out of VMMC in 2011/12. It is estimated that this will increase to R350 million by 2013/14. A number of sources have suggested that expenditure against this figure has been low. However, assessing expenditure on VMMC has been extremely difficult. One of the challenges cited by Treasury is that it is difficult to determine precisely what is being spent on VMMC because it requires a number of inputs, such as personnel and theatre time, which are not funded directly through this intervention. For the next National Strategic Plan, the Department of Health must evaluate and clearly define which interventions associated with VMMC will be included in the budget. Furthermore, monitoring and evaluation systems must be developed to assess the success of the intervention.
The Department should consult with the Orange Farm circumcision researchers who have a lot of experience with costing circumcision.
A well organised monitoring and evaluation programme for VMMC sites needs to be established and implemented. All sites offering and reporting figures and statistics for VMMC should be independently evaluated. The evaluation should include a question and answer component that ensures a correct minimum package of services is offered and voluntary consent is confirmed and documented. The minimum package of services should include: extensive education on the risks and benefits of medical circumcision; education on HIV prevention; one on one counselling; HIV, STI and vitals screening; post operative counselling and condom distribution.
The national circumcision policy will also address traditional circumcision, which is common among South African men as a rite of passage to manhood. The draft circumcision policy document recognises that traditional circumcision often does not provide the same preventative benefit as medical circumcision as the entire foreskin is not always removed. If traditional circumcision is funded through the national HIV prevention budget, then the Department of Health must ensure that these circumcisions are safe and provide the same level of protection as medical circumcision. Traditional circumcision should also provide the same minimum package of services.
Several devices for providing circumcision are currently being tested. Some are being used in South Africa despite insufficient safety and efficacy data. The Tara KLamp is widely used in KwaZulu-Natal and a circumcision camp using the AlisKlamp was recently carried out in the Western Cape. The Tara KLamp has been found to be unsafe and there is not consensus on the safety of the AlisKlamp. Government should immediately halt the use of these clamps and only World Health Organisation approved methods of providing circumcision should be allowed. Further, government should investigate the allegations of corruption around the procurement of the Tara KLamp. [INSERT LINK: http://www.quackdown.info/article/king-car-and-clamp/].
In several places, particularly rural KwaZulu-Natal, circumcision numbers are being boosted by running circumcision camps for young men. We are concerned that these camps do not provide adequate counselling or informed consent. VMMC is necessary, but its implementation must be carried out without shortcuts to boost numbers. Human rights must be respected and VMMC programmes must be consistent with the Constitution. The Orange Farm project has shown how this is possible and yet still reached large numbers of people. The circumcision camps should be stopped.
Non-surgical Device Provides Safe and Effective Circumcision without Need for Anaesthetic or Stitches. 4/10/11
The PrePex device was safe and effective as a means of performing bloodless adult male circumcision that can be performed by non-physician staff without need for anesthesia, suturing, or sterile settings
By Michael Carter
4 October 2011
A device that provides non-surgical male circumcision without anaesthetic or the need for stitches is effective, safe and can be used in non-sterile environments, investigators from Rwanda report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.
The single-centre study involved 55 young men who were circumcised using the PrePex device. This uses fitted rings to clamp the foreskin, leading to the death of tissue in the foreskin, which is then removed bloodlessly.
“The PrePex device applies controlled radial elastic pressure and hence requires no anesthesia,” write the investigators. “Use of the PrePex device is a nonsurgical procedure that can be performed in a standard consultation room, because the distal foreskin is necrotic when removed, bloodlessly.”
Randomised controlled trials have shown that circumcised men have their risk of infection with HIV reduced by between 53% and 60%. Both the World Health Organization and UNAIDS recommend consideration of male circumcision along with other preventative measures in countries with large, generalised and predominately heterosexual epidemics.
Only 15% of Rwandan men are circumcised. However, the government has plans to circumcise up to 2 million men. Given the country’s limited resources this will be difficult to achieve unless a non-surgical method of circumcision that can be performed by nurses in a non-sterile environment is found.
A method of male circumcision that could meet these requirements is the PrePex device.
Investigators at the Kanobe District and Military Hospital, Kigali, evaluated its safety and effectiveness in 55 men.
The study had two phases. In the first, the feasibility of the procedure was evaluated in five individuals. The device was applied and removed in a sterile environment by a physician. In the second phase, the remaining 50 patients were circumcised using PrePex in a non-sterile environment by a doctor or nurse.
The investigators explained that as the rings employed by PrePex only touch intact, healthy skin there is no need for its application or removal to be performed in a sterile environment.
All five patients enrolled in the feasibility phase of the study were successfully circumcised. No adverse events were reported, and all had completely healed within 28 days of the removal of the device.
Circumcision was also successful in all 50 individuals enrolled in the main phase of the study. The device and foreskin were removed between five and seven days after application, somewhat earlier than in the feasibility phase.
The first 20 patients in this phase of the study had the device applied and removed without any form of pain control. However, because some individuals reported discomfort, the remaining 30 patients were treated with 1 g of paracetamol 30 minutes before each procedure.
“We now believe that ibuprofen administered immediately after placement may be a better means of managing discomfort,” comment the investigators
Only one adverse event occurred after the removal of the device. This involved swelling and occurred in a patient with urethritis caused by a sexually transmitted infection. The swelling disappeared after two days of therapy with the anti-inflammatory drug ibuprofen.
Removal of the foreskin was accompanied by light oozing in two patients. However, this resolved after ten seconds of applied pressure.
A remnant of dead foreskin tissue remained in place after device removal, but this dropped off spontaneously within one to two weeks.
The physician removing the device and dead foreskin detected a slight odour in several instances, but none of the patients complained about smell.
Complete healing was achieved a median of 21 days after the removal of the device. In two patients, however, healing took up to 42 days.
Application of the device took a mean of 4.3 minutes, and its removal (and that of the dead foreskin tissue) a mean of 3.8 minutes.
“Although most of the procedures were handled by physicians, we noted no differences in procedure time, pain, adverse events, or healing time related to whether procedures were performed by a nurse or a physician,” write the authors. “Further study is warranted to document the feasibility of entrusting the procedure to nurses, but these preliminary results are encouraging and potentially important for large-scale male circumcision programs.”
The investigators conclude: “The PrePex device was safe and effective as a means of performing bloodless adult male circumcision that can be performed by non-physician staff without need for anesthesia, suturing, or sterile settings…these promising results could prove to be a significant advance in HIV prevention programs in sub-Saharan Africa.”
Experts Divided over Baby Circumcision Plan. 21/8/11
A controversial plan to circumcise newborn babies is among a string of drastic new proposals to tackle the scourge of HIV.
By Prega Govender
21 August 2011
A controversial plan to circumcise newborn babies is among a string of drastic new proposals to tackle the scourge of HIV.
They are contained in the first draft of the National Strategic Plan for HIV and Aids, STIs and TB launched by the South African National Aids Council (Sanac).
The discussion document, which will become the blueprint for Sanac's fight against the pandemic over the next five years once finalised, will be officially launched on World Aids Day on December 1.
The proposed goals of the new strategy include reducing the rate of new HIV infections by 50% and new HIV infections in children by 90% by 2016.
Other proposals include offering circumcisions to young men before they become sexually active and preventing unintended pregnancies, especially among young girls, through sexual and reproductive health information and education in schools.
In addition, the plan suggests universal HIV testing and TB screening on an annual basis for every South African 12 years and older who previously tested negative or whose test status is unknown.
While medical practitioners this week welcomed plans to circumcise young men before their first sexual encounter, they were sharply divided over the proposal on neonatal circumcisions.
Dr Ashraf Coovadia, a paediatrician at Rahima Moosa Hospital in Gauteng, said encouraging young men to be medically circumcised had been a scientific recommendation for some time.
Studies conducted in Kenya, Uganda and South Africa have shown that there was a reduction of between 50% and 60% in HIV infection among men who had been circumcised.
"The medical fraternity believes it's one of the very good medical, evidence-based options in the prevention of HIV," said Coovadia.
Durban paediatrician Dr Thahir Mitha said scientific evi-dence pointed to the benefits of neonatal circumcision.
"At least 25% to 30% of the country's 700-odd paediatricians support neonatal circumcisions," he said.
But Professor Johan Smit, a neonatologist at Tygerberg Children's Hospital in the Western Cape, said circumcising newborns "was not in the best interests of the child".
"The procedure is not without risks, and newborn circumcision is not based on any scientific evidence. It is based on the extrapolation of scientific data obtained by three studies on adult males.
"It should be left to parents to decide, following counselling, about the risks and benefits of such a procedure."
Gerard Payne, advocacy manager for the Aids Consortium, said they supported medical circumcisions in males as a preventive measure, "but we haven't taken a stance on neonatal circumcisions".
Minister of Health Aaron Motsoaledi said he welcomed the proposal on circumcision, saying studies had proven that it was effective in the prevention of HIV. He also supported neonatal circumcisions and urged neonatologists who took issue with this to raise their concerns.
Writing in the June edition of the South African Journal of Bioethics and Law, YA Vawda and LN Maqutu of the University of KwaZulu-Natal's law department examined the ethical, legal and public health considerations of circumcision of newborns as an HIV-prevention strategy.
They concluded that the public health hazard of HIV and Aids could justify such a move.
According to the Sanac document, key sectors of the population that should be targeted for prevention, care and treatment interventions include young girls, men having sex with men, and mobile and migrant populations such as truck drivers and mine and construction workers.
It also advocates distributing condoms at taverns and shebeens, and preventing mother-to-child transmission by increasing testing of pregnant women and providing treatment.
Community Reacts to Medical Male Circumcision. Living with AIDS # 485. 18/8/11
The community of Soweto, the sprawling township to the south of Johannesburg, has welcomed the rollout of medical male circumcision in the area.
By Khopotso Bodibe
18 August 2011
The community of Soweto, the sprawling township to the south of Johannesburg, has welcomed the rollout of medical male circumcision in the area.
Having seen a member of his family suffer due to AIDS and through volunteering as a home-based care giver with his local clinic’s HIV and AIDS programme, Thulani Radebe of Senaoane, Soweto, knows only too well the effects of HIV and AIDS on individuals, families and communities. Through his clinic in Senaoane, Thulani learned that he can also get help… he can get additional protection from HIV infection by getting circumcised.
“I got information that if your foreskin is intact, you are likely to get diseases like STIs. So, I decided to remove it but I found that private doctors were too expensive. Then, my cousin explained to me that I can circumcise for free at Zola Clinic. I was happy and I went to Zola Clinic. They counseled me and the good thing about it is they even tested me for HIV. My results came back negative. They then circumcised me. I’m avoiding infection as it’s mostly us, the youth, who are most vulnerable”, says Thulani.
He was speaking at the recent launch of the Zola Clinic Medical Male Circumcision Centre. He says after his circumcision he has since recruited about 20 of his friends to also go for medical circumcision. Thulani adds that being circumcised has also helped him hygienically.
“The good thing is that when I pass urine it no longer splashes on my pants. My urine shoots straight. Even when I wash my penis, I no longer have white, smelly particles underneath the foreskin. So, I encourage other guys to circumcise so that we, South African men, can be clean”.
The ANC Councillor in the Zola community, Nomsa Hlomendlini, a proud woman of Xhosa origin, opted for her grand-children to be circumcised medically, instead of the traditional way.
“I’m a Xhosa girl, but brought up here in Jo’burg. I never brought a boy into this world. I only have four girls. And with my family tradition and culture, I’ve always been very scared. Thank God that you didn’t give me a boy because I was scared when I went to Eastern Cape at home for our tradition because I always saw them when they went to the mountain. But since I had grand-children, I have four boys. Today the two are here right now as we are talking. They are patients here.
And now I know they are men”, Hlomendlini says.
Steeped deep in tradition in some cultures, male circumcision, is nothing new. It is, if you like, ancient practice modified - with benefits for modern health.
“Let us remember that circumcision is a cultural practice of many ethnic groups. Others do it after the birth of their sons, others do it as a sign of boys graduating to manhood, others do it for religious reasons, to mention but a few examples. This practice has been around since time immemorial.
The important thing to note is that medical male circumcision reduces the risk of HIV infection and lowers the risk of acquiring sexually transmitted infections. It is definitely not a solution to HIV infection”, says Salfina Mulauzi of the city of Johannesburg’s Health and Human Development unit.
Warning that medical male circumcision is not the solution to HIV prevention, Mulauzi added that, in order to turn the tide against the epidemic, all available strategies need to be exhausted.
“I hope that you will spread the message to our men and youth so that we can put brakes to the spreading of this disease. The CoJ Health and Human Development firmly believes that medical male circumcision will assist in lowering the rate of infection if all the dos and the don’ts are understood by our men and young men, in particular”.
Themba Thwala, a traditional leader who lives in Zola, is one of many traditional healers the clinic has trained for its primary health care community out-reach programme. Although he’s in favour of medical male circumcision, he is concerned that the service does not involve cultural teachings of manhood.
“A lot of young men do come for circumcision because they’ve heard that they won’t contract sexually transmitted infections when circumcised. They don’t circumcise because they want to grow up and become men, but they are rushing to have sex. I’d like it if the circumcision centre can be linked to a traditional school where young men can be taught how to become men”, says Thwala.
Circumcision Proves yet Again that it can Reduce HIV. Living with AIDS # 483. 4/8/11
Medical male circumcision has helped reduce HIV acquisition among men in the Orange Farm area, south of Johannesburg, by about 76% since the rollout of the intervention three years ago.
By Khopotso Bodibe
4 August 2011
Medical male circumcision has helped reduce HIV acquisition among men in the Orange Farm area, south of Johannesburg, by about 76% since the rollout of the intervention three years ago.
Scientific research trials have theoretically proven that medical male circumcision can protect men from HIV infection by up to 60%. Now a study of a community of men who, over the last three years, have taken up medical circumcision, has shown the practical benefits of the intervention over a sustained period of time. The Bophelo Pele Medical Male Circumcision Centre in Orange Farm, run by the Centre for HIV and AIDS Prevention (CHAPS), is the first to run a public sector service offering medical male circumcision following research showing its benefits. Since its formation three years ago, the centre has been circumcising about 1 000 men between ages 15 and 49 per month on average. The review of the service shows that the intervention has dramatically reduced HIV acquisition among men in the Orange Farm area, south of Johannesburg.
“We found that the risk of them getting HIV after circumcision remains reduced in that about 76% of those people that we’ve circumcised, who were HIV-negative in 2007, still are HIV-negative today”, says Dr Ntlotleng Mabena, Operations Manager for CHAPS.
To arrive at the conclusion the study took into consideration factors including the risky sexual behaviour that the men still take.
“We were actually trying to see if our counselling intervention also has an effect in terms of people reducing their risky behaviour. What the study found, unfortunately, is that men in this community are still not using condoms as optimally as they are supposed to use... People will use condoms with their not-so-frequent partners, but won’t use condoms when they sleep with their frequent partners”, Dr Mabena says.
But this is a worrying trend which remains difficult to understand.
“We put in a lot of effort in counselling people about risky behaviour and use of condoms. So, it’s quite worrying to find that all these efforts are not really translated into actions by people who get this thorough counselling. There are a lot of arguments. We can speculate in trying to identify why people don’t use condoms. But, ultimately, we really don’t know what the reason is behind that”, she says.
Asked if some men think that because they are now circumcised that they are actually protected and, thus, using condoms is not really a priority, Dr Mabena said:
“One big argument before the whole rollout of circumcision was that circumcision might encourage men to have indiscriminate sex without considering condoms and all those things. They may translate the message of reduction of HIV as a complete protection. What we found in this study is that there has not been a change in behaviour in terms of men engaging in risky sex. We compared a group of uncircumcised men to circumcised men. Both of them behaved the same.
The circumcised men do not assume that the circumcision protects them better or completely. The behaviour is more or less the same”.
Having said that, Dr Mabena is on a mission to encourage as many men as possible to circumcise. The Orange Farm Medical Male Circumcision Centre is a model on which the national Health Department has based the rollout of medical male circumcision across the nine provinces.
“When an opportunity presents itself to action in order to reduce the risk of HIV infections, all responsible people should grab such opportunities with both hands”, according to MEC for Health and Social Development in Gauteng province.
MEC Mekgwe has set a massive target for medical male circumcision. She says by the end of 2012, about 125 000 men will have been circumcised in Gauteng.
“(It’s) because you can see the zeal, the will, but also the way our communities are responding to this particular issue. We have committed to bring the service closer to where people live”, she says.
But Mekgwe was also quick to state that the Abstain, Be faithful and Condomise message remains relevant as ever. She said being circumcised is not a license to have irresponsible sexual behaviour or too have multiple sexual partners.
Medical Circumcision Need not be at Odds with Traditional Initiation. 21/7/11
Every year the potential benefits of being circumcised are overshadowed by reports of botched traditional circumcisions
21 June 2011
MEDIA ADVISORY: The South African winter school holidays coincide with a surge in traditional circumcisions, as young men head to initiation schools throughout the country.
In the context of South Africa’s HIV epidemic, this should be good news - particularly as a number of promising studies have shown that circumcised men have a 60% reduced risk of acquiring HIV from their female partners.
But every year the potential benefits of being circumcised are overshadowed by reports of botched traditional circumcisions.
According to the Centre for HIV/AIDS Prevention Studies (CHAPS), a solution might be at hand.
“We’ve seen that in some communities medical male circumcision can be incorporated into the traditional initiation process to ensure safety and quality of circumcision procedures,”explains Dirk Taljaard, CEO of CHAPS.
CHAPS is an initiative run in partnership with the Anova Health Institutethat is dedicated to the safe and innovative implementation of medical male circumcision in South Africa.
Taljaard and his team have experienced the benefits of combining medical circumcision with traditional initiation first-hand when clinical managers from the Bophelo Pele Male Circumcision Centrecollaborated with a traditional initiation school in the Orange Farm community, last year.
“By working closely with the traditional leaders and respecting their needs, we were able to perform the circumcisions in a controlled medical environment,” says Taljaard.
“This meant that the traditional initiates experienced minimal complications and could proceed unhindered with the remainder of their initiation ritual,” he added.
CHAPS believe that this kind of cooperation can ensure that traditional initiates reap the full benefits of circumcision whilst keeping the risk of complications to a minimum and without tampering with the integrity of the initiation process at large.
But cooperation on this scale will require both traditional leaders and clinic staff to come to the party. Clinic management must be willing to accommodate initiation requirements - like only using all-male medical teams. It is also likely that the willingness of traditional leaders to incorporate medical circumcision will vary.
Nevertheless, the team feel that taking time to carefully and respectfully negotiate cooperation between initiation schools and the growing number of facilities that are equipped to provide free and safe medical male circumcision could be a winning strategy for responding to South Africa’s HIV epidemic while reducing adverse events related to circumcision.
New Studies Back Circumcision Campaign. 21/7/11
New cases of HIV among men fell by an astonishing 76% after a circumcision programme was launched in a South African township.
By Richard Ingham
21 July 2011
Rome - A campaign to encourage African men to get circumcised to prevent infection by HIV gained a powerful boost on Wednesday by three new studies unveiled at the world Aids forum in Rome.
New cases of HIV among men fell by an astonishing 76% after a circumcision programme was launched in a South African township, researchers reported.
Had no circumcisions been carried out, the tally of new infections among the overall population, men and women combined, would have been 58% higher.
"This study is a fantastic result for a simple intervention which costs 40 euros [R390], takes 20 minutes and has to be done only once in a lifetime," said David Lewis, of the Society for Family Health in Johannesburg and the University of the Witwatersrand.
In 2006, trials in Kenya, Uganda and South Africa found foreskin removal more than halved men's risk of infection by the human immunodeficiency virus (HIV).
Longer-term analysis found the benefit to be even greater than thought, with a risk reduction of around 60%.
After pondering risks and benefits, health watchdogs set in motion circumcision campaigns in 13 sub-Saharan countries that have been badly hit by the Aids virus.
Advocates call it "surgical vaccine," describing it as a cheap yet effective form of prevention.
Sub-Saharan Africa is home to two-thirds of the 33m people living with HIV. As of mid-2010, around 175 000 circumcisions had been carried out in the 13 countries considered priorities, according to UNAids.
The new study was conducted between 2007 and 2010 in Orange Farm, a township of 110 000 adults, where more than 20 000 circumcisions had been performed, especially in the 15-24 age group which is most sexually active.
Greater sexual pleasure
Two other studies released in Rome added to the good news about circumcision:
- Circumcised men say they experience greater sexual pleasure after surgery, a finding that should help overcome unease about the operation.
Investigators at the University of Makerere interviewed 316 men, average age 22, who had been circumcised between February and September 2009.
A year after the operation, 220 of the volunteers said they were sexually active, of whom a quarter said they used condoms.
A total of 87.7% said they found it easier to reach an orgasm after being circumcised, and 92.3% said they experienced more sexual pleasure.
- Newly-circumcised men are just as likely as uncircumcised men to practice safe sex, according to interviews conducted among 2 207 men in western Kenya, six months after they had had the operation.
This helps ease concerns that circumcised men are tempted to abandon condom use in the belief they are completely shielded from HIV.
No 100% protection
France's 2008 Nobel laureate Francoise Barre-Sinoussi, who in 1983 co-identified HIV as the source of Aids, said over-confidence in circumcision was a major anxiety.
"Nothing provides 100-percent protection, not even a vaccine," she told AFP. "Let's stop thinking that one preventative tool is enough. Circumcision has to be part of a combined approach."
The theory behind the benefits of circumcision is that the inner foreskin is an easy entry point for HIV. It is rich in so-called Langerhans cells, tissue that the Aids virus easily latches on to and penetrates.
On the downside, male circumcision does not reduce the risk for women who have intercourse with an HIV-infected man, and the protective benefit does not seem to apply to homosexual intercourse.
There is an indirect advantage, though. The fewer men who are infected with HIV, the smaller the risk of infection for others.
Five Years On from Circumcision Trial, Nine in Ten Participants are Circumcised and HIV Incidence is Two-thirds Lower. 28/2/11
If the men who got circumcised during the trial were included, then the overall efficacy of circumcision over the whole period from the start of the study was 73%.
By Gus Cairns
28 February 2011
Five years after the ending of one of the three big randomised controlled trials of male circumcision as an HIV prevention measure, four out of five men who were in the control arm of the trial and thus not circumcised have opted to get circumcised, a follow-up study presented to the 18th Conference on Retroviruses has found.
The study also found that, if anything, the protective effect ascribed to circumcision appears to have strengthened over time.
The post-trial analysis was conducted on the randomised controlled trial of male circumcision as an HIV prevention measure conducted in Rakai, Uganda, in 2005-6 (Gray 2007). In this study 4996 HIV-negative men aged 15 to 49 were randomised either to be immediately circumcised or to be offered circumcision at the end of the trial.
The study was designed to last two years but was terminated early in December 2006 when it was found that HIV infections were just under half as common (efficacy, 51%) in men who had been randomised to be circumcised compared with men in the control group.
Later analyses showed that this efficacy underestimated the true effectiveness of circumcision. The HIV infection rate in men who actually got circumcised was 58-60% lower than in men who remained uncircumcised, and 70% lower in men with high numbers of partners.
Dr Xiangrong Kong of Johns Hopkins University told the conference in Boston that by the end of the fifth year after the study ended just over 80% of the control group, who had not been circumcised during the trial, had opted for circumcision and, out of 2916 men who were uncircumcised at the last scheduled visit during the trial, only 372 men now remained uncircumcised. Including the intervention group and excluding those lost to follow-up, 90% of those who entered the study had been circumcised.
Looking at men who were not circumcised during the trial, HIV incidence in men who got circumcised, in the post-trial period was one infection per 181 men per year after circumcision (0.55%), and in men who remained uncircumcised one infection per 60 men a year (1.67%). Circumcision was thus 68% effective. If the trial period was included this made very little difference and efficacy still stood at 67%.
If the men who got circumcised during the trial were included, then the overall efficacy of circumcision over the whole period from the start of the study was 73%.
There are data on sexual behaviour for the first 2.8 years since the end of the trial. Before the trial, there had been concerns that circumcision might produce behavioural disinhibition in men and an increase in unsafe sex, especially once men knew circumcision worked.
In the original trial, 18% of participants reported consistent condom use during the trial and 52% did not use them at all. During the follow-up period, condom use declined by 4.3% in consistent condom users to 13.5% and the proportion who never used them increased by 6% to 58.2%.
But there was no difference in decreases in condom use between circumcised and uncircumcised men, and in fact condom use levels now are almost exactly what they were at baseline before the start of the study. The declines in condom use therefore probably reflect reduced availability of condoms and safer sex advice post-trial, rather than any disinhibiting effect of circumcision.
There was no change in the number of non-marital sexual partners, and a 9.4% decrease in the number of men who reported alcohol use during sex, again with no difference between circumcised and uncircumcised men.
These findings are remarkably similar to a post-trial analysis 3.5 years after the end of one of the other two circumcision efficacy trials, in Kisumu, Kenya, presented at the 2008 International AIDS Conference, which found a long-term efficacy of 65% for circumcision and no increase in risk behaviour.
Male Circumcision Curbs Spread of HIV over Time, Risky Behavior does not Increase. 20/7/11
The first “real world” results are available
By Meredith Mazzotta
20 July 2011
Three years after the voluntary medical male circumcision (MC) campaign rolled out in the Orange Farm Township in South Africa, the first “real world” results are available showing a marked reduction of HIV acquisition among circumcised adult men with a 55 percent lower HIV prevalence (proportion of HIV-infected people) among circumcised men compared to their uncircumcised counterparts and overall reduction in HIV incidence (the number of new cases) among men 15 to 34 years old of 76 percent.
Earlierrandomized controlled studies have shown medical male circumcision to reduce the risk of men acquiring HIV through vaginal sex by up to 60 percent. It is rare indeed for on-the-ground implementation of an intervention to yield even greater efficacy than was measured in a randomized clinical trial.
Earlier randomized controlled studies have show medical male circumcision to reduce the risk of men acquiring HIV through vaginal sex by up to 60 percent.
The ANRS 12126 trial involved 110,000 adults and shows MC roll-out is effective at the community level in curbing the spread of HIV. The free service was offered to all willing male residents 16 years of age and older.
“After three years of this project, people are still coming to us to get circumcised,” said Dr. Betran Auvert of the University of Versailles, principal investigator of the ANRS trial. When the trial started, circumcision prevalence among men in Orange Farm was at 10 percent; now it is 50 percent, and even higher among young people, he said at a press conference Wednesday afternoon at the 2011 International AIDS Conference in Rome.
“We calculated that without MC in this community HIV prevalence would have been 25 percent higher and without MC in this community HIV incidence among all men would have been 58 percent higher,” Auvert said at the late-breaker session
Also crucially important, men are not changing their sexual risk behavior after having been circumcised, Auvert said. Circumcised men were found to be younger, more educated, less likely to be married and more aware of their HIV status than those who were not circumcised.
Another MC study with results reported at the conference revealed that of 316 men interviewed one year after having been voluntarily circumcised, 92.3 percent said they experienced more sexual pleasure after the operation and 87.7 percent found it easier to reach an orgasm. The researchers at the University of Makerere in Uganda also revealed that nine out of 10 men said they were happy with the look of their penis after having the operation, and 95.4% said their partner was also pleased.
Political Leadership Key to Male Circumcision Success. 18/7/11
Countries that have been quick to incorporate medical male circumcision into their HIV prevention programmes are already seeing good results compared with those that have been slower to embrace the procedure
18 July 2011
Rome - Countries that have been quick to incorporate medical male circumcision into their HIV prevention programmes are already seeing good results compared with those that have been slower to embrace the procedure, say experts.
Following three African trials that proved the efficacy of male circumcision in preventing vaginal HIV transmission to heterosexual men, the UN World Health Organization in 2007 developed guidelines for the scale-up of voluntary medical male circumcision. Some 14 African countries have incorporated these into their national HIV programmes.
“In countries where there has been political leadership and community buy-in, we are already seeing results from male circumcision scale-up, while in countries like Uganda – where one of the randomized controlled trials took place – we see that HIV incidence is on the rise in comparison to neighbouring countries where male circumcision programmes are in place and incidence is falling,” said Catherine Hankins, UNAIDS chief scientific adviser, at the 6th International AIDS Conference on HIV Pathogenesis, Treatment and Prevention in Rome.
Uganda’s President Yoweri Museveni has been accused of undermining efforts to increase male circumcision by his scepticism about its ability to prevent HIV. Most recently, Museveni visited western Uganda, where media reports quoted him as saying organizations that promoted the procedure were misguiding and could put the lives of many people in danger “since it had not been proven to be scientifically true”.
Although the country launched a national male circumcision policy in 2010, progress in scaling it up has been slow.
Lesotho, Malawi, Rwanda and Uganda have so far failed to achieve any momentum in achieving 80 percent coverage of male circumcision recommended in order for the procedure to have the maximum benefit, according to the US President’s Emergency Plan for AIDS Relief. Ethiopia and Swaziland have achieved 12 and 14 percent respectively, while Botswana and Zambia have achieved 4 percent and South Africa and Tanzania have reached 3 percent. Mozambique, Namibia and Zimbabwe have each achieved 1 percent coverage.
Leading the pack is Kenya, which has set the standard for male circumcision scale-up in Africa, circumcising an estimated 290,000 adult and adolescent men since the programme started in November 2008. The programme has primarily focused on western Kenya’s Luo community, which has the country’s lowest circumcision rates and highest HIV prevalence levels.
“We have had tremendous leadership from Prime Minister Raila Odinga, who comes from the Luo community and has strongly endorsed male circumcision, as well as from the cultural leaders of the Luo people,” said Peter Cherutich, head of HIV prevention at Kenya’s National AIDS and Sexually transmitted infections Control Programme. “Key to the success is the quick translation from research to policy and implementation, as well as task-shifting and the formation of effective partnerships for scale-up.”
Apart from scaling up male circumcision at health facilities, Kenya holds an annual “rapid results initiative” to boost numbers over a four- to six-week period; in 2010, the campaign provided male circumcision to 36,000 men and boys over 30 days.
According to US government and UNAIDS estimates, Kenya is on its way to averting 47,000 adult HIV infections between 2009 and 2025, saving US$247 million in the process.
Elsewhere on the continent
In Swaziland, the recent endorsement of male circumcision by King Mswati III is likely to boost the country’s efforts to scale up the practice.
In Tanzania, where the government announced plans to circumcise at least 2.8 million men and boys between the ages of 10 and 34 over a five-year period, a rapid results campaign in early 2011 saw more than 10,000 boys and men circumcised over six weeks. According to JHPIEGO, an international health NGO and affiliate of Johns Hopkins University, which is working with the Tanzanian government to scale up male circumcision, the initiative could have averted 2,000 new HIV infections.
Zimbabwe has set a goal of circumcising 1.2 million men by 2015, and has reached close to 30,000 men already, despite scepticism about the country’s capacity to scale up the programme.
UNAIDS estimated that one HIV infection is averted for every five to 15 male circumcisions performed.
Circumcision Demand Shoots Up. Living with AIDS # 479. 7/7/11
Winter months are normally associated with the traditional circumcision season in South Africa.
By Khopotso Bodibe
7 July 2011
The winter months are normally associated with the traditional circumcision season in South Africa. Thus, it is not entirely surprising that clinics that offer medical male circumcision are also experiencing a surge in the number of boys who want to be circumcised this winter.
In just one week following the start of the winter school holidays over 1000 boys queued up to get circumcised at the Zola and the Bophelo Pele clinics in Soweto and Orange Farm, south of Johannesburg, respectively. By 11h00 on the morning of my visit, more than 30 boys had already been circumcised at the Zola Clinic for Medical Male Circumcision.
“This morning, so far, we have done 35. By 12h00 we would have done 50. By 15h00 we would have done 85. By 17h00 we would have done 120”, said Dr Thembinkosi Ngwenya, a senior doctor at the clinic.
Dr Dino Rech, co-founder and medical director of the Centre of HIV and AIDS Prevention Studies (CHAPS), which in partnership with government, runs the Zola and Orange Farm medical male circumcision clinics, said the surge in numbers was expected.
“The clinic’s always busy and we average around 50 boys a day in normal months. I think a lot of boys have heard about it and they wait for school holiday periods - and there is still the traditional belief that in winter it’s a better time to circumcise because it’s cold and more hygienic. So, we see men waiting for the winter school holidays, specifically, but school holidays in general - when we have a surge of sustained numbers of up to 100 boys a day that we’re doing”, Said Dr Rech.
In one week only, from 27 June to 01 July, the Zola Clinic for Medical Male Circumcision has performed 559 circumcisions, while the Bophelo Clinic in Orange Farm has circumcised 525 boys. The demand has meant that working hours and some of the staff turn-around had to increase.
“A normal working day would normally be from 09h00 until about 16h30. We’re starting at 07h00 and we’re ending at 19h00. With our Saturday shifts normally being 09h00 – 13h00, our Saturday shifts have been extended to 14h00 – 15h00 to try and do extra boys. We’ve had to just increase the doctors. Generally, there is one doctor that mans the clinic when our numbers are at around 50 a day. But to go at a 100 and above, we’re having to use two and, sometimes, a third doctor. But our nursing staff is maintained the same. The pressure’s on everyone, but the nurses really take the bulk of the pressure working at an intense rate for extended periods of time”, according to Dr Rech.
Most of the advertising for the clinics is through word of mouth. Fifteen year-old Buhle, who also goes by the name Mr Swagger, is one of the 35 boys who had already had the fore-skins removed by 11h00 on the day of my visit to Zola Clinic.
“My cousin told me that in Zola Clinic there is circumcision for free. He came first and then I circumcised today”, said the teenager with the bling-blings.
Why did you want to circumcise, I asked Buhle.
“To avoid the diseases because in South Africa there are many diseases by having sex with no condom. So, it protects you from the diseases because if you are circumcised, it’s 60% less diseases”, he replied.
Did you have to talk to your parents about circumcising?
“Yes, it’s them who told me that I have to come circumcise”, he said.
Then, he gushed about the quality of counselling he got at the centre.
“Oh, counselling! It’s the counseling that made me to be here today because I wasn’t going to be here because I was scared. The counselling is very good because it’s talking to you to know how to know yourself, know your status… they even test you here… high blood, sugar. They were telling us about condoms, how to use them. Condoms are important because if you are circumcised there is 60% less (chances of getting HIV), but if you use condoms that 40% is going to be on… that means 100% safer for you”.
Are you already sexually active, I went on to ask.
“Haai, no! I’m still young for that! After marriage”, then he laughed.
Professional nurse and centre manager at Zola Clinic, Pauline Mulashi-Biola, said they have circumcised more than 5 000 men since the service opened in November 2010. On average, the young men who come in for circumcision are between the ages of 18 – 35. But since the winter school holidays started, the age has dropped to 15 - 20. However, they will not circumcise any young boy without the consent of the parents or guardians.
“Now it’s a lot of school boys – the 15 years until 17 years. They have to come with the parents for -approval… for the consent form”, Mulashi-Biola, said.
Not only has the clinic increased the number of circumcised boys. It has also increased the number of boys who take up HIV counselling and testing. And so has the Bophelo Pele centre in Orange Farm. Over 80% of the 1084 boys who were circumcised at both centres have accepted the HIV test. Scientific research shows that circumcised men have a 60% less risk of infection. Combined with the use of condoms, the protectiveness is increased.
Study Reveals why Some Men Fear Circumcision. 6/7/11
Fear of pain, long periods of abstinence from sex, and long periods away from work
By Nicholas Anyuor
6 July 2011
The length of post-surgical period one is required to abstain from sex is among reasons discouraging men from going for circumcision in Nyanza.
A study indicates some men believed they would have to abstain from sex for up to six months, which many consider too long a period.
The World Health Organisation and the joint United Nations Programme on HIV and Aids recommend abstaining from sex for six weeks, for the wound to heal completely.
The studies were conducted by researchers from the University of Illinois at Chicago (UIC), the Nyanza Reproductive Health Society (NRHS), Impact Research and Development Organisation and the University of Nairobi with support from the Male Circumcision Consortium in three districts in the province.
The study participants also cited missing time from work during the healing period after the procedure as one of the deterrents.
The men believed that one could be away from work from one to 12 weeks as the wound healed.
"The recommended time is actually about four days for those who are engaged in physical labour, while those who do sedentary jobs can resume work immediately after the procedure," explained Dr Walter Obiero, the clinical manager at the Nyanza Reproductive Health Society.
The study, carried out in the month of May, involved 121 men, of ages 18 to 40. The subjects were recruited at market places, shopping centres, and workplaces in Kisumu East, Nyando and Kisumu West districts in Kisumu County.
The study group
The study targeted bicycle transporters and other workers in the informal sector, students, farmers, business people, teachers, fishermen, drivers, and religious leaders.
The study also revealed that fear of complications, such as bleeding, pain, and delayed healing, was also a hindrance to the exercise.
"Men think these side effects are much more common than they actually are. Just 2.7 per cent of circumcised men in Kenya reported complications after the surgery, all of which were resolved with treatment," said Obiero.
However, HIV/Aids prevention was not the most common reason mentioned for choosing male circumcision, according to the study.
Some participants were hesitant to believe that the procedure offers partial protection against HIV infection because they did not understand how it could be protective.
"We have to do continuous advocacy, coupled with correct messaging about male circumcision, to win over those shying away due to misconceptions," said Dr Charles Okal, the provincial Aids and STI coordinator in Nyanza
Circumcision can be the Kindest Cut. 8/4/11
Sometimes this culture is traditional and part of a ritual aimed at the wellbeing of society; sometimes it is medical and aimed at reducing health risks to individuals.
Mail & Guardian
Deborah Ewing and Pieter Fourie
8 April 2011
Circumcision is a physical event that always has cultural significance. Sometimes this culture is traditional and part of a ritual aimed at the wellbeing of society; sometimes it is medical and aimed at reducing health risks to individuals.
Often traditional and medical cultures meet, and circumcision is then performed as a ritual in which the health benefits are made explicit. Sometimes they clash and the one culture characterises the other as harmful.
Research has shown that the risk of a circumcised man contracting HIV during vaginal sex is reduced by up to 60%, compared with that of an uncircumcised man, although the risk to a female is not reduced. Since 2007, medical circumcision has been promoted as part of a comprehensive strategy to prevent HIV. In 2010, the South African government, in line with World Health Organisation (WHO) recommendations, began to target boys and men aged 15-49 for circumcision, purely for HIV risk reduction. There is little doubt that neonatal circumcision will soon be adopted as best practice.
Medical circumcision and the provision of antiretrovirals (ARVs) are now at the forefront of multilateral, international and national HIV prevention campaigns. Circumcision is aimed at reducing the risk of HIV infection across an entire group of people (men), whereas the roll-out of ARVs in this hyper-epidemic aims to reduce the viral load not only in individuals but in society as a whole.
But WHO policy-makers and health professionals are quick to warn that we should guard against viewing medical circumcision and ARVs as the new magic bullet. They are not the "terrific twins" that will save us, yet there is a real danger that we might focus so exclusively on these biomedical interventions that we neglect the broader sociocultural context that used to inform prevention campaigns.
Until recently, prevention was mainly about abstinence, safer sex and reducing the numbers of sexual partners in the context of broader social determinants of health. Thabo Mbeki's attempt to have a national conversation about poverty as a key determinant of health became tragically lost in his own denialist folly -- and heaven knows, we don't want to go there again.
Maybe our failure as a society to heed the systemic cultural lessons of Aids begat this new era in which medical circumcision has become an exemplar of medical triumphalism. This has happened to the exclusion of either traditional circumcision or serious introspection about sexual culture. Consequently, as a society, in spite of the increasing efforts of gender-focused civil society organisations, we remain reluctant to confront existing notions among men and women of what it means to be a man. Men's perception of sexual risk and responsibility for preventing HIV remain largely unchallenged.
By shying away from culture and constructing it as a single (traditional) thing (and thus essentially backward and harmful), and by privileging the biomedical in this way, we are denying ourselves the opportunity to use Aids to learn more about ourselves and to allow our culture to adapt and respond to new circumstances and challenges, as they do and should. The reality is that neither the traditional nor the biomedical culture can solve the problem alone: neglecting one culture in favour of the other will come at a cost to all of us over the longer term.
It would be much more constructive to cast aside spurious notions of superiority and to focus on the common values that underlie both medical and traditional cultures: values geared to the survival, wellbeing and improvement of society.
A recent workshop in Durban that brought together traditional and medical circumcision practitioners from several provinces revealed remarkable areas of consensus. There is broad support for the practice of circumcision, with a real emphasis on respect for individuals as well as for the context in which they live. Most gratifyingly, neither the traditional nor the medical culture claimed a monopoly on wisdom. The traditional practitioners were open to medical training to improve health and safety, whereas the biomedics recognised the value of incorporating into initiation cultural instruction on sexually responsible behaviour.
This is the moment for learning, at a societal level, to expand this consensus and nascent goodwill and address those areas about which there is still disagreement. These areas include the age of circumcision, the partial or full removal of the foreskin, the role of women, the surveillance of the practice within traditional contexts, working with government and, significantly, the need for the biomedical approach to incorporate a greater emphasis on sustained sexual behaviour change after circumcision.
We still have a chance to use Aids as a lens through which to interrogate what it means for men truly to respect themselves and their sexual partners and to counter the deeper drivers of gender-based violence. If we do not, we may eventually defeat HIV/Aids using circumcision, drugs, condoms, microbicides and possibly a vaccine, but we will remain ill-equipped to respond with courage and compassion when the next crisis comes along.
NAIDS Chief Commends New Circumcision Device. 17/3/11
"This is simple technology that can be rolled out to the entire world," Sidibé said.
By Edwin Musoni
17 March 2011
The visiting Executive Director of UNAIDS, Michel Sidibé, said that Rwanda's new male circumcision device, the PrePex system - signals a major revolution in the global fight against HIV.
Sidibé, who also doubles as the Under Secretary-General of the United Nations, made the remarks after witnessing how the device is used during his visit to Nyamata Hospital.
"What I have witnessed today marks a revolution in terms of circumcision. This is simple technology that can be rolled out to the entire world," Sidibé said.
The PrePex System, a new device and methodology for rapid adult male circumcision, works through a special elastic mechanism that fits closely around an inner ring, trapping the foreskin, which dries up and is removed after a week.
The system does not need a sterile environment or anaesthetic, and men can be back at work within a short time, rather than taking several days to heal. "It takes only two minutes to conduct circumcision using this system meaning it is time saving, there is no pain to the patient, and it contributes to the reduction of HIV contraction by 66%," Sidibé added.
He, however, noted that there is need to link the scientific evidence and cultural change to stem new HIV infections.
The Permanent Secretary in the Ministry of Health, Dr. Agnes Binagwaho, said that her ministry is proud to be behind the groundbreaking research which is likely to change the world. Binagwaho is one of the researchers on the new system.
"The most interesting thing about this system is that, it doesn't require going to the theatre, it can be done from any clean environment. It is also cost-effective and eliminates factors such as anaesthetic and highly trained staff. Any well-trained person can conduct it," Binagwaho said.
According to Dr. Leo Ngeruka, research on the system is still on-going and volunteers are above the 21 years. In a related development, a ten-man delegation from Zimbabwe also visited Nyamata Hospital to witness how the PrePex System works.
Several African countries have expressed interest in the system.
Medical vs Traditional Male Circumcision Debate Rages. Living with AIDS # 466. 10/3/11
The South African Health Department’s drive to circumcise as many men as possible has ignited fierce debate among young men.
By Siphosethu Stuurman
10 March 2011
The Health Department’s drive to circumcise as many men as possible to reduce their risk of contracting HIV has ignited fierce debate among young men.
Some are traditionalists who believe that the only way to be circumcised is to go to the mountains as a rite of passage into manhood. Others are modernists who believe that it’s safer to be circumcised by the hands of a Western medicine practitioner for future health benefits.
Best friends, Manosa Nthunya and Phumele Jabavu, are but only two of a possibly large number of young men who hold opposing views on the matter. The pair are ordinary twenty-something year olds, who both love watching the latest teen flick movies and are very close. However, they are fierce rivals when it comes to the subject of male circumcision.
Twenty two year old Manosa Nthunya intends to get himself medically circumcised, even though his best friend is persuading him to consider traditional circumcision rather.
“I could list many reasons for refusing to go the traditional route, but mainly, it’s my disdain with the whole practise, in general. A belief that if you go to the mountains… you are now a man! I generally believe that its crap. Going to the mountains (for) a week or a month does not make you a man at all”, says Nthunya.
Nthunya is a mixture of Sotho and Xhosa and has been under pressure from both his parents to go to a traditional initiation school. Both the Sotho and Xhosa cultures staunchly subscribe to traditional circumcision as a rite of passage into manhood. His friends are also advising him to honour his culture. But he feels that he is not disrespecting his cultural obligations, but simply exercising his democratic rights.
“I believe as an individual, even though I am Sotho, I still have the right to decide what it is that I would like to take from my culture and what it is that I would not take. If we have to follow culture even when it goes against our own logic, then I have an issue with that. But there are certain things from my culture which I genuinely respect, such as the norms we are supposed to keep... you know respecting one’s elders and speaking to people in a certain way”.
Twenty five year old Phumelele Jabavu, who’s studying Law at Wits, disagrees with his best friend’s views. Jabavu was circumcised through the traditional initiation schools and is a proud Xhosa man.
“I went the traditional route because it was my rite of passage as a Xhosa man. Because the only way I could feel as an authentic Xhosa man… was if I undergo that traditional ceremony”.
So, one wonders if Jabavu feels “superior” or more of a man than his peers since he’s gone to a traditional initiation school.
“Look, I’ll be honest... manhood... the general term... is not defined by circumcision alone. However, I would have to say that if it’s part of your culture, if it’s part of your tradition and if you do not do it, unfortunately in some cultural settings, you’ll not be recognised as a true man”, he says.
Nthunya and Jabavu will probably remain at odds about whether traditional or medical circumcision makes one a man or not for the rest of their lives. But it would also seem that the practice of circumcision itself is different the way it’s done medically and traditionally.
South Africa recently adopted a policy to roll out medical male circumcision among young men as a means of protecting them from acquiring HIV infection. This follows scientific clinical studies that have shown that medical male circumcision can reduce HIV acquisition by up to 60% in heterosexual men.
“When one gets circumcised, the foreskin which is the moist mucous membrane of the penis is removed, and that’s where germs usually like to hide or stick. And that’s how one can get HIV or any other sexually transmitted diseases - that it will attach to the foreskin - and if the foreskin is removed, then the penis will be easy to clean and germs cannot attach that easily, including HIV or any other STI’s” says Dr Limakatso Lebina,a medical circumcision surgeon from Zuzimpilo Clinic, in Johannesburg.
She further explained that there is a difference between traditional and medical circumcision.
“There has been the notion that, especially with traditional male circumcision, that not the entire foreskin is removed. So, if you still have some foreskin, then we cannot say your risk has been reduced or not” says Dr. Lebina.
The General-Secretary of the Congress of Traditional Leaders of South agreed that the country is facing a major HIV epidemic facing the country.
“We encourage our people to go for a test and know their status before they come to us. We will then seek medical advice on how we should deal with this issue. But when there is no disclosure, it becomes something that we did not envision to see”, he said.
But, he pointed out that traditionalists will work with medical circumcision surgeons’ only one condition:
“We’ve been saying for a long time we don’t have an issue with a medical practitioner coming to our culture to assist us, but we are saying those doctors should be graduates of our own institution. You cannot go to an institution without knowing it, whether you are a qualified doctor and you know how to operate circumcision. Our processes are not limited to that particular operation” Kgosi Thobejane said.
Circumcision: The Surgical AIDS Vaccine. 22/2/11
Circumcision helps prevent HIV infection. Why would AIDS-ravaged San Francisco even think of banning this proven, safe procedure?
Beryl Lieff Benderly
22 February 2011
Voters in San Francisco — the city that has probably suffered from AIDS more grievously than any other in America — may soon vote on whether to ban a safe, one-time procedure that protects against the virus that causes AIDS almost as effectively as the annual flu shot protects against the flu. Millions of dollars and years of research have thus far failed to overcome the diabolical obstacles to making an HIV vaccine. No doubt exists, however, that another treatment provides protection so effective that health experts have called it a “surgical vaccine.” Unlike a flu shot, this protection lasts a lifetime and, at no extra charge, also helps reduce HIV risk for a man’s sexual partners.
By now you may have guessed that this remarkable procedure is male circumcision (the word is Latin for “cutting around”), the ancient operation that removes the foreskin, the sleeve of tissue that sheathes the tip of the penis. Circumcision plays an important role in both the Muslim and Jewish religious traditions as well as in initiation rituals practiced by ethnic groups around the world, particularly in sub-Saharan Africa. Recently, however, retired hotel credit manager Lloyd Schofield, a San Francisco resident who calls himself an “intactivist” and considers circumcision mutilation, has announced that he is gathering signatures to put a referendum on the November city ballot that would ban the procedure. “Just as females are protected from having a drop of blood drawn from their genitals, baby boys deserve the same protection,” Schofield told CNN. To qualify the proposition, proponents would need to gather slightly more than 7,000 signatures by late April.
Schofield is pushing the circumcision ban even though multiple lines of very strong evidence — from epidemiology, physiology, microbiology and three large, internationally recognized “gold standard” clinical trials — converge on the conclusion that removing the foreskin drastically cuts a man’s risk of becoming infected by HIV. It also reduces his risk of other sexually transmitted diseases and cancer of the penis and his female partners’ risk of cervical cancer. Moreover, the operation is safe, takes less than half an hour, heals in weeks and is so common that 80 percent of American men are circumcised. Nor is there scientific evidence of untoward effects, either immediately after healing or later in life, on men’s health, sexual performance or desire.
The three controlled clinical trials took place in Kenya, South Africa and Uganda, in areas where circumcision rates are low and HIV levels high. More than 11,000 men, most of them young, all of them HIV-negative, uncircumcised and willing to undergo the operation, were randomly assigned either to be circumcised immediately by a doctor, or to be in the control group and wait for circumcision until after the study ended. The three trials were all stopped early, however, because of interim results so strong — a 60 percent reduction in infection risk — that researchers could no longer ethically withhold a procedure shown to be so beneficial. After the South African clinical trial had run for 18 months, for example, 49 of the 1,446 members of the control group had contracted HIV. But just 20 of the 1,431 in the circumcision group had become infected.
Dr. James Shelton, science adviser to the Bureau of Global Health of the U.S. Agency for International Development, believes the true reduction in risk is even larger than 60 percent but was masked by the structure of the experiment. Detailed statistical analysis of the results, he writes, reveals “a protective effect of 76 percent.” That analysis would raise the level of protection into flu-shot range, which begins at 70 percent, according to the Centers for Disease Control and Prevention.
The World Health Organization and UNAIDS, the United Nations’ HIV/AIDS agency, describe the trial results as “compelling.” The two groups now recommend circumcision as “part of a comprehensive HIV prevention package.”
A number of African countries have responded with programs to provide circumcision on a wide scale, particularly to men who already are or are about to become sexually active, because they make the most immediate impact on infection rates. As knowledge of circumcision’s protective effect has spread, uncircumcised men have flocked to have the operation — among other things, women are urging their husbands to go — and parents have increasingly asked to have their sons circumcised. In 2006, a near-riot erupted in Mbabane, the capital of Swaziland, when men waiting outside a clinic learned that they wouldn’t all be getting the appointments they hoped for.
Circumcision’s origins are unknown, but its history goes back at least 4,000 years, as shown by tomb paintings from Egypt’s sixth dynasty depicting men undergoing the procedure. The Hebrews, of course, have practiced it since ancient times, and it was customary among other peoples in the Middle East and East Africa long before the birth of Islam. Circumcision’s ceremonial uses generally involve establishing identity, whether as a member of a community or as an adult. Many scholars argue, however, that the practice first arose out of health concerns, especially to avoid the painful irritations and infections that can result from sand becoming lodged under the foreskins in dry, desert climates. That was the reason, for example, that Australian army doctors during both world wars performed large numbers of circumcisions on soldiers serving in North Africa and the Middle East.
Depending on the ethnic and religious composition of a particular country, the number of circumcised males in Africa ranges from less than 20 percent to more than 80 percent. The large difference in HIV rates between countries with high and low rates of circumcision became obvious more than 20 years ago, alerting scientists to the potential protective effect of the procedure.
Researchers believe that the area between the foreskin and the penis shaft provides a hospitable area for HIV to exist, post-intercourse. And physiological research has identified a likely mechanism for infection there: The foreskin contains a particular type of cell that can provide the HIV virus a direct route into the body. These cells — known as Langerhans cells and discovered by the same German doctor who also found the better-known isles or islets of Langerhans in the pancreas — are plentiful on the underside of the foreskin but absent from the rest of the penis. Like the T cells that are a major target of the HIV virus, Langerhans cells belong to the immune system and are highly susceptible to HIV infection.
The shaft of the penis lacks Langerhans cells but contains a protective material called keratin that helps block entry of the virus. After circumcision, keratin develops in the tip of the penis, rendering it less vulnerable. The HIV protection that circumcision provides is not perfect, and public health authorities emphasize that circumcised men must still practice safe sex to limit risk.
Still, the clinical trials demonstrated the strong protective effect of circumcision in vaginal intercourse, which is important in Africa because the epidemic there has spread largely by heterosexual activity and involves people of both sexes. The logic of the physiology, however, argues that circumcision should also protect men who take the insertive role in sex with other men, although this proposition has not been tested. It is clear, however, that by reducing the number of men who become infected, circumcision also reduces their partners’ exposure to the virus.
“Herd immunity” is the name epidemiologists give to the reduction in risk that people not themselves vaccinated enjoy when a vaccine cuts the amount of an infectious agent that is circulating in a population. With HIV, this type of protection extends not only to circumcised men’s female partners but, by cutting women’s risk, to their babies as well. Fewer men becoming infected with HIV means fewer people of both genders and all ages getting the infection.
In rich countries in recent years, HIV treatment has improved so drastically that being infected no longer constitutes an imminent death warrant. Modern drug therapies now keep HIV-positive people alive for years, but in the United States each year, nearly 60,000 new people still join the more than 1.2 million already living with HIV. And 1 in 5 people with the infection don’t know they have it, which helps it continue to spread. People are still dying, and treatment is costly and complicated.
Any injection offering a 60 percent reduction in the risk of contracting this plague would be received as a miracle in the HIV-ravaged regions of the world — and probably as a Nobel Prize-worthy triumph in the scientific community. Despite all these advantages, of course, some people do not think circumcision appropriate for themselves or their sons. That is certainly their right. But why would anyone — in San Francisco, which has known firsthand the grievous cost of HIV, or anywhere else — want to deprive those who wish this protection of the ability to obtain it?
Cutting Out Old Practices to Tackle HIV. 10/12/10
It was simply not done in our culture
10 December 2010
NOZINTOMBI Mbokane (not her real name) broke years of tradition when she took her 13-year-old son to hospital to be circumcised.
"None of the men in my family had ever done it. It was simply not done in our culture," said the 42-year-old siSwati-speaking mother.
A caregiver, Mbokane looks after HIV infected patients in their homes.
Mbokane, of Nhlazatshe in Mpumalanga, said she had heard about the benefits of male medical circumcision through her work.
Studies have shown that male medical circumcision (the removal of the foreskin) cuts the chances of infection by 60 percent.
The foreskin contains cells that are highly receptive to HIV and removing it in some instances reduced the risk of infection.
This, however, excludes traditional circumcision for ritual initiation because only part of the foreskin is removed.
Mbokane said she would explain the benefits to her younger son, now three, when he is older.
"I want him to do it when he is older and is able to withstand the pain. My son missed a few days of school when he had the procedure, but I am glad he did," she said.
Faced with a burden of HIV-Aids, the people of Elukwatini, which is part of Mpumalanga's Gert Sibande District Municipality, are considering male medical circumcision as a means to circumvent the spread of the virus.
At a community health day at Elukwatini Stadium hosted by the MTN Foundation, chief executive of Embhuleni Hospital Mothepana Ralefe encouraged men to be circumcised.
The foundation provided HIV counselling and testing, dental screening and check-ups for lifestyle diseases such as diabetes and hypertension.
Ralefe said the hospital had the capacity to perform 10 operations per week but the uptake was slow.
"Since July we haven't reached 50 operations. Last month only eight people came forward to be circumcised and five of them were children under the age of 12," Ralefe said.
Ralefe said male medical circumcision was still foreign to the community.
"It is something that people here are not used to. We need to mobilise traditional leaders to encourage more men to be circumcised."
She said the district had the fourth highest number of HIV prevalence out of 46 district municipalities in South Africa.
Pensioner Maseko Mdanyelwa, 66, said young men should be encouraged to undergo circumcision.
"I would encourage my grandsons to do it if it meant protecting them from HIV. We must be willing to try new things to protect ourselves from HIV and to prevent more people from getting it," he said.
Circumcision May not Curb Gay HIV Transmission. 8/12/10
Value of circumcision for gay and bisexual men remains questionable
8 December 2010
While circumcision has been shown to lower a man's risk of contracting HIV through heterosexual sex, a new study indicates that the value of circumcision for gay and bisexual men remains questionable.
In a study of more than 1,800 men from the US and Peru, researchers found that overall, the risk of contracting HIV over 18 months did not significantly differ between circumcised and uncircumcised men.
Over the study period, 5% of the 1,365 uncircumcised men became HIV-positive, as did 4% of the 457 circumcised men, according to findings published in the journal Aids.
All of the men in the study reported having sex with other men and were considered to be at increased risk of HIV infection because they were already infected with the genital herpes virus (herpes simplex type 2), which can make people more susceptible to HIV.
Circumcision common in US
Male circumcision is far more common in the US than in most other countries, and 82% of the 462 American men in the study were circumcised, compared with just 6% of the 1,360 Peruvian men.
The researchers did find some hints that circumcision could be protective among men who primarily had insertive sex with other men. Among men who said they'd had insertive sex with their last three male partners at least 60% of the time, circumcision was linked to a 69% lower HIV risk.
That difference, however, was not statistically significant, which means the finding could be due to chance.
Taken together, the results "indicate no overall protective benefit from male circumcision" when it comes to male-to-male HIV transmission, write the researchers, led by Dr Jorge Sanchez of the research organisation Impacta Peru, in Lima.
They add that studies should continue to look at whether circumcision affects HIV risk from insertive sex and do so in larger, more diverse study groups.
Health messages enforced
In general, the researchers write, public-health messages for gay and bisexual men should "reinforce the importance of condom use for HIV prevention."
The findings may help inform debate over whether circumcision could stand as a weapon against HIV transmission among men who have sex with men.
In 2005 and 2006, three clinical trials in Uganda, South Africa and Kenya showed that circumcision can reduce a man's risk of HIV infection through heterosexual sex by up to 60%.
The World Health Organisation now recommends medically supervised circumcision as one way to lower men's risk of HIV in countries where heterosexual transmission is common.
But the public-health value of circumcision in other countries, including the US, is a contentious issue. Most HIV infections in the US are related to homosexual sex or IV drug use and studies have yet to find strong evidence that circumcision lowers HIV transmission among men who have sex with men.
Circumcision is thought to lower the heterosexual transmission of HIV and other sexually transmitted diseases through several mechanisms. One is by reducing the amount of mucosal tissue exposed during sex, which limits the viruses' access to the body cells they target.
Another theory is that the thickened skin that forms around the circumcision scar helps block the viruses' entry.
One reason circumcision might have little effect on homosexual HIV transmission is that it would have no impact on the risk from receptive anal sex. Experts have also pointed out that in wealthier countries, many HIV-positive people are on powerful anti-viral drugs that reduce the risk of transmission, and any added effect of circumcision might be small.
Currently, the American Academy of Paediatrics does not recommend routine circumcision for newborns, citing insufficient evidence of overall health benefits. The US Centres for Disease Control and Prevention, meanwhile, is in the process of developing recommendations on adult and infant circumcision for lowering HIV risk
Regiment for Circumcised Men. 1/12/10
KwaZulu-Natal is leading the mass roll-out of male medical circumcision in the country
By Kerry Cullinan
1 December 2010
The Zulu King has invited the almost 18,000 men who have been circumsized in KwaZulu-Natal this year to form a special regiment to fight HIV and women and child abuse.
The regiment will be established this month (Dec) at the annual uMkhosi wokweshwama (first fruit ceremony) held at King Goodwill Zwelithini’s palace.
KwaZulu-Natal is leading the mass roll-out of male medical circumcision in the country after studies found that circumcision cut men’s risk of HIV by some 50 percent.
Traditional male circumcision was abolished in KwaZulu-Natal by King Shaka, apparently because he could not afford to let his warriors take time off for the ritual.
However, it was reintroduced in the province by King Zwelithini in April this year in a bid to prevent the spread of HIV in the country’s worst hit province.
The province has been circumcising boys from the age of 15 and men at health facilities as well as at special weekend camps run together with traditional leaders.
A recent reportback by provincial authorities to the King was told that 17,690 men had been circumcised between April and November.
However, provincial Premier Zweli Mkhize cautioned that “care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection”.
“Male circumcision must be considered as just one element of a comprehensive HIV prevention package that includes the correct and consistent use of male or female condoms, reductions in the number of sexual partners, delaying the onset of sexual relations and abstaining from penetrative sex,” Mkhize told the reportback meeting.
Nationally, the health department has declared that medical male circumcision is part of its HIV prevention campaign and a wide variety of groups have been involved in promoting it.
Health Minister Dr Aaron Motsoaledi is very supportive of KwaZulu-Natal’s campaign and has called on other provinces to replicate it.
However, the mass male circumcision campaign has courted controversy by using a plastic device called the Tara Klamp in some circumcisions instead of the traditional forceps method. This has been heavily criticised by a number of doctors and the Treatment Action Campaign (TAC) for being more painful and increasing the risk of infection.
Men circumcised with the Tara Klamp are now routinely given antibiotics to prevent infection and the province has agreed to do a retrospective study on men circumcised with the clamp and with forceps to evaluate the methods.
Snipping for Better Health Outcomes. 3/11/10
Government commits up to R40-million to increasing coverage.
By Lungi Langa
3 November 2010
Provincial Health Departments will accelerate their male circumcision rollout as government commits up to R40-million to increasing coverage.
Male circumcision has shown to reduce by 60 percent the risk of men becoming infected with HIV.
In his Medium Term Expenditure Framework, Minister of Finance Pravin Godhan committed an extra R100-million towards HIV prevention.
The R100-million allocation forms part of the R1,5-billion set aside for HIV programmes between 2010 and 2013. Gordhan said more than 300 000 people are put on ARV treatment each year and it would increase to 400 000 in the next three years.
Fidel Hadebe, spokesperson for the health department said the department had allocated R60-million to purchasing additional male condoms and the rest to male circumcision.
"It's always good to see funds going towards effective prevention services and to specifically see medical male circumcision being put on the agenda and directly funded," said Brian Honermann, a researcher with SECTION27.
He said it was unfortunate that the KwaZulu Natal Department of Health would likely continue to use its share to fast track its circumcision rollout using the controversial Tara KLamp "which has been shown to have a greater incidence of adverse effects compared to the standard forceps method".
Honermann said besides being unsafe the Tara KLamp was more expensive than the forceps methods.
The Young Communist League of South Africa commended government for recognising the need to accelerate male circumcision. The group said it would work together with the national as well as provincial health departments to ensure circumcision is safe and to clamp down on illegal operators.
According to reports the Department of Health in KwaZulu Natal performed 10 229 circumcisions since the start of this year. The department announced it would be circumcising prisoners and priests from various churches to motivate male members of the church to follow the lead of the priests.
Dr Francois Venter, president of the HIV Clinicians Society of Southern Africa said they were impressed with the leadership shown by the Department of Health and wished that “all provinces would be as proactive”. He said it was delightful to see government putting funds in proven interventions such as circumcision.
Venter said the society was puzzled as to why the KwaZulu Natal Department of Health continued to use the Tara KLamp method “when the only data we have on it is that it has more side effects and is more expensive than the WHO approved method”.
“KZN risks undermining an excellent programme with this device,” he said.
TAC Tackles the Tara Klamp. 3/11/10
“a massive unethical medical intervention”
3 November 2010
The Treatment Action Campaign has published a four part series on what they call “a massive unethical medical intervention” in Kwazulu-Natal.
The series tells the story of the Tara Klamp, an unsafe male circumcision device, being used by the KwaZulu Natal health department. The stories warn that the device will injure thousands of men and claim that the device has been sold to the state by what it calls “unscrupulous business people with shady pasts”. Read the stories here.
Counselling Key to Success of Male Cut. 2/11/10
Male circumcision reduces a man's risk of contracting HIV through vaginal sex by up to 60 percent
2 Novenber 2010
Kisumu - When Kenya launched its national voluntary male circumcision campaign in 2008, critics worried that it could lead to greater sexual risk-taking - but men in the western Nyanza Province seem to be disproving this theory.
"When I heard people say male circumcision helps in reducing HIV infection, I went there with the sole purpose that it would lessen the burden of having to use a condom," said 23-year-old Victor Oluoch. "But after that, I have known a lot through the counselling I received; I use a condom every time with anybody... I am not married so I am not going to trust anybody."
A key component of Kenya's programme, which aims to circumcise more than one million men by 2013, is HIV testing and compulsory counselling on HIV prevention, including messages about the importance of continued condom use, as circumcision does not offer full protection from the virus. This counselling appears to have been effective in preventing a phenomenon known as "risk compensation", whereby an intervention that lowers an individual's HIV risk may cause them to take greater risks through other behaviours.
A small 2010 study by the University of Illinois in Kisumu, capital of Nyanza Province, found that most respondents - whether circumcised traditionally or in health facilities - reported either no behaviour change or improved protective behaviour, such as increased condom use and fewer sexual partners.
The research revealed an understanding among the 30 respondents surveyed that male circumcision only provided partial protection against HIV.
The authors speculated that the low levels of risk compensation were due to the effects of counselling, HIV testing and condom availability.
A separate 2007 study, also conducted in Nyanza, found that circumcised men did not engage in more risky sexual behaviours than uncircumcised men in the first year after the operation.
Sending the right message
Most men in Kenya are circumcised as teenagers during rites of passage into adulthood that do not generally feature HIV education. Paul Wasike was circumcised during the traditional ceremony of western Kenya's Bukusu community, when he was told that after circumcision, he was man enough to have sex with as many girls as he chose.
"For people like me who were cut at the traditional ceremony, it is sex and adulthood that was emphasized, but I have heard it being talked about on the radio and everywhere that circumcision cannot prevent you from [getting] HIV unless you use a condom or are faithful," said Wasike.
"There is a need to look at how different types and quantity of HIV prevention counselling among men getting circumcised may lead to different types of risk perceptions and behaviours post-circumcision," Thomas Reiss, lead author of the University of Illinois study, told IRIN/PlusNews. "Those circumcised in traditional ceremonies where there is no prevention counselling might vary in risk perception to those circumcised in institutional settings."
Five of the study's respondents reported that they did engage in risky sexual behaviour after circumcision; one man continued to have unprotected sex with his primary girlfriend but reported using condoms with his two other girlfriends.
Donald Were, 31, a married father of three, did not participate in the study but said curiosity was a major factor in having unprotected sex after circumcision.
"You have been having the skin and now when it is not there, you are just curious... you want to test how it [sex] feels without it," he said. "After knowing, then you turn to a condom. I tried it, but with my wife - I can't try it with somebody I don't trust."
Ultimately, Reiss said, preventing risk compensation was a question of information.
"Some people may be misinformed about the protective effects of male circumcision... others may not understand the actual risks of their behaviour and need to be counselled about the risks of their current sexual behaviour and how they can still contract HIV even if circumcised," he said. "Basically it comes down to getting the correct information about HIV risk and circumcision protection to men and women," he said.
New Model Shows Future Impact of Circumcision on Africa's HIV Epidemic Probably Underestimated. 25/10/10
Rate of HIV transmission from circumcised men to women was reduced by 46%.
By Keith Alcorn
25 October 2010
Projections of the impact of circumcision on the HIV epidemic in sub-Saharan Africa based on clinical trials may underestimate the number of infections that can be averted by around 40%, according to an international group of epidemiological modellers.
The findings, published in advance online by the journal Sexually Transmitted Infections, come from new epidemiological modelling work that incorporates findings from a pooled analysis of two recent studies that evaluated the impact of circumcision on HIV transmission from men to women.
The epidemiological modellers, from Imperial College, London, Weill Cornell Medical College, New York, and Fred Hutchinson Cancer Research Center, Seattle, took two existing models of the impact of circumcision on HIV incidence and applied data from a pooled analysis of two recent studies.
The models projected HIV incidence in Zimbabwe and Kisumu, Kenya, using data from a number of locally relevant studies to inform the assumptions about sexual behaviour.
However the original models lacked information about the rate of HIV transmission from circumcised men to women, and about the rate of HIV transmission during the period of wound healing after men were circumcised.
Neither model took into account the interaction between sexually transmitted infections (some of which increase the risk of HIV transmission) and circumcision (which may reduce the risk of men acquiring sexually transmitted infections).
In order to update the models, the epidemiologists took data from a pooled analysis of two studies which had each evaluated the rate of male-to-female transmission in circumcised men.
This pooled analysis found that from two years after the operation (when the effect begins to become apparent in trials and cohort studies) the rate of HIV transmission from circumcised men to women was reduced by 46%.
Assuming that only 50% of men remained uncircumcised after ten years and no men resume sex during the wound healing period, HIV incidence would be reduced by 20.5% in Zimbabwe, where no men had been circumcised before the intervention. In Kisumu, Kenya, where 25% of men were already circumcised, ensuring that half of all men are circumcised would lead to a 7.4% reduction in HIV incidence after ten years.
One concern about circumcision programmes is the potential for men to acquire or transmit HIV during the 4-5 week wound healing period after the operation. The modelling found that even if all men remained sexually active throughout the wound healing period – the most pessimistic assumption possible – HIV incidence would still fall by 19% in Zimbabwe and 6.2% in Kisumu after a decade.
Adding in the information about the rate of male-to-female transmission resulted in a greater projected reduction in HIV incidence. Over 20 years, HIV incidence would fall by 28% in Zimbabwe and 16.8% in Kisumu, and specifically among women, it would fall by 23.7% in Zimbabwe and 13.9% in Kisumu after 20 years.
The reduction in incidence could be as great as 43% after 20 years in Zimbabwe, and a reduction of at least 23% could be expected. the researchers calculated.
Fewer circumcisions would be required to avert each infection – 28% fewer in Zimbabwe and 41% fewer in Kisumu – implying that circumcision could be more cost-effective than previously calculated.
The new figures show that assuming no change in sexual behaviour as a result of circumcision, previous projections underestimated the effect of circumcision on HIV incidence by at least 40% in Zimbabwe and by 79% in Kisumu.
The researchers say that “projections for the impact of circumcision interventions on population-level HIV may need to be dramatically revised: the impact of male circumcision implementation could be realised much sooner and with greater cost-efficiency than had previously been thought.”
Infant Male Circumcision for HIV Prevention 'Promising'. 28/9/10
Circumcising infant boys could become part of Kenya's voluntary male circumcision programme
28 September 2010
Kisumu — Circumcising infant boys could become part of Kenya's voluntary male circumcision programme, at present restricted to over-15s, if an ongoing pilot project in the western province of Nyanza recommends it.
June Odoyo, of the University of Manitoba project, told IRIN/PlusNews that the programme, which seeks to test the acceptability and safety of the procedure as well as the ability of medical staff to provide infant circumcision, had so far proved successful.
"The prospects for it are promising and it has proved viable," he said.
The pilot, which began in October 2009 and is due to end in October 2010, involves training nurses and clinical officers to provide infant circumcision at five government health facilities in Kenya's Nyanza province.
It is being conducted by the University of Manitoba under the leadership of the Nyanza Province Male Circumcision Task Force, which is part of the National AIDS and Sexually transmitted infections Control Programme.
Despite initial resistance from cultural leaders in the region, male circumcision has been widely accepted in Nyanza, with more than 110,000 men undergoing the procedure since 2008. According to Odoyo, acceptance for infant circumcision was likely to be more varied.
"While the acceptance among parents is reasonably high, it is also very variable depending on where the health facility is situated," he said. "Rural areas experience high cases of cultural resistance to the programme, while the acceptability in urban areas is comparatively high."
Odoyo noted that infant circumcision was preferable because it used a special tool known as the Mogen Clamp, takes a relatively shorter time to heal and does not involve stitching as is the case for adult circumcision. Studies show a lower rate of complications with infant circumcision.
A 2010 Rwandan study published by the Public Library of Science found that infant male circumcision was highly cost-effective when compared to circumcision among other age groups.
Male circumcision has been shown to reduce men's risk of becoming infected with HIV through heterosexual intercourse by up to 60 percent. UNAIDS and the UN World Health Organization have issued guidelines on the scale-up of male circumcision for HIV prevention.
Male Cut No Answer to AIDS Spread, Says Expert. 21/8/10
Male circumcision is no excuse for not using condoms as a protective gear against HIV/AIDS
21 August 2010
Arusha — Male circumcision is no excuse for not using condoms as a protective gear against HIV/Aids, medical experts have warned following assertions that circumcision can protect one from the virus.
They said although it was one of the effective interventions for prevention of HIV to men, male circumcision should not be considered a barrier to infection of the virus that causes Aids.
Dr. Mwele Malecela, the acting director general of the National Institute of Medical Research (NIMR), a government research body on health and medical matters, stated in Arusha recently that circumcision "can only assist" males from contracting HIV/Aids.
She described as false information often circulated by some people that circumcised men were safe from HIV virus even if they did not use condoms or any protective gear.
The NIMR boss wondered how circumcision alone could keep off the virus when even the condoms were not 100 per cent perfect in preventing the transmission of the virus from one partner to another.
"It (circumcision) is not and cannot be an execuse for not using condoms," she told journalists at the end of the week-long 24th NIMR Annual Joint Scientific Conference.
Dr. Malecela stressed that the national anti-HIV/Aids prevention package should remain the same as recommended by experts with the advocacy and public sensitisation spearheaded by national and local leaders.
She noted that people going around discouraging the use of condoms or claiming that male circumcision was the panacea for not contracting the deadly disease should be ignored.
However, the accomplished scientist admitted that surveys occasionally carried out within the country had indicated that HIV prevalence was higher in areas with low practice of circumcision.
Dr. Asha Kigoda, the deputy minister for Health and Social Welfare said male circumcision was being considered an additional intervention against HIV infection but stressed that more research would continue.
"To scale up male circumcision in the context of HIV prevention, the government should ensure both safety and high coverage over a short period of time," she said when she closed the conference organised by NIMR.
Presentations on circumcision vs HIV/Aids were among the most interesting during the conference with some researchers pressing for male circumcision to be considered as part of the comprehensive HIV/Aids preventive package.
Scientific experts who carried the research at different levels and in various parts of the country are reported to have concurred that circumcision was an effective intervention for HIV prevention in men.
However, they were unanimously agreed that there was dearth of information regarding the cultural attitudes and practices towards circumcision, especially now with the HIV/Aids pandemic. Most tribes in Arusha region do practice circumcision to men.
It was found out that traditional circumcision which is widely practiced across the country could easily become a conduit for the pandemic because it was being conducted in unhygenic conditions and using crude tools.
"Traditional circumcision is associated with high levels of complications", the researchers noted, stressing the need to ensure that the practice is safe by engaging the tribal leaders and traditional circumcisers.
Best methods to reduce "complications" without compromising cultural and social significance of traditional circumcision practices, it was further argued, was possible through having national male circumcision programme.
A survey in three districts; Tarime in Mara region, Bukoba Rural (Kagera) and Ileje in Mbeya, for instance, found varying levels of surgical complications such as excessive bleeding associated with circumcision.
Only about 37 per cent of those circumcised in Tarime and 44 per cent in Bukoba Rural went through the surgery at the health facility. In Ileje, almost all of them had the 'cut' at the hospitals.
Complications from excessive bleeding were much higher in Tarime (69 per cent) compared to Bukoba Rural (41 per cent) as were cases of infections (also 69 per cent in Tarime) and 47 per cent in Bukoba Rural.
Disfigurement of male genital organs through circumcision were also among the risks of leaving the delicate yet age old practise at the hands of traditional practitioners, the study further observed.
For instance, 68 per cent of those circumcised in Tarime had cases of disfigurement compared to Bukoba Rural where the use of traditional circumcisers was not as high as the former district.
Researchers further found out that age of circumcision varied from one district to another, a situation which can complicate problems associated with the practice and chances of using circumcision to minimise HIV cases.
Although research findings documented over the years have indicated that the practice significantly reduces the risk of HIV acquisition, there is no conclusive assertion that it can indeed prevent infection.
The debate was rekindled during the just-ended annual scientific conference organised by NIMR with most local researchers knowing too well this was not an entirely new subject.
There was a consensus, however, in the on-going fight against the pandemic male circumcision should be promoted as is the case elsewhere in Africa as there were proven indications of its positive role in anti-HIV/Aids drive.
Some scientific trials have shown that male circumcision reduces by up to 60 per cent a man's chances of becoming infected with HIV during sexual intercourse. It only provides minimal protection and should not replace other interventions to prevent transmission of HIV.
Africa: Tracking the Male Circumcision Rollout. 2/3/10
Medical male circumcision is now widely recognized as an important HIV prevention tool, and several African countries have included it in their national HIV strategies.
2 March 2010
Medical male circumcision is now widely recognized as an important HIV prevention tool, and several African countries have included it in their national HIV strategies.
IRIN/PlusNews lists the progress of 13 nations in eastern and southern Africa identified as priority countries for male circumcision scale-up by the UN World Health Organization.
Kenya: An estimated 85 percent of men are circumcised, but just 40 percent of those in Nyanza province, which has the country's highest prevalence, have had the procedure. In 2008 the government launched a national campaign and by the end of 2009 more than 90,000 men had been circumcised, 40,000 of them during a two-month "rapid results" initiative in Nyanza.
The government aims to have all uncircumcised men - an estimated 1.1 million - undergo the procedure by 2013. Kenya is the only African country to have successfully rolled out male circumcision on such a large scale.
Zambia: Male circumcision prevalence is 13 percent, and Zambia aims to circumcise about 250,000 men every year. More than 16,000 men were circumcised at 11 sites in 2009, and the goal is to have 300 sites offering the services by 2014.
Swaziland: The Ministry of Health and Human Services plans to provide circumcision to 80 percent of men aged 15 to 24 by the end of 2014. Just eight percent of Swazi men are circumcised. The country - which has the world's highest HIV prevalence - developed a male circumcision strategy in 2008; by the end of 2009 more than 5,000 men had undergone the surgery.
Botswana: Five centres of excellence have been identified to scale-up circumcision services, and Botswana's Ministry of Health aims to reach at least 460,000 HIV negative men and boys below the age of 49 by 2012. More than 4,300 men have been circumcised since April 2009.
Zimbabwe: In April 2009 the pilot phase of service delivery began, during which 1,818 men were circumcised at four sites. A national male circumcision policy was launched in November 2009.
Rwanda: Since 2008 the government has been rolling out male circumcision in the army, where prevalence is 4.5 percent compared to a national rate of three percent. A recent study suggested that Rwanda should also be scaling up circumcision across a broad range of age groups, especially the very young, where the procedure was found to be highly cost-effective.
South Africa: The government has been criticized for moving too slowly in developing a national circumcision strategy. By December 2009 the country had a draft policy but no mechanisms for training, quality assurance, or monitoring and evaluation.
South Africa has the world's largest HIV-positive population.
About 35 percent of men are circumcised. Data from the only site currently providing free circumcision - Orange Farm, near Johannesburg - reveals that 14,253 men were circumcised in 2009.
Namibia: A draft policy was submitted to parliament and training of surgical health professionals is underway. Five circumcision pilot sites have been identified, two of which are in operation. A 2009 field analysis showed that the unit cost per procedure was very high: US$88 for adults and $72 for newborns.
Lesotho: About 4,000 men are circumcised annually at government and private clinics. A policy has been approved but is yet to be launched, and formal scale-up has not yet started. The Puisano Outreach Organization, a local NGO, is engaged in male circumcision campaigns throughout the country.
Tanzania: A 2009 situation analysis found male circumcision was accepted, even among traditionally non-circumcising communities, and 70 percent of Tanzanian men were circumcised. A national policy is being developed and three demonstration sites have been set up.
Mozambique: No formal policy for male circumcision has been developed, but an existing operational plan for HIV prevention includes circumcision. Five pilot sites have been selected for scale-up in 2010.
Malawi: The country is conducting data analysis to inform its male circumcision strategy. A local NGO, Banja la Mtsogolo, is providing male circumcision services in its clinics, where it has 19 trained clinicians performing the procedure.
Uganda: This is one of the three countries where studies showed the link between male circumcision and HIV, but only 25 percent of men are circumcised and HIV prevalence is rising. There has been some criticism for failing to start male circumcision quickly enough - the country still has no policy, nor has it started service delivery.
Amazulu Set to Circumcise Again After 200 Years. 20/1/10
Pietermaritzburg – The KwaZulu Natal government will start a massive male circumcision programme before the end of this year to help prevent the spread of HIV, Premier Dr Zweli Mkhize announced yesterday.
“We believe that circumcision will help us to reduce HIV infections. Before the end of this year, we will be counting the number of people who have undergone the procedure,” he said.
Mkhize was addressing more than 100 traditional heads and government leaders who gathered at Pietermaritzburg’s Royal Show Grounds yesterday to discuss reviving the custom of male circumcision.
The KwaZulu Natal government recently decided to throw its weight behind Zulu King Goodwill Zwelithini’s plan to revive the custom, which was abandoned by the Zulus two centuries ago.
The circumcision custom was abolished by King Shaka because he felt that too many men were unable to take part in war because they had septic wounds from circumcision.
Mkhize said a number of studies had shown that while male circumcision did not provide complete protection against HIV infection, it lowered the risk of heterosexual HIV transmission.
A 2005 study in South Africa had also found that male circumcision reduced the risk of acquiring HIV infection by 60%, the KwaZulu Natal government said.
Two studies in Uganda produced similar results.
According to pamphlets circulated during the workshop, in a given act of unprotected sex with an HIV-positive woman, a circumcised man had a 60% lower risk of being infected than an uncircumcised man.
Mkhize was, however, quick to point out that a circumcised man could still get infected. “We need this programme because our province has the highest number of HIV-positive people. We are trying everything which we think can help us to reduce infections.”
Circumcisions would be conducted by health professionals and properly trained people to prevent deaths resulting from sceptic wounds.
Many people die every year in the Eastern Cape of septic circumcision wounds.
It was important for the procedure to be done by well-trained people, Mkhize said. – Sapa
British Journal: Circumcision Cuts HIV Transmission by 60%. 15/2/10
As the surgical procedure - minor for male infants - has been shown to reduce the risk of HIV infection by 60 percent
The Jerusalem Post
By Judy Siegel-Itzkovich
15 February 2010
WHO, UN program recommend procedure for all.
Jews, and later Muslims, knew what they were doing when requiring all boys to undergo circumcision, as a meta-analysis of research carried out in 21 countries and just published in the online BioMed Central Urology confirms.
One out of every three males in the world has been circumcised, and the procedure is almost always safe, especially when performed on infants and in sterile conditions.
As the surgical procedure - minor for male infants - has been shown to reduce the risk of HIV infection by 60 percent, the World Health Organization and the Joint United Nations Program on HIV/AIDS have recommended neonatal and adult circumcision.
The British journal also found that complications are even more rare when the circumcision is performed by non-medical experts in the ritual under suitable conditions, due to their usually greater experience than surgeons.
The paper was authored by Dr. Helen Weiss and Natasha Larke of the London School of Hygiene and Tropical Medicine, Dr. Daniel Halperin of the Harvard School of Public Health, and Dr. Inon Schenker of the Jerusalem AIDS Project.
There have long been protests over the years in Britain and other countries against ritual circumcision of male infants, on the grounds that "they have not been asked for consent" and that there was "no medical justification" for the ritual practice. But the accumulation of studies showing that it indeed protects health (and even reduces papillomavirus infection in women who have sexual relations with circumcised males) have made the latter argument irrelevant.
The systematic review of 52 relevant papers written in a variety of languages and countries, including in Israel and Arab states, found that circumcision of newborn and older male babies by trained staff rarely results in complications. There are more risks among older males, especially when the circumcisors were not well trained or experienced, or performed the surgery under unsanitary conditions or with inadequate equipment.
The team found that among boys before their first birthday, the frequency of relatively minor adverse events such as hemorrhaging, inflammation and infection was low (median 1.5% for any adverse event), while severe complications were very rare. If the boy was older than one year, circumcisions by medical providers tended to be associated with more complications (median 6%), although there were still few serious complications. However, more complications - and more severe ones - were observed when the foreskin was removed as a rite of passage into adolescence by inexperienced circumcisors or with inadequate equipment and supplies.
Although Jewish circumcision, usually on the eighth day after birth, was not singled out in the study, it is performed without general or other anesthesia according to Jewish law. Three Israeli studies were included in the meta-analysis
The authors concluded that "male circumcision is commonly practiced and will continue to occur for religious, cultural and medical reasons. There is a clear need to improve safety of male circumcision at all ages through improved training or re-training for both traditional and medically trained providers, and to ensure that providers have adequate supplies of necessary equipment and instruments for safe circumcision."
Operation Abraham, a consortium of eight Israeli medical institutions working voluntarily and facilitated by the Jerusalem AIDS Project, in 2008 trained 10% of all surgeons in Swaziland in performing safe, swift circumcisions on adult men to help protect them against HIV infection. Last year, five Muslim Senegalese doctors were brought to Israel to discuss teaming up West African and Israeli medical circumcisors for future training in southern Africa.
Israel is the only country in the world with extensive experience in adult male circumcision, because of the campaign to perform the ritual on large numbers of non-Jewish immigrants from the former Soviet Union and other countries who want to convert to Judaism.
"The whole subject of Israeli excellence in saving lives by promoting male circumcision for HIV prevention could be taken up by American Jewish leaders as the new paradigm for Israel-Diaspora cooperation for global health causes," said Dr. Schenker of the Jerusalem AIDS Project.
Circumcision Clamp Slammed. 8/7/10
It is much more painful that the surgical route and has more adverse events.
By Anso Tom
8 June 2010
HIV doctors and activists have slammed a male circumcision clamp that is being aggressively marketed in South Africa and the rest of the continent with a small study showing that it is much more painful that the surgical route and has more adverse events.
In a joint statement released yesterday the Southern African HIV Clinicians Society and the Treatment Action Campaign said although they supported the implementation of a country-wide voluntary male medical circumcision (VMMC) programme, they had concerns about the Tara KLamp (Subs: CORRECT).
They doctors and activists said they were deeply concerned that a Malaysian company, Taramedic Corporation, and its South African partner, Carpe Diem Enterprises, were aggressively marketing a circumcision device called the Tara KLamp (TK) to several sub-Saharan African countries, including South Africa, Lesotho, Kenya, Botswana and Zimbabwe.
A randomised controlled trial in adolescents and adults found a very high rate of adverse events and much greater pain associated with this device compared to the standard forceps-guided circumcision technique.
“The TK must be withdrawn from sale and distribution for adolescent and adult circumcision throughout sub-Saharan Africa until the device's safety concerns are addressed,” the statement said.
The TK is a circumcision device that is clamped onto the foreskin with the purpose of necrotising it. After approximately seven days the device, along with the foreskin, usually falls off. In some cases the device does not fall off forcing the patient to have the TK removed surgically.
The Orange Farm clinical trial showed that Voluntary Medical Male Circumcision can reduce a heterosexual male’s risk of contracting HIV by 60%. In 2005 the Orange Farm researchers performed a randomised controlled trial to see if the TK could be used as an alternative method of circumcision. 35 men were circumcised with the TK and 34 with the standard forceps-guided technique that was used during the original trial.
Adverse events from use of the TK were far higher: 37% compared to 3.4% for the forceps-guided method. This was a statistically significant result. Men circumcised using the TK also reported worse pain than men circumcised using the forceps-guided method. Furthermore, the device saw 97 men refused to participate in the trial, 94 of them giving the reason that they did not wish to use the TK.
The TK trial was stopped early due to the unacceptably high rate of adverse events. The researchers concluded, “Given the high rates of adverse events in this study and the low number of available studies, we strongly caution against the use of the TK for young adults, and we recommend careful evaluation of the procedure when performed on children.”
Carpe Diem Enterprises is the distributor of the TK in South Africa. The statement accused the company of disregarding the safety concerns raised in the Orange Farm study. The device's website states, “This invention enables circumcisions to be performed not only safely and easily but also ----- for the first time in surgical history ----- enables circumcisions to be performed just as aseptically, at home, on the roadsides or out there in the bush, as in an operating theater. ”
The device is marketed as a faster method of performing circumcisions, as it can be carried out in less than 10 minutes. However, this is not much faster than the medical forceps-guided method of circumcision and does not outweigh safety concerns. It also does not take into account the additional time needed to surgically remove the device from some patients.
The TK is also more expensive than the forceps-guided method of circumcision. The Treatment Action Campaign said that according to discussions with the manufacturer, the TK is being sold to general practitioners for R160 excluding VAT. However the device only slightly reduces the number of surgical instruments needed in a circumcision. “Consequently we estimate that using the TK adds significant cost, even without considering the extremely large additional cost that would be incurred from hospitalisations due to increased adverse events,” the statement said.
“The attitude of the company towards critical research of its device is exemplified by Dr. G. Singh, the inventor of the TK, who made the following threat in an email exchange with one of the authors of the Orange Farm study, ‘All it needs is a simple withdrawal of your manuscript and gracefully accept the reality. I am even not asking for an apology, for I am a very forgiving man..... but there is a limit!’,” the TAC statement revealed.
The statement claimed that the TK has also been used throughout the region as a part of the evangelical mission of the marketers of the device, Tony Lawrence and Magda Van Der Walt. A book promoting the device and the work of Tony Lawrence states the following:
“Twice per year... young male initiates in South Africa alone take an important step toward manhood by undergoing circumcision during a time of initiation … But what should be a glorious occasion for these teenagers often turns out to be a nightmare. One out of five boys end up with their genitals partially or fully amputated.... The Seize the Day foundation is rescuing these children in a holistic way. Among other things, Tony Lawrence and the seize the day volunteer distribute a pack to each initiate. (The pack contains a TK and a bible) ... The solution is to circumcise and evangelize.”
“The TK is being aggressively marketed and, at times, with an inappropriate religious agenda. The marketers of the device make unsubstantiated claims and disregard safety concerns. They have threatened researchers who published data critical of the TK. The TK must be withdrawn from use throughout sub-Saharan Africa for adults and adolescents until its safety concerns are addressed” the statement said.
Circumcision May Protect Against HIV Due To Changes In Bacteria. 08/1/10
Friday, January 08, 2010
The reduction in HIV infection risk after circumcision may be the result of a decline in bacteria on the surface of the penis that assist the process of infection, according to findings from the research team that helped establish the evidence base for using male circumcision as an HIV prevention strategy.
If this is the case, and if the bacteria can be eliminated without removing the foreskin, such a procedure might provide an important non-surgical alternative to circumcision in settings where the procedure is culturally unacceptable or difficult to implement.
The recent study, which appears in the January 2010 edition of PLoS ONE, analysed penile swabs taken from twelve participants in the Rakai, Uganda circumcision study, which enrolled almost 5,000 uncircumcised HIV-negative men and randomised half of them to be circumcised.
The twelve members of the follow-up study cohort were randomly chosen from the subset of men who had undergone circumcision and were still HIV-negative one year after the procedure.
Many different types of bacteria live on and in the human body, and changes in levels of these bacteria may affect health through complex pathways that are not well understood.
The Rakai study team used penile swabs taken before circumcision and one year after circumcision to examine how the twelve men’s bacterial make-up had changed. They found that the samples contained more than 40 distinct bacterial families, including both aerobic (oxygen-requiring) and anaerobic (non-oxygen-requiring) bacteria.
The most notable difference between the pre-circumcision and post-circumcision samples was a major reduction in anaerobic bacteria. The researchers proposed that the removal of the foreskin may have eliminated a micro-environment that fosters the growth of anaerobic bacteria.
Their hypothesis is bolstered by the observation that the female partners of circumcised men are less likely to develop bacterial vaginosis, a vaginal infection associated with the presence of a higher-than-normal level of anaerobic bacteria.
The specific way in which anaerobic bacteria may facilitate HIV transmission is hypothesised to involve Langerhans’ cells, a component of the immune system that functions in two different ways in relation to HIV. When inactivated Langerhans’ cells encounter particles of HIV, they work against HIV. However, Langerhans’ cells that have become activated play a role in helping the virus infect the body.
Anaerobic bacteria may activate Langerhans’ cells in the genital area, which would help explain why circumcision bestows partial protection against HIV. Removal of anaerobic bacteria via circumcision may result in less Langerhans’ activation, leaving the virus with a smaller gateway to infection.
The researchers believe that their discovery may have significant public health implications, in part because of the limited demand for male circumcision, which is thought to reduce a man’s risk of acquiring HIV through heterosexual sex by about 60%.
“Large-scale population-based male circumcision programs may not always be feasible due to cultural, logistical, and financial barriers,” they write. “Thus, it is important to better understand the biological mechanisms by which male circumcision reduces the risk of HIV infection as this may lead to the development of novel, non-surgical prevention strategies.”
According to a press release announcing the article’s publication, 70% of men worldwide are estimated to be unlikely to undergo circumcision.
The press release noted that the reduction in anaerobic bacteria is only one of multiple proposed explanations for why circumcision makes it harder for HIV infection to occur. Following circumcision, the top layer of the inner foreskin becomes thicker, perhaps providing a more effective barrier against HIV.
Also, reducing the amount of mucosal tissue exposed to vaginal secretions could result in fewer opportunities for HIV to interact with the immune cells that it targets.
“These potential explanations are not mutually exclusive and may work in concert to reduce HIV risk,” said Dr. Lance Price, one of the article’s authors.
The research team plans to look for specific bacteria associated with greater HIV risk, and to explore how such bacteria might be eliminated.
Price LB et al. The effects of circumcision on the penis microbiome. PLoS ONE 5: e8422, 2010.
Circumcision Modestly Reduces Risk of Male-to-Female HIV Transmission. 25/3/10
Male circumcision modestly reduces the risk of an HIV-positive man transmitting HIV to a female sex partner, an analysis of the Partners in Prevention study published in the journal AIDS suggests.
25 March 2010
Male circumcision modestly reduces the risk of an HIV-positive man transmitting HIV to a female sex partner, an analysis of the Partners in Prevention study published in the journal AIDS suggests.
The risk of contracting HIV was 40% lower for the partners of circumcised men than uncircumcised men, but this reduction in risk was not statistically significant.
Randomised studies have shown that male circumcision reduces the risk of HIV acquisition for men by up to 60%.
Less is known about the effect of male circumcision on the incidence of male-to-female HIV transmission.
However, one recent study showed that HIV incidence was similar in the female partners of HIV-positive men who elected to be circumcised and the partners of men who remained uncircumcised. In addition, the study showed that the partners of recently circumcised HIV-positive men had a short-term increase in the risk of contracting HIV if sexual intercourse was resumed before wound healing.
To gain a better understanding of the impact of male circumcision on the risk of male-to-female HIV transmission, investigators from the Partners in Prevention HSV/HIV Transmission Study looked at the rate of new HIV infections that occurred during the study in women according to their male sexual partner’s circumcision status.
Importantly, the men in this study had undergone circumcision in childhood. Therefore it was able to determine the effects of circumcision on HIV transmission risk after full wound healing.
The study involved 1096 heterosexual couples where the man was HIV-positive and the woman HIV-negative. These couples were recruited in eastern and southern Africa between 2004 and 2007. The study’s primary aim was to see if prophylactic therapy with aciclovir reduced the risk of HIV transmission. No protective effect was found.
Median CD4 cell count amongst the men was 424 cells/mm3, with median viral load being 4.3 log10 copies/ml.
A total of 34% of men were circumcised. Men in eastern Africa (39%) were more likely than men in southern Africa (24%) to be circumcised.
The female partners were followed for a median period of 18 months. A median of four episodes of vaginal sex with their male partner was reported per month. Approximately 7% of these were unprotected. During follow-up, approximately 13% of men started antiretroviral therapy.
A total of 64 women contracted HIV during the study. The overall incidence rate was 3.8 per 100 person years.
The investigators were able to genetically link 50 of these seroconversions to the male study partner.
Analysis showed that HIV incidence was approximately 40% lower in these genetically linked transmissions amongst women whose partner was circumcised (hazard ratio 0.57; 95% CI, 0.29 to 1.11, p=0.10). However, this could have been down to chance as this reduction in risk was not statistically significant.
The investigators then excluded men who started antiretroviral therapy, and looked at transmission risk according to circumcision status and viral load.
They found the partners of men who were uncircumcised and had a viral load above 50,000 copies/ml had a 47% reduction in the risk of infection with HIV. This reduction in risk was of borderline significance (HR = 0.53; 95% CI, 0.26 to 1.07, p=0.07).
“We found a nonstatistically significant decreased risk of HIV-1 transmission from circumcised HIV-1 infected men to their female partners, compared with couples with uncircumcised HIV-1 infected men,” comment the investigators. They say that a larger sample size is probably necessary to determine if the apparent reduction in risk of transmission is statistically significant.
“This finding adds to a limited body of data relating circumcision status in HIV-1 infected men to the risk of male-to-female HIV-1 transmission, data which may be helpful for programs working to scale up male circumcision for HIV prevention,” they add.
Two possible biological reasons for the non-significant reduction in HIV transmission for the female partners of circumcised men are offered by the investigators. First, circumcision may reduce the risk of ulcerative sexually transmitted infections. However, the investigators note that the incidence of genital ulcers was comparable between the circumcised and uncircumcised men in their study. Alternatively, microtrauma or inflammation to the foreskin could facilitate transmission from uncircumcised men.
Baeten JM et al. Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples. AIDS 24: 737-44, 2010.
Infant Circumcision is Safe, Suggests Study. 17/2/10
Circumcision, done by experts, is safer for infants than older boys.
The Med Guru
17 February 2010
A new meta-analysis by a team of researchers from UK has established that circumcision, done by experts, is safer for infants than older boys.
The research jointly initiated by Dr Helen Weiss and Natasha Larke from the London School of Hygiene & Tropical Medicine, Dr Daniel Halperin of the Harvard School of Public Health and Dr Inon Schenker of the Jerusalem AIDS Project found that circumcision also prevented the risk of developing AIDS.
It may be noted that male circumcision is the amputation of some or all of the foreskin called prepuce from the penis.
Dr Helen Weiss informs, “Male circumcision is commonly practiced and will continue to occur for religious, cultural and medical reasons. There is a clear need to improve safety of male circumcision at all ages through improved training or re-training for both traditional and medically trained providers.”
“And it must be ensured that providers have adequate supplies of necessary equipment and instruments for safe circumcision,” he adds.
The researchers collected data from 52 past studies done on the subject from 21 countries to come up with this finding.
They examined the effect of neonatal, infant, and child circumcision through the gathered material and found that tiny tots who were less than one year old showed lesser frequency of adverse effects associated with circumcision. The severe complications were also relatively lower in these infants.
Adverse effects of circumcision include excessive bleeding, swelling, and infections.
The systematic study also found that circumcision done by medical experts on children aged one year or older suffered more complications with lesser adverse effects.
Severe complications were, however, reported in kids who got the procedure done by inexperienced practitioners who lacked the necessary equipment.
“The whole subject of Israeli excellence in saving lives by promoting male circumcision for HIV prevention could be taken up by American Jewish leaders as the new paradigm for Israel-Diaspora cooperation for global health causes,” says study co-author, Dr Inon Schenker of the Jerusalem AIDS Project.
Circumcision and AIDS
Past data has also helped the researchers conclude that circumcision in infant boys can reduce the chances of acquiring HIV/AIDS by 60 per cent.
This is why the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS recommends neonatal and adult circumcision.
The study and its findings have been detailed in the February issue of the online medical journal, BioMed Central Urology.
Malawi: Clinics Dispel Male Circumcision Myths. 13/4/10
Male circumcision (MC), which can reduce HIV among men by up to 60 percent, is controversial in Malawi and government has yet to implement mass male circumcision
13 April 2010
Lilongwe - Male circumcision (MC), which can reduce HIV among men by up to 60 percent, is controversial in Malawi and government has yet to implement mass male circumcision. But a chain of private clinics has rolled out the measure with some surprising results.
Banja La Mtsogolo (BLM) - Future Family in the local Chichewa language - a private family planning organization, rolled out the procedure at its network of 30 national clinics in 2009 and is the only organization offering it as part of an HIV prevention package.
The UN World Health Organization recommends circumcision and Malawi's National HIV Prevention Strategy 2009-2013 acknowledges its role, but falls short of outlining a clear policy.
Brendan Hayes, the head of BLM, admitted that MC has been a hard sell.
"In Malawi, you've got very big differences in the HIV epidemic from north to south and those differences don’t correlate to differences in circumcision prevalence. High prevalence rates are in the southern part of the country, which is also where we have the most circumcision ... but you're still only talking about one in three men," he told IRIN/PlusNews.
"These differences aren't totally inexplicable but I think it's made people more cautious about moving forward with male circumcision."
Confusion and controversy
Southern Malawi has a large migrant labour population and an HIV prevalence rate of about 18 percent, accounting for almost 70 percent of the country's HIV infections, according to government figures. Circumcision is culturally less prominent in northern Malawi, where prevalence rates are also lower.
The mismatch between HIV prevalence and traditional circumcision rates has raised doubts among some high-level health officials, most notably Principal Secretary for HIV and AIDS within the Presidency, Dr Mary Shawa.
Earlier this year, Shawa argued in local newspapers that she had not yet been presented with enough clinical evidence on MC, and its efficacy was questionable given high HIV prevalence rates among traditionally circumcising populations in the south.
Shawa also questioned the acceptability of the practice among ethnic groups that did not perform the procedure.
The BLM programme is small and resource-constrained, causing the organization to be wary of creating large-scale demand through social marketing campaigns that might outstrip its capacity, and create windows for unsafe back-alley procedures. Its clinic in the high-density neighbourhood of Kawale in Lilongwe, the capital, performs about 100 circumcisions a month at a cost of about US$8 each.
"We're getting clients from all the major ethnic groups in basically representative proportions, so we're not just displacing the traditional circumcision sector or providing services just to Muslim clients," said Hayes.
Surprisingly, traditional circumcisers - who often carry out the procedure as a right of passage for adolescent initiates - support the clinics. Arnold Kumwenda, a BLM clinical officer, said traditional circumcisers were learning to meld traditional teachings with safer clinical circumcisions.
"Some [traditional circumcisers] do the education but they come here for the procedure," Kumwenda told IRIN/PlusNews. "When the boys go home, they stay in their homes instead of maybe going to the bush and then only after [the wound has healed] do they go."
By accompanying the boys, traditional practitioners learn about after-care and receive HIV counselling from BLM. Hayes said most BLM clients heard about the services by word-of-mouth - a good indicator of latent demand.
Word on the street
About 55 percent of men undergoing MC at Kawale made use of HIV testing services as part of the counselling process. Many came because their partners had heard of the benefits of MC, and the chance of avoiding the human papillomavirus, which could lead to cervical cancer, was also a strong incentive.
"Even I believed that circumcision was only for Muslims, but now the information is getting so widespread from [former] clients, girl friends and friends that there are lots of Christians coming," said Bertha Nyirenda, an HIV counsellor and tester at Kawale.
Protecting his partner from cervical cancer as well as partial protection from HIV made health worker Lazzar Phiri* go for circumcision after talking it over with his fiancé.
He has since become a resource for interested friends. "I sometimes talk about it with work mates, and friends have been talking about it to each other," he said. "I know ... two of them that came for male circumcision just because of me."
Hayes said BLM was looking into the feasibility of partnering with private doctors to expand its MC capacity, which might become crucial in implementing a future government rollout in a country where doctors and clinical officers are in short supply.
News before 2010
Calls for Circumcision In HIV Fight. 7/12/09
SCIENTISTS have called for the speedy inclusion of male circumcision in the comprehensive HIV prevention package.
This despite questions raised about human rights and the confusing message it might send to people.
Studies have shown that male circumcision reduces the risk of contracting HIV in heterosexual men by more than 50percent if done correctly. Work is being done on the policy to include circumcision in the HIV National Strategic Plan (NSP), but there are ethical issues around it.
One of the main issues is when to circumcise the child. The Children’s Act prohibits circumcision of males under 16 years of age. It only exempts the procedure when performed in accordance with religious practices or for medical reasons on the recommendation of a doctor.
Mark Heywood, deputy chairperson of the SA National Aids Council, said: “Though the Children’s Act says no child under 16 years should be circumcised without a medical or religious reason, we feel that it should be done because it is in the best interest of the child.
“The Constitution does provide for a parent or guardian to decide for a child for medical reasons or if it’s in their best interest. In the case of male circumcision it is. We recommend that children under 16 years should only be circumcised after proper counselling and with their consent. We are calling on the government to speedily include it in the HIV NSP,” he said.
Apart from age restriction , concerns have been raised about the message it might send to people.
“Male circumcision reduces the risk of contracting HIV in men. Studies conducted in Orange Farm over a two-year period proved that. But people must know that condoms are still the best protection we have. Circumcision must be promoted in such a way that it does not lead men to believe that they can have riskier sex,” said Olive Shisana of the Human Sciences Research Council.
Zulu King Lauded For Medical Male Circumcision Move. 7/12/09
The Congress of South African Trade Unions (COSATU) has welcomed King Goodwill Zwelithini’s announcement this weekend that he supports medical male circumcision and will encourage his followers to undergo the procedure which could prevent up to 60% of men acquiring HIV.
Zwelithini revealed at the controversial bull killing – ukweshwama – in Nongoma, KwaZulu-Natal on Saturday that he was going to revive circumcision within the Zulu nation and that medical doctors would be involved in the ritual.
The South African National AIDS Council and the health department are in the process of finalising the country’s policy and guidelines on medical male circumcision which will be added to the HIV prevention basket.
COSATU spokesperson Patrick Craven quoted clinical trials from Kenya, South Africa and Uganda which have found that men who have been circumcised are up to 60% less likely to become infected with HIV.
“The King’s decision could therefore lead to a substantial reduction in HIV infection, especially in the KwaZulu Natal province which currently has the highest incidence,” said Craven.
Traditional circumcision was banned by King Shaka, who believed the time it took to heal kept too many young warriors away from their military duties in his army.
“But King Zwelithini has been prepared to end nearly two centuries of tradition in the interest of saving lives, and the federation notes that the practice of circumcision among Zulus will be done by medical practitioners to avoid unnecessary deaths,” said Craven.
COSATU agreed in the statement with KwaZulu-Natal premier Dr Zweli Mkhize who said that although circumcision would assist in the fight against the pandemic, “on its own it does not prevent the spread of sexual transmitted diseases."
“For the rate of infection to come down, responsible sexual behaviour and the use of condoms is just as necessary for circumcised men,” the trade union said.
It called upon all sections of society to re-examine all their cultural practices in the light of the HIV/Aids threat and to ask for example whether the normal age for circumcision of 22 to 24 is not far too late to prevent infection among boys who normally become sexually active many years earlier.
Click here to read the Treatment Action Campaign's policy brief on voluntary male circumcision.
Swaziland: Marketing the Cut. 4/12/09
MBABANE, 4 December (PLUSNEWS) - A steady stream of young men from urban townships and rural farms are lining up for a procedure that few Swazi men have undergone since the custom of removing a man's foreskin died out in the 19th century.
"We are happy with the turnout - it shows our outreach efforts are working," said Sibusiso Simelane, Assistant Clinical Director at Litsemba Letfu (SiSwati for Our Hope) Male Clinic in Matsapha, halfway between the capital, Mbabane, and the central commercial hub of Manzini.
"They come for MC [male circumcision], but 92 percent of the men get tested for HIV," Simelane said. Every day 35 patients are circumcised by appointment at Swaziland's first clinic specifically for men, but walk-in patients are also welcomed; the procedure is free and those who arrive early can be out by lunchtime.
When the Ministry of Health and Human Services opened the facility in October 2009, it committed to making Swaziland the first country in the world where 80 percent of males in the age group most vulnerable to HIV infection (15 to 29 years) would be circumcised by 2014.
Clinical Director Dr Khumbulani Moyo attributed the procedure's low complication rate - 2 percent - to extensive counselling of patients and adherence to quality assurance standards established by the World Health Organization. "It all starts with the counsellors," said Simelane. "We cover the risks and benefits of MC."
Counsellors emphasise that MC only reduces a man's chances of contracting HIV by about 60 percent and should be combined with other prevention strategies. "We ask the patients to come with their partners, so they will also understand the procedure, and know why they cannot engage in sex for six weeks during the recuperation time," said Simelane.
Sipho, 20, a farm worker, silently deliberated for several minutes before completing the form consenting to the elective surgery. "The health motivator told me about this place; she told me about circumcision and even arranged transport," he said.
The next step is a counselling session, during which he is told the results of his HIV test before undergoing the 20-minute procedure. He is given a local anaesthetic, and tries "not to not think of the doctor cutting" while he listens to soothing music on the radio. Soluble sutures are used to save him a return trip to the clinic.
With funding from the Bill and Melinda Gates Foundation and the US President's Emergency Plan for AIDS Relief, health motivators are sent around the country to raise awareness about the clinic's services by Population Services International (PSI), a non-profit social marketing organization.
"They go to rural areas and find patients at schools and community centres. Private companies request presentations to be made to their staff," said Jessica Green, the clinic's Technical Services Director.
The health motivators collect contact information from men expressing an interest, and clinic staff follow up to make appointments. The clinic will start offering treatment for all sexually transmitted infections in 2010.
"A clinic for men is exciting because it gives men a chance to come together and discuss their health," said Bongiwe Zwane, a communications officer at PSI Swaziland. "They tell their friends about this place, which is very professional and confidential; word-of-mouth has been very positive."
Male Circumcision: Why The Delay? 3/12/09
JOHANNESBURG, 3 December (PLUSNEWS) - Countries all over Africa are at various stages of developing and implementing policies to roll out mass male circumcision to prevent HIV, but until recently South Africa has done little more than talk about a strategy of its own.
Results from three randomized clinical trials released in 2005 and 2006 provided compelling evidence that circumcision could reduce a man's risk of HIV infection during heterosexual intercourse by as much as 65 percent.
One modelling study found that in the unlikely event of all adult men in sub-Saharan Africa being circumcised in the next 10 years, two million new infections could be averted. Acceptability studies confirmed there was a high demand for the procedure, and most men understood it would not protect them from HIV completely.
The scientific world needed no more convincing that male circumcision should be scaled up as soon as possible, particularly in a high-prevalence country like South Africa. Governments, civil society and traditional leaders have taken a more cautious approach.
South Africa's National AIDS Council (SANAC) raised the possibility of providing male circumcision services in 2007, but there was a lack of political support, according to Prof Helen Rees, head of SANAC's HIV Research Prevention Committee and executive director of the Reproductive Health and HIV Research Unit at the University of the Witwatersrand, in Johannesburg.
Rees told the Social Aspects of HIV/AIDS Research Alliance (SAHARA) Conference in Johannesburg on 2 December that SANAC had a much stronger civil society voice by 2008, when the issue of male circumcision was raised again.
This time, the women's sector wondered how male circumcision would benefit them, and traditional leaders were worried that medical circumcision would conflict with the traditional circumcision that is part of young men's initiation rites for several ethnic groups in South Africa.
After lengthy consultations, SANAC issued a number of recommendations including that rollout costs should not divert funds from female condom distribution and other programmes directly benefiting women; the procedure should be offered as part of a comprehensive sexual health package, including HIV counselling and testing; and communities should be informed that male circumcision was only partly effective in preventing HIV infection.
Rees said the health department had produced a draft set of guidelines and was conducting a feasibility and costing analysis. "We still don't know if we're just going to have guidelines, or a policy, or how we're going to pay for it," she told delegates. "But there is a sense of urgency at SANAC, and at every meeting updates of progress are given. I would hope that, starting in 2010, we would start to see it being phased in."
AIDS activists have expressed frustration at South Africa's slowness in turning an evidence-based prevention strategy into policy, but several social scientists at the SAHARA conference were concerned that campaigns promoting male circumcision in other countries were not framing messages carefully enough.
Prof Rebecca Upton, of the University of Botswana, told "a cautionary tale" based on research she conducted during a national campaign to promote male circumcision for HIV prevention. Many young men she interviewed said being circumcised was a free pass to having unprotected sex, while some young women believed that if their partner was circumcised he was likely to be HIV-negative.
"We have heard that if you get circumcised you will be safe, then you are protected - taking the blanket off is important if you want to be able to have sex. Most girls who want a baby, they also want you to be circumcised now," a 19-year-old male university student told her.
"I'm not arguing with science," Upton said. "But we need to keep listening to very important underlying cultural and social factors as we move forward with these male circumcision campaigns."
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Kenya: The Million Man Cut. 17/11/09
The Kenyan government is expanding services to meet the growing demand for voluntary medical male circumcision after the launch of a national campaign a year ago. (KISUMU, 17 November (PLUSNEWS)
"We believe the launch of a rapid results initiative to scale up what we are already offering will help meet the demand; our target is an ambitious one to see to it that at least 1.1 million of the uncircumcised men in this country get the cut by the end of five years," said Jackson Kioko, director of medical services in western Nyanza Province.
Results of three random trials in South Africa, Kenya and Uganda in 2005 and 2006 demonstrated that medical male circumcision reduced the risk of HIV infection among men by up to 60 percent.
According to the Kenya AIDS Indicator Survey 2007, 85 percent of Kenyan men are circumcised; HIV prevalence is higher by three-to-five times in uncircumcised men. There are about 1.2 million uncircumcised men between the ages of 15 and 49 in Kenya, most of whom live in Nyanza Province, where fewer than 50 percent of men are circumcised.
Since the launch of the national campaign in November 2008, an estimated 40,000 men have been circumcised and 124 sites opened and equipped with facilities and personnel to offer the service. The government has trained 700 health workers in the province to offer the services in various health facilities.
"The trained health workers will ensure people who demand these services get them in a safe and timely manner and the training of others is ongoing across the various provinces within the country," Kioko added.
The government also plans to roll out mobile medical circumcision. "We do not want people to opt out simply because the services are not near them and we are making arrangements that we go to them rather than them coming to us," Kioko said. "We will, in the near future, offer infant medical circumcision; this has the potential to help people in time before their sexual debut."
Experts remain emphatic, however, that male circumcision must not be viewed as a complete prevention tool. "It is refreshing to see that research is being put to use, but we should take precautions to ensure that we constantly give information that male circumcision must work along with other HIV infection prevention strategies to be effective," said Kawango Agot, head of the Nyanza Reproductive Health Society.
"We have plans to launch a study to look into the sexual behaviours of men who have been circumcised to find out if they are engaging in risky behaviours due to the fact that they have been circumcised," she added. "We hope this will ascertain if indeed people are engaging in [risky sex]."
A 2007 study in Kisumu, provincial capital of Nyanza, found that circumcision did not result in increased HIV risky behaviour. It found that as male circumcision became more widely promoted, there would be a need to monitor "risk compensation" associated with the procedure.
Study: Men With Larger Foreskins Are More Likely to Contract HIV. 2/11/09
November 2, 2009
Men with larger foreskins are more likely to become HIV positive, according to a new Uganda-based study as reported by Reuters
. Researchers from Johns Hopkins University’s Rakai Health Sciences Program in Uganda said their findings—published October 28 in the journal AIDS—support the argument that circumcision is a viable HIV prevention method for men.
The investigation followed 965 Ugandan men, all of whom were initially HIV negative. Researchers observed a direct correlation between foreskin size and HIV infection risk.
“Mean foreskin surface area was significantly higher among men who acquired HIV,” researchers wrote. Study authors believe that the foreskin has many immune cells called dendritic cells, and that HIV can enter the body through these cells.
While multiple studies show that circumcision helps prevent female-to-male HIV transmission, the procedure does not protect female sex partners from contracting the virus.
Division Over Circumcision. 22/9/09
Cape Town - Promoters of male circumcision as a weapon against HIV will have to reckon with a Zulu belief that partial circumcision means better sex, according to researchers.
An article in the latest issue of the South African Medical Journal, reports that interviews in a rural community in KwaZulu-Natal revealed "rich traditional understandings" of male circumcision.
People had strong negative views on circumcision that involved removal of the foreskin.
"These perceptions seem to originate in historical tensions between Zulus and the Xhosas regarding male circumcision," they said.
"In contrast to the Xhosa practice of full circumcision, Zulus traditionally promoted partial circumcision (ukugweda).
"Here, the foreskin is not removed, but an elastic band of tissue under the penis glans is cut, allowing the foreskin to move easily back and forth."
The researchers, from the Human Sciences Research Council and the University of California, said men and women taking part in the interviews understood the difference between full and partial circumcision, but preferred ukugweda.
They felt it helped prevent infections, and helped avoid sensitivity and pain during sex.
"Participants felt that if the tissue under the penis gland is uncut, the foreskin is not able to move back and forth easily, which interferes with erection and causes the penis to bend downward painfully.
"A partial cut is believed to allow sperm to move freely and to enhance pleasure for men and women."
The researchers said male circumcision was being widely promoted on the assumption that the term was unambiguous.
However, their study showed a widely-held alternative meaning in the rural community where they conducted their interviews.
They said there was a need to distinguish between medical male circumcision, and its benefits, and ukugweda, whose HIV benefits were unknown.
"For successful uptake in these contexts, strategies to overcome historically negative cultural perceptions of male circumcision among Zulus, as well as positive associations of partial circumcision with enhanced sexual pleasure, are required," they said.
Trials in South Africa, Uganda and Kenya have shown that full circumcision has a dramatic effect in reducing HIV transmission.
The World Health Organisation said in 2007 that there was "compelling evidence" that circumcision reduced heterosexually acquired HIV-infection in men by about 60%.
It said male circumcision should be considered "an efficacious intervention".
UNAIDS Estimate that One Infection Will be Avoided for Every 5 to 15 Men Circumcised. 10/9/09
In the high HIV prevalence countries of southern Africa, between five and fifteen men will need to be circumcised to prevent one HIV infection in the ten following years, at a cost of between $150 and $900 per infection prevented.
These are the conclusions of an expert review of mathematical models of the impact of male circumcision, organised by UNAIDS, WHO and the South African Centre for Epidemiological Analysis, and published in the open access journal PLoS Medicine.
The group also concluded that even if circumcised men either reduced their use of condoms or resumed sex too soon after the operation, circumcision would remain beneficial on a population level. They also concluded that women will indirectly benefit from circumcision.
Although there is compelling evidence from randomised controlled trials that male circumcision can reduce the risk of men acquiring HIV through heterosexual sex, the longer-term population-level impact of introducing or expanding male circumcision services remains uncertain. Questions have remained about the cost-effectiveness of male circumcision as an HIV prevention measure in the short, medium, and long term.
A number of different mathematical models have been developed to estimate the likely impact (and several have been previously described on aidsmap.com
). However, the models have used different baseline assumptions and input variables, and so have sometimes produced slightly different results.
In order to come to a consensus about a number of key questions related to the impact of male circumcision, an expert group was convened to review the findings from six previous modelling studies.
Most of the models were based on assumptions from settings where at least 80% of men are not currently circumcised, where HIV is predominantly spread through heterosexual transmission and where HIV prevalence is greater than 15% of the general population. Prevalence is this high in southern African countries such as Zimbabwe, Zambia, Botswana, Namibia and South Africa, but not elsewhere in the continent.
The published paper does not contained detailed numerical projections of the impact of circumcision in various circumstances, and concentrates on the situation in the highest prevalence countries. The group used the modelling studies to come to a broad consensus on the answers to the key questions.
What is the expected impact on HIV incidence?
The models predict that, over ten years, one new HIV infection would be averted for every five to 15 men circumcised. In some circumstances, if almost all men are circumcised, HIV incidence could be reduced by around 30–50% in ten years.
In countries with a somewhat lower HIV incidence and prevalence, circumcision would have less impact. The group agreed that in such countries, circumcision programmes which focused on specific subpopulations could have a substantial impact. Such groups could be chosen on the basis of their low rates of circumcision or their higher HIV risk (men with HIV-positive partners; men with sexually transmitted infections; soldiers, truck drivers, migrant workers, etc).
What is the impact on women?
Circumcision does not directly benefit women, and if men resume sex too soon after being circumcised, women are actually at increased risk of HIV infection.
Circumcision Not 'Beneficial' In Protecting Men Who Have Sex With Men From HIV, Study Finds 26/8/09
Kaiser Family Foundation
Circumcision "doesn't help protect gay men" from HIV, according to a study presented by CDC researchers at the agency's 2009 HIV Prevention Conference in Atlanta, the Associated Press
reports. For the study, researchers looked at nearly 4,900 men who had sex with HIV-positive men, "and found the infection rate, about 3.5 percent, was approximately the same whether the men were circumcised or not," the AP reports. Peter Kilmarx, chief of the epidemiology branch in the CDC's HIV division, concluded that circumcision "is not considered beneficial" in preventing the spread of HIV among men who have sex with men. "However, the CDC is still considering recommending it for other groups, including baby boys and high-risk heterosexual men," the article states. "The research ... is expected to influence the government's first guidance on circumcision" (Stobbe, 8/25).
A Boston Globe
editorial also discussed circumcision and HIV. The editorial states, "There is no evidence that circumcision protects against male-to-male transmission of the virus, or from men to women. Still, a technique that reduces the prevalence of the disease will ultimately benefit all groups." In addition, "While a majority of U.S. parents already circumcise their babies, rates are lower among two groups that suffer disproportionately from HIV/AIDS: African-Americans and Hispanics." The Globe concludes, "No one should be forced to circumcise a son. But where the health benefits are clear, the CDC should be equally clear in its recommendations" (8/26).
Circumcision Should be the in Thing. 14/8/09
JOHANNESBURG, 14 August (PLUSNEWS) - William Maiko, 18, waiting at the Bophelo Pele Male Circumcision Centre in the township of Orange Farm, about 45km south of Johannesburg, South Africa, is amazingly composed for someone about to have his foreskin surgically removed.
"I've heard we must come and circumcise so that we cannot get sick," he said. "My parents think it's a good thing." Maiko is one of about 100 men aged 15 and up who come to the centre every day and briefly occupy one of seven curtained-off beds in a one-room surgery.
One of the five nurses administers an anaesthetic and prepares the patient, while the doctor works his way around the room performing the surgery. An electronic cauterising device seals the wound more efficiently than stitches and the patient is usually up and out of the door in under 20 minutes.
"It was less painful than I expected," said Sibusiso Mbele, 18. "I'll tell my friends it's a good thing to come here."
No national policy
South Africa's policy on circumcision is still being finalised, guidelines need to be drafted and health workers trained, so the Bophelo Pele centre is the only one in the country offering free male circumcisions.
Other countries in southern Africa have already begun rolling out mass male circumcision programmes in response to evidence that circumcision, safely performed in a medical setting, lowers a man's risk of contracting HIV by about 60 percent.
In South Africa, public health facilities only perform circumcision for medical reasons; those choosing it for other reasons must pay a private practitioner.
Despite its limited geographical reach, Bophelo Pele has circumcised about 12,000 men since January 2008 and demonstrated that mass male circumcision is a feasible and cost-effective HIV prevention strategy.
Dirk Taljaard, the project manager, estimates that each circumcision costs between US$25 and $37, depending on the number of procedures performed that day; $17 goes on the surgical kit, the rest is spent on staff, operating costs, and an extensive outreach campaign that aims to educate every household in the township about male circumcision.
From counselling to surgery
Before getting the cut, Maiko had to attend a group session where he received general information about how to protect himself from HIV and was shown illustrations of a circumcised and uncircumcised penis. Staff discovered early on in the project that many men thought they had been circumcised during traditional initiation rites but still had intact foreskins, or were only partially circumcised.
Maiko had attended initiation school but his father took him away the day before the circumcisions were performed. "He was thinking that it's not safe to circumcise there."
After learning about the benefits of male circumcision, not only for protection against HIV, but also for hygiene and a reduced risk of genital cancer, men who decide to have the procedure are given an individual counselling session and offered voluntary HIV counselling and testing (VCT).
About 35 percent accept the offer - not bad in a group that HIV testing campaigns have found hard to reach - and those who test positive can still go ahead if their CD4 count (a measure of immune system strength) is above 200.
The men are encouraged to bring their female partners to the counselling sessions, or at least discuss what they have learned and tell them that they must abstain from sex for six weeks to allow the wound to heal.
Maiko has not talked to his girlfriend about getting circumcised. "It's just a surprise," he said, smiling shyly. "She'll never say nothing because she knows she will get infected from me, or I'll get infected from her if I didn't circumcise."
He knows that circumcision will only give him partial protection from HIV. "They tell us that you must [still] use condoms," he said.
Men are told to return within three days of the procedure, so staff can check for infection or failure to heal, but less than two percent have any problems.
Taljaard said men mentioned protection against HIV and other sexually transmitted diseases as their main reason for circumcision, but a quick sample of those waiting at Bophelo Pele revealed other reasons.
The opinions of female partners appeared to carry weight. "A friend of my wife's brought his son here, so my wife told me, 'Why didn't you do this thing before?'" said Phineas Soko, 48. "Some nations do this thing, but us Zulus know nothing about this."
Soko gave in to pressure from his wife and friends. "I see some of the guys say you're supposed to cut this thing [because] sometimes you catch diseases," he told IRIN/PlusNews.
Younger men thought women preferred sex with a circumcised man - 40 percent of women surveyed by Bophelo Pele did in fact say they preferred circumcised men, but their reasons had more to do with hygiene than sex.
Brian Makholo, 25, is taking advantage of the free service to deal with a painful condition he has suffered from all his life: 'phimosis', or a too tight foreskin.
Taljaard said the centre offered men many sexual health benefits that were not readily available in the public health sector, and "It's often the first time they're offered these services."
He sees no reason to delay rolling out a mass male circumcision programme - the risks are minimal, the cost low considering how many infections could be averted, and the demand plentiful.
The South African government may struggle to finance a national male circumcision programme, but in other countries international donors have been willing to fund a relatively inexpensive intervention that lasts a lifetime. "Doing nothing, I think, is not acceptable anymore," said Taljaard.
© IRIN. All rights reserved. HIV/AIDS news and analysis: http://www.plusnews.org
[This item comes to you from PlusNews, part of IRIN, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs. The opinions expressed do not necessarily reflect those of the United Nations or its Member States. Reposting or reproduction, with attribution, for non-commercial purposes is permitted. Terms and conditions
Officials Weigh Circumcision To Fight H.I.V. Risk. 23/8/09
Public health officials are considering promoting routine circumcision
for all baby boys born in the United States to reduce the spread of H.I.V.
, the virus that causes AIDS.
The topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention
by the end of the year, has yet to be released.
Experts are also considering whether the surgery should be offered to adult heterosexual men whose sexual practices put them at high risk of infection. But they acknowledge that a circumcision drive in the United States would be unlikely to have a drastic impact: the procedure does not seem to protect those at greatest risk here, men who have sex with men.
Recently, studies showed that in African countries hit hard by AIDS, men who were circumcised reduced their infection risk by half. But the clinical trials in Africa focused on heterosexual men who are at risk of getting H.I.V. from infected female partners.
For now, the focus of public health officials in this country appears to be on making recommendations for newborns, a prevention strategy that would only pay off many years from now. Critics say it subjects baby boys to medically unnecessary surgery without their consent.
But Dr. Peter Kilmarx, chief of epidemiology for the division of H.I.V./AIDS prevention
at the C.D.C., said that any step that could thwart the spread of H.I.V. must be given serious consideration.
“We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Dr. Kilmarx said. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”
He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, because it spreads through different routes and because the health systems are so disparate as to be incomparable.
Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.
There is little to no evidence that circumcision protects men who have sex with men from infection.
Another reason circumcision would have less of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.
But newborn circumcision rates have dropped in recent decades, to about 65 percent of newborns in 1999 from a high of about 80 percent after World War II, according to C.D.C. figures. And blacks and Hispanics, who have been affected disproportionately by AIDS, are less likely than whites to circumcise their baby boys, according to the agency.
Circumcision rates have fallen in part because the American Academy of Pediatrics
, which sets the guidelines for infant care, does not endorse routine circumcision. Its policy says that circumcision is “not essential to the child’s current well-being,” and as a result, many state Medicaid
programs do not cover the operation.
The academy is revising its guidelines, however, and is likely to do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics
He said the academy would probably stop short of recommending routine surgery, however. “We do have evidence to suggest there are health benefits, and families should be given an opportunity to know what they are,” he said. But, he said, the value of circumcision for H.I.V. protection in the United States is difficult to assess, adding, “Our biggest struggle is trying to figure out how to understand the true value for Americans.”
Circumcision will be discussed this week at the C.D.C.’s National H.I.V. Prevention Conference in Atlanta, which will be attended by thousands of health professionals and H.I.V. service providers.
Among the speakers is a physician from Operation Abraham
, an organization based in Israel and named after the biblical figure who was circumcised at an advanced age, according to the book of Genesis. The group trains doctors in Africa to perform circumcisions on adult men to reduce the spread of H.I.V.
Members of Intact America
, a group that opposes newborn circumcision, have rented mobile billboards that will drive around Atlanta carrying their message that “circumcising babies doesn’t prevent H.I.V.,” said Georganne Chapin, who leads the organization.
Although the group’s members oppose circumcision on broad philosophical and medical grounds, Ms. Chapin argued that the studies in Africa found only that circumcision reduces H.I.V. infection risk, not that it prevents infection. “Men still need to use condoms
,” Ms. Chapin said.
In fact, while the clinical trials in Africa found that circumcision reduced the risk of a man’s acquiring H.I.V., it was not clear whether it would reduce the risk to women from an infected man, several experts said.
“There’s mixed data on that,” Dr. Kilmarx said. But, he said, “If we have a partially successful intervention for men, it will ultimately lower the prevalence of H.I.V. in the population, and ultimately lower the risk to women.
Circumcision is believed to protect men from infection with H.I.V. because the mucosal tissue of the foreskin is more susceptible to H.I.V. and can be an entry portal for the virus. Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases
like herpes and syphilis
, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with H.I.V. from infected partners if they were circumcised.
style="margin: 6pt 0cm 0pt;">However the group concluded that women would benefit indirectly because their likelihood of meeting an HIV-positive male partner would decline. Moreover, reductions in sexually transmitted infections in both men and women would reduce women’s risk of acquiring HIV.
What is the impact of circumcising HIV-positive men?
Circumcision of an HIV-positive man does not reduce his risk of transmitting the virus. In fact, if a man with HIV resumes sex too soon after circumcision, incomplete healing could lead to an increased risk of HIV transmission. Two models addressed this issue, and concluded that this is unlikely to have an impact on a population level because the post-healing time is relatively short.
Moreover the group noted that systematic exclusion of men with HIV from circumcision might lead to stigma for all uncircumcised men. One model indicated that targeting circumcision to men with the highest risk of HIV exposure will provide the greatest overall benefit, even though this will also recruit more men with HIV infection.
What is the effect of risk compensation?
If men believe that circumcision protects them fully against infection, there is the possibility of an increase in sexual risk-taking. Three models suggested risk compensation by circumcised men and their partners would only have a “small effect” at the population level, unless it was to the extent of complete abandonment of condoms.
However, if increases in risk-taking took place across the entire adult population, this would substantially reduce the benefit of circumcision. The group recommend intensive communication campaigns to prevent this occurring.
Do the effects vary by age group of men circumcised?
The models showed that circumcising men who have not started sexual activity leads to the greatest population-level benefit in the long term, but circumcising 25 to 34-year olds has the biggest benefit in the first 20 years. Circumcising 50-year old men has little effect on HIV incidence.
The group did not find that circumcising new-born babies would be cost-effective. Although circumcision at this stage is safer and cheaper, the impact on HIV would not be seen for over 20 years.
How do the effects vary with speed of service scale-up?
The group concluded that rapid initial scale-up leads to a greater impact and is more cost-effective, with fewer circumcisions required to avert one infection, at a lower cost.
What are the discounted savings?
The models estimated that each infection that is prevented because of circumcision costs between $150 and $900, calculated over a ten-year time period. When calculated over twenty years, the cost per prevented infection is $100 to $400. Costs will be higher in lower prevalence countries.
These costs are based on $30-$60 per adult circumcision, and a life-time treatment cost of $7,000 per HIV infection (first-line therapy only).
Findings from the modelling studies have been used to refine and validate a pragmatic, decision-makers' programme planning tool
which can model what the scale-up of male circumcision may achieve and cost in specific settings.
UNAIDS/WHO/SACEMA Expert Group. Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision Making? PLoS Med 6(9): e1000109. doi:10.1371/journal.pmed.1000109
High Demand For Male Circumcision. 22/7/09
CAPE TOWN - South Africa’s male circumcision (MC) research project in Orange Farm outside Johannesburg has circumcised over 9 000 men since January 2008, but are unable to assist men coming from outside their catchment area because of restrictions on the trial conditions.
“We have clients coming from all over the country with high demand for our services from other areas, but we can’t enroll the men because the research project is restricted to only Orange Farm,” said Cynthia Nhlapo, Programme Manager of the Bophelo Pele Male Circumcision Centre.
Nhlapo was presenting at a satellite session at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) which ends tonight.
The South Africa government has been consulting for over a year with Deputy Director General Yogan Pillay telling an IAS 2009 meeting earlier this week that the country was busy formulating policy on the intervention which has scientifically shown to offer men 60% protection against HIV infection. An AIDS vaccine offering 60% efficacy would be considered a major breakthrough in the fight against HIV.
Toby Kasper, country representative for the MC project in neighbouring Botswana said they had set a target of conducting 1 000 circumcisions in the first three months of operation, but that they had reached 1 360 within the first two months.
“Some clinics are booked until the end of the year,” he said. He said the challenge was to balance between raising knowledge on MC while not overwhelming service delivery facilities.
Chivuli Ukwimi of the Society for Family Health in Zambia said research had shown that the acceptability of male circumcision stood at 80% in the country.
“The programme received a massive boost when government accepted male circumcision as an HIV prevention strategy,” he said.
Zambia has circumcised 1 500 men via its mobile sites which offer services over weekends while static sites circumcised over 2 000 men.
Male Circumcision Improves Sex for Women 21/7/09
WebMD Health News
July 21, 2009 (Cape Town, South Africa) -- Women whose male sexual partners were circumcised report an improvement in their sex life, a survey shows.
Researchers studied 455 partners of men in Uganda who were recently circumcised. Nearly 40% said sex was more satisfying afterward. About 57% reported no change in sexual satisfaction, and only 3% said sex was less satisfying after their partner was circumcised.
Also, some women said their partner had less or no difficulty maintaining or getting an erection.
Among the 3% of women who reported reduced sexual satisfaction, the top two reasons were lower levels of desire on the part of either partner.
Top reasons cited by women for their better sex life: improved hygiene, longer time for their partner to achieve orgasm, and their partner wanting more frequent sex, says Godfrey Kigozi, MD, of the Rakai Health Sciences Program in Kalisizo, Uganda.
Kigozi tells WebMD he undertook the survey because some activists have objected to male circumcision as a means of combating HIV because of a lack of data on female sexual satisfactions.
The findings were presented at the Fifth International AIDS Society Conference on Pathogenesis, Treatment and Prevention of HIV.
The women in the study all participated in the landmark Rakai circumcision trial, one of three studies that showed that the procedure reduces a heterosexual man's risk of acquiring HIV by more than 50%.
"We included only women who said they were sexually satisfied before [their partner was circumcised]," Kigozi says. "Then we asked them to compare their sexual satisfaction before and afterward."
Men feel much the same way, he adds. In a previous survey, 97% of men said their level of sexual satisfaction was either unchanged or better after they were circumcised.
Naomi Block, MD, of the CDC's HIV Prevention Branch, who chaired the session at which the study was presented, says that other surveys have shown that women don't expect their sex lives to change if their partners are circumcised.
But those were "what if?" surveys, she tells WebMD, while the new study involves women whose partners were actually circumcised.
The findings are "good news" as they show that the use of circumcision to fight HIV is acceptable to women, Block says.
Polly F. Harrison, PhD
Male Circumcision Does Not Decrease Sexual Satisfaction. 20/7/09
CAPE TOWN - Nervous giggles filled a meeting room at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) yesterday when discussions turned to the sexual satisfaction of the female partners of circumcised men and the “cosmetic outcome” of the circumcision.
“How did you measure the sexual satisfaction of the women partner?” a delegate from Zimbabwe asked while a delegate from Botswana quizzed the researcher on whether they had reports from who thought the “circumcised penis looks ugly, it’s awful”.
Three research studies have shown unequivocally that male circumcision leads to a 50 to 60% reduction in the transmission of HIV to the male partner. It has shown no protective benefit to the woman partner.
Godfrey Kigozi of the Rakai Health Sciences Programme in Uganda described how they had recorded the sexual satisfaction of 455 women between the ages of 15 and 49 who were partners of men who had been circumcised as part of the initial trials to test the efficacy of male circumcision.
Researchers collected information from the women before their partners were circumcised and after with the women self reporting the changes in sexual pleasure.
Around 57% of the women reported no change in sexual pleasure while 39% reported an improvement. A total of 3% reported less satisfaction.
Kigozi said they quizzed the women on why their sexual satisfaction was less and they blamed it on the fact that the man’s sexual desire had decreased and that their partner was struggling to achieve an erection.
The vast majority who reported improved sexual satisfaction placed improved hygiene and the fact that their partner took longer to achieve an orgasm, resulting in longer sex, top of their list.
On a more serious note, Tim Lane of the University of California San Francisco reported on observational data from the Soweto Men’s Study which was showing that there was a lower risk of HIV infection among circumcised men who have sex with men (MSM).
Early indications are that the odds of infection among uncircumcised MSM reporting insertive anal intercourse with male partners was four and half times higher than among insertive circumcised MSM.
A staggering 40% of the men studied reported also having sex with women. Lane said it was important to consider a randomized controlled trial of circumcision among MSM.
Deputy Director General for Strategic Health Programmes in the South African health department Dr Yogan Pillay said he was interested in learning about experiences from other countries as “we are in the process of finalising a policy around male circumcision.”
Male Circumcision Does Not Protect Women 17/7/09
JOHANNESBURG, 17 July (PLUSNEWS) - New research suggests that circumcising HIV-positive men does not reduce the risk of their female partners becoming HIV-infected.
The findings, reported on 17 July in the British medical journal, The Lancet, emerged from a clinical trial in Rakai District, southern Uganda, involving 922 HIV-infected men and 163 of their HIV-negative female partners.
Half the men were circumcised at the start of the two-year trial; the other half, who made up the control group, were circumcised at the end of it. Their uninfected female partners were followed up after six, 12 and 24 months to determine whether they had acquired HIV from their male partners.
Male circumcision has become a recommended HIV-prevention strategy since three clinical trials, one of which was also held in Rakai, showed that the procedure could reduce the HIV risk to men by as much as 60 percent. Until now, little was known about whether male circumcision also reduced the risk of HIV infection in women.
Previous observational studies suggested that the partners of circumcised HIV-infected men were less likely to acquire HIV, but the trial in Rakai failed to confirm this. Out of 92 couples in the circumcised group, 18 percent of the women became infected during the study period, compared to 12 percent of women in the uncircumcised control group.
Male circumcision may actually have increased the HIV risk to some of the women in the intervention group. After six months, women whose partners ignored advice to abstain from sex for at least six weeks after the circumcision procedure had an HIV acquisition rate of 27.8 percent, compared to 9.5 percent among women whose male partners delayed sex until healing was complete, and 7.9 percent among women with uncircumcised partners.
The trial was stopped early because of "futility", meaning that the accumulation of further data was unlikely to produce substantially different results.
The findings are likely to have important implications for the male circumcision programmes being rolled out in a number of countries with high rates of HIV, including Zambia, Swaziland, Kenya and Uganda. The programmes have received substantial backing from governments, international donors and UN agencies.
In an accompanying comment in The Lancet, Jared Baeten, of the University of Washington's Departments of Global Health and Medicine, cautioned that the results of the Rakai trial "should in no way hinder programmes working to scale up circumcision services for men at risk for HIV".
Circumcising HIV-positive men may not directly reduce HIV risk to their female partners, but large-scale male circumcision programmes would benefit women in the long term by bringing down overall HIV prevalence in communities.
Baeten also agreed with the study authors that the results should not prevent HIV-infected men from qualifying for the procedure, because excluding them could lead to stigmatization and deny them other health benefits, including a reduction in genital ulcer diseases.
The findings reinforced the need for men undergoing the procedure to receive extensive counselling about the importance of delaying sex for at least six weeks afterwards, the continued need to use condoms, and to reduce partner numbers.
[This item comes to you from PlusNews, part of IRIN, the humanitarian news and analysis service of the UN Office for the Coordination of Humanitarian Affairs. The opinions expressed do not necessarily reflect those of the United Nations or its Member States. Reposting or reproduction, with attribution, for non-commercial purposes is permitted. Terms and conditions: http://www.irinnews.org/copyright.aspx
Male circumcision - What's the Latest? 23/6/09
JOHANNESBURG, 23 June (PLUSNEWS) - It has been two years since the World Health Organization recommended male circumcision (MC) as an HIV prevention measure, and countries in Southern Africa - the region hardest-hit by AIDS - have been slowly gearing up to provide widespread access to the procedure.
IRIN/PlusNews has compiled a list of the progress made so far in eight southern African countries.
Botswana: Botswana's Ministry of Health has set a target to circumcise 80 percent of eligible men, or about 460,000, by 2012. Initially, the procedure was rolled out to 26 public hospitals, but at the beginning of 2009 less than 20 percent of males had access to MC services, according to the US President's Emergency Plan for AIDS Relief (PEPFAR).
In April, a further six public clinics and 17 private clinics began providing circumcision, the Botswana Press Agency reported.
Lesotho: Male circumcision services are still limited, with about 4,000 men circumcised annually through a mix of government clinics and NGOs such as Christian Health Association (CHAL) and the Lesotho Planned Parenthood Association.
A national strategy on male circumcision is being developed. Male circumcision done in the health sector would cost about USD$56 per procedure, UNAIDS has found.
Malawi: As of December 2008, the country was conducting research to review feasibility, cost implications and cultural issues.
A national task force on male circumcision and HIV prevention has been established, according to UNAIDS.
Namibia: The procedure is currently offered at some state hospitals. The country has completed a situation analysis to understand the attitudes, impact, and resource implications of implementation.
A Male Circumcision Task Force and a Male Circumcision action plan is due to be presented to parliament this year.
South Africa: Activists have been frustrated by the government's lack of urgency in introducing MC. The government announced recently it was assessing how to make it part of its HIV prevention programme. The move comes after extensive consultations with the National AIDS Council as well as traditional leaders.
The only facility in the country offering the procedure free of charge is the Bophelo Pele centre in the township of Orange Farm - the site of one of three randomised controlled trials that confirmed MC's protective effect against HIV.
Swaziland: Swaziland was one of the first countries to implement "mass" male circumcision, and by the end of 2008 had circumcised more than 2,000. But inadequate capacity meant a low key campaign to avoid over demand.
The country is expected to receive a 5-year US$50 million grant to scale up this year through the Bill & Melinda Gates Foundation, which aims to extend the procedure to 650,000 men in Zambia and Swaziland.
Zambia: In June 2009, the government announced they were working on a plan to reach 50 percent of all men and 80 percent of all new born babies by 2020.
The government offers MC at the University Teaching Hospital in the capital, Lusaka, the General Hospital in Livingstone and satellite facilities in the rest of the country.
Zimbabwe: Although donors have pledged resources, the country has been slow to take up the campaign. At the recent HIV/AIDS Implementers' Meeting held this month in Namibia, government officials reported the country had so far performed only 140 circumcisions through state facilities. The Ministry of Health, however, is set to open male circumcision clinics in Bulawayo, Mutare and Mt Darwin by the end of June and is currently training physicians to conduct the procedure.
Circumcision To Reduce HIV Risk 25/5/09
Gaborone - The process of circumcising nearly half a million males in Botswana by 2012 will prevent almost 70 000 new HIV infections by 2025, a report published on Thursday said.
"Scaling up safe male circumcision has the potential to reduce the impact of HIV/Aids in Botswana significantly," said a report published in the International Aids Society journal 2009.
Researchers estimated that the process could cost the state about $47m (just under 34m euros).
The report boosted government's newly launched campaign to circumcise 460 000 men, over the five years, in a bid to curb the spread of the disease.
The health ministry said the initiative was prompted by a series of studies which found that circumcised men were two to three times less likely to contract HIV.
Government is currently running television and radio campaigns to encourage men to visit clinics for safe circumcision procedures.
According to a Unaids report, HIV prevalence among pregnant women in Botswana was last measured at 43% in 2003.
The rapid spread of HIV and Aids once threatened the survival of the approximately two million people of the land-locked southern African country, until the introduction of antiretroviral drugs in 2003.
© News24 2003. ALL RIGHTS RESERVED.
Studies Provide Sufficient Evidence To Recommend Male Circumcision As HIV Intervention, South African Researchers Say. 16/4/09
Kaiser Daily HIV/AIDS Report - Thursday, April 16, 2009
Researchers from the South African Cochrane Center concluded Wednesday that sufficient evidence exists that male circumcision reduces the risk of HIV transmission among heterosexual men and the procedure should be considered an appropriate HIV intervention strategy, the SAPA/Mail and Guardian reports. Located at the South African Medical Research Council, the Cochrane Center is part of the Cochrane Collaboration, an international network of researchers that reviews the effects of interventions to inform health care decisions and policy. Although the center in the past did not recommend male circumcision as an HIV prevention tool because of insufficient evidence, researchers "changed their previous conclusions" after reviewing data from three recent African trials, Nandi Siegfried, co-director of the center, said.
According to Siegfried, circumcision helps prevent against HIV by removing foreskin cells, which contain receptors that enable the virus to enter the cells. She said, "Research on the effectiveness of male circumcision for preventing HIV in heterosexual men is conclusive," adding, "No further trials are required to establish that HIV infection rates are reduced in heterosexual men for at least the first two years after circumcision." Although Siegfried recommended that policymakers include male circumcision as an additional intervention in HIV prevention programs, she also noted that officials should consider cultural and environmental factors when designing circumcision programs.
According to the SAPA/Mail and Guardian, researchers will need to conduct further studies to determine whether male circumcision provides protection against HIV to female sexual partners or to men who have sex with men (SAPA/Mail and Guardian, 4/15).
Reprinted from kaisernetwork.org. You can view the entire
Kaiser Daily HIV/AIDS Report, search the archives, and sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv . The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.
Experts Weigh Success of Circumcision Against HIV. 4/11/08
November 4, 2008
Cape Town - Circumcised men in South Africa are currently as likely to be HIV-positive as their uncircumcised counterparts, according to a study in the latest edition of the South African Medical Journal.
Its publication comes amid growing calls for governments around the world to promote voluntary circumcision as a tool in the fight against HIV.
The study was conducted by staff at the Medical Research Council and the Human Sciences Research Council.
They said the removal of the foreskin reduced the probability of HIV infection.
However, just over 40 percent of the men in their sample of 3 025 were circumcised only after their first sexual activity.
Of those circumcised after their 17th birthday, two thirds were sexually active before circumcision.
"HIV prevalence was equal among circumcised and uncircumcised men (11.1 percent versus 11 percent)," the researchers said.
When they looked only at the sexually active men in the sample, circumcision still showed no protective effect.
"The first key finding from this study was that male circumcision does not appear to be protective against HIV infection among men in South Africa, irrespective of whether they are sexually active or not," the researchers said.
There was a clear need for more research on the feasibility of a policy of mass circumcision in communities where traditional circumcision "may be done too late to offer the maximum protection, and the long-term protection of circumcision may be eroded by risky sexual behaviour".
One of the researchers, MRC statistician Catherine Connolly, told reporters that though circumcision itself reduced the chances of HIV infection, it was "not a magic bullet".
"If you have multiple concurrent partners, eventually you'll probably sero-convert," she said.
Any mass circumcision programme would have to be one aspect of a multi-dimensional programme that also looked at aspects such as attitude and behaviour.
Circumcision is practised as a traditional coming-of-age ritual by a number of ethnic groups in South Africa, including the Venda and Xhosa people. – Sapa
Other News reports on this matter:
Minister Breaks Bad News About AIDS Prevention. 8/02/08
08 February 2008
Science and Health Editor
CAPE TOWN — Health Minister Manto Tshabalala-Msimang expressed doubts yesterday about the merits of male circumcision in preventing HIV transmission, saying new research suggested the procedure might make women more vulnerable to the disease.
Last year the World Health Organisation (WHO) recommended that countries hard-hit by HIV/AIDS encourage male circumcision, after three large studies showed it could halve the risk of men getting the virus from infected women.
“I’ve just had very shocking news this morning,” the minister told traditional leaders gathered in Cape Town to debate male circumcision ahead of a WHO meeting in Brazzaville in April.
She told reporters later she had been informed by local scientists Gavin Churchyard and Glenda Gray of new research indicating that women who had sex with circumcised HIV-positive men appeared to be at greater risk of infection than women who had sex with uncircumcised men.
Prof Churchyard, who heads the Aurum Institute for Health Research, said that research presented at the 15th Conference on Retroviruses and Opportunistic Infections in Boston this week indicated circumcising HIV-positive men might increase the chance of harm to women. There were “incredibly high” rates of HIV transmission in the first six months after circumcision, probably because the men were having sex before their wounds had healed, he said.
The research had important public health implications, as it meant a mass circumcision programme would have to be coupled with HIV testing, said Churchyard. “Circumcision reduces the risks for uninfected men, so it would have an overall effect on the population, and women could still benefit indirectly.”
The study presented at the conference was carried out in Uganda and funded by the Bill and Melinda Gates Foundation. It compared the annual HIV incidence in the wives of men who had been circumcised to wives of men who had not.
According to media reports and a video recording of the presentation, the annual HIV rate in the wives of the men who had been circumcised was 14,4% over two years, compared to 9,1% among the women whose husbands had not been circumcised. The researchers emphasised that the results could have been due to chance, as the findings were not statistically significant.
AIDSmap reported the study’s principal investigator, Maria Wawer of Johns Hopkins University, as saying the results were “unexpected and somewhat disappointing”. If the results were not due to chance, they might be due to men having sex before their circumcision wound had healed. Both groups reported the same level of condom use. Wawer said the results posed a challenge to the mass roll-out of male circumcision in Africa.
The results were “not good, not good at all,” said the health department’s HIV/AIDS head, Nomonde Xundu.
The president of the Southern African HIV Clinicians Society, Dr Francois Venter, said the minister was “right to be concerned ”.
CROI: Circumcising HIV Positive Men may Increase HIV Infections in Female Partners, but Fewer STIs Seen. 3/02/08
February 03, 2008
There was a trend towards higher HIV incidence in the wives of HIV positive men who were circumcised compared with wives of men left uncircumcised, in the latest prevention study conducted in Rakai province, Uganda, investigators revealed at a press conference on the opening day of the Fifteenth Conference on Retroviruses and Opportunistic Infections in Boston.
In 2006, a randomised trial of circumcision in Rakai reported that circumcision led to an almost 50% reduction in a man’s risk of acquiring HIV through heterosexual sex. The impact of male circumcision on transmission of HIV to the female partner remains unknown, and the study reported today set out to examine the effects.
In the Gates Foundation-funded study, 1015 HIV positive men were randomised either to immediate circumcision or circumcision delayed by two years. Of these 770 were married and were asked to invite their wives into the study; 566 wives enrolled of whom 245 (43%) were HIV-negative and therefore in a serodiscordant relationship.
The annual HIV incidence rate in the wives of the men who were circumcised was 14.4% over two years of follow-up compared with 9.1% in women whose partners remained uncircumcised. This result may be due to chance as it was not statistically significant, but was described as “unexpected and somewhat disappointing” by lead investigator Maria Wawer of Johns Hopkins University, Baltimore. It was not due to behavioural disinhibition; condom use was the same in both arms.
Wawer said that these results were an additional challenge to the rolling-out of mass circumcision programmes in Africa, which are expected following the positive results from three randomised controlled trials of circumcision in HIV negative men, one of them conducted within the Rakai community.
She said: “It is inevitable that some HIV positive men will seek circumcision. It is the only HIV prevention modality that leaves a mark, and no one wants to be the only guy in the village who is uncircumcised if it becomes regarded as a mark of HIV.”
If the increased incidence in the partners of circumcised HIV-positive men is real and not due to chance, it may largely have been due to men resuming sex before their circumcision wound was certified as having healed, Wawer added. Five out of 18 wives of men who resumed sex more than five days prior to certified wound healing (28.8%) became HIV-positive themselves. In contrast six out of 63 wives of men who resumed sex no earlier than five days prior to certified wound healing were infected (9.5%) and this was statistically equivalent to six out of 68 wives of men who remained uncircumcised (8.8%).
After six months, HIV incidence declined to 5.7% a year in partners of circumcised men and 4.1% in wives of uncircumcised men, which was also not statistically significant.
The results may be partly due to HIV-positive men tending to heal more slowly from circumcision than HIV negative men. Seventy-one per cent of HIV positive men had healed completely by 30 days after circumcision, compared with 83.2% of HIV negative men.
Wawer said: “It is imperative people don’t resume sex in the post-operative period, and because of this slightly longer healing time we are saying don’t resume sex until six to eight weeks after the operation.”
She added that even in the RCT in HIV negative men, the benefit from circumcision did not start to appear until more than six months after the operation.
Effect of circumcision on STIs
There was better news from this and another study of the effect of circumcision on sexually transmitted infections (STIs). In the Rakai study, the circumcised HIV-positive men had a third less genital ulcer disease (GUD) than those who remained uncircumcised (10.1% versus 15.8%) and this was statistically significant (p = 0.002). However rates of all STIs and of bacterial vaginosis were the same in wives of circumcised and uncircumcised men.
Another study presented by Aaron Tobian of the same team investigated the effect of circumcision on the acquisition of genital herpes (HSV-2) in HIV-negative men, and on the incidence of GUD, bacterial vaginosis and trichomonas in their wives.
There was a 25% reduction in HSV-2 acquisition in the circumcised men, and a 25% reduction in GUD, a 20% reduction in bacterial vaginosis, and a 50% reduction in trichomonas in their wives. Severe bacterial vaginosis fell by 60% (two per cent in wives of circumcised men versus 6.5% in wives of uncircumcised). All these results were statistically significant.
Among 62 men who became HIV-positive during the trial, 38 (61%) either had HSV-2 before the trial (47%) or seroconverted simultaneously to HIV and HSV-2 (14%).
“All the STIs observed are cofactors of HIV,” Tobian commented. “These effects may influence the positive effect of circumcision on HIV acquisition.”
Wawer M et al. Trial of circumcision in HIV+ men in Rakai, Uganda: effects in HIV+ men and women partners. Fifteenth Conference on Retroviruses and Opportunistic Infections, Boston. Abstract 33LB. 2008.
Tobian A et al. Trial of male circumcision: prevention of HSV-2 in men and vaginal ..
Male Circumcision Programs in Africa Difficult. 7/09/07
Kaiser Daily News
[Sep 07, 2007]
A physician shortage, lack of medical regulation and low education levels are making it difficult to implement safe male circumcision programs in Africa in an effort to curb the spread of HIV, the Wall Street Journal reports (Schoofs, Wall Street Journal, 9/7). According to final data from two NIH-funded studies -- conducted in Uganda and Kenya and published in the Feb. 23 issue of the journal Lancet -- routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65%. The results of the Uganda and Kenya studies mirrored similar results of a study conducted in South Africa in 2005. In response to the findings, the World Health Organization and UNAIDS in March recommended the procedure as a way to help reduce transmission of the virus through heterosexual sex (Kaiser Daily HIV/AIDS Report, 8/10).
According to the Journal, less than 20% of men in African countries with high HIV prevalence -- such as Malawi, Rwanda, Zambia and Zimbabwe -- are circumcised. In Kenya, more than 80% of men are circumcised; however, complications from the procedure are common and show the potential risks of implementing widespread circumcision programs throughout the continent, the Journal reports.
A 2004 study among 1,000 African boys and teenagers who received circumcisions found that 35% of those circumcised by ritual circumcisers -- who often have only rudimentary medical training -- experience side effects such as infection, excessive bleeding and painful urination. The study also found that 17% of those circumcised in medical settings, including private clinics, experienced adverse side effects. Less than 2% of those circumcised with modern medical procedures and equipment experienced the side effects, the study found.
Some health workers in Africa lack adequate equipment to perform safe circumcision, such as scissors sharp enough to not leave ragged edges. Many ritual circumcisers often perform the procedure without sterilization or bandages, and because the penis is rich in blood vessels, excessive bleeding and infection can occur if the vessels are not tied properly. In addition, lignocaine, a local anesthetic commonly used in Kenya, can cause irregular heartbeat and cardiac arrest if injected into the bloodstream rather than into tissue. Many Kenyans with little education do not understand the difference between ritual healers and doctors, the Journal reports.
According to the Journal, some social advocates in Kenya are urging parents to have their sons circumcised in medical rather than ritual settings. In addition, increased education in the country has spread knowledge about sanitary medical procedures. Some Christian churches in the country have begun to offer safe, medical circumcisions in their communities.
Peter Cherutich, a member of the Kenyan Ministry of Health's circumcision task force, said he hopes the government will begin to offer no-cost circumcisions. The government is seeking support from donor governments and international organizations to fund such a program, the Journal reports (Wall Street Journal, 9/7). The President's Emergency Plan for AIDS Relief last month announced it would begin providing money for male circumcision programs in some African countries in an effort to reduce the spread of HIV. PEPFAR focus countries have been invited to request program funding to increase access to the procedure (Kaiser Daily HIV/AIDS Report, 8/20).
According to Cherutich, the health ministry's circumcision task force will consider training nurses to perform the procedure to help address the shortage of physicians available to provide circumcisions. However, he added that it might not help solve the problem because the majority of nurses in Kenya are women, and many traditional cultures object to women performing the procedure. Cherutich said that increased access to safe circumcision could "make a huge difference in the HIV epidemic" (Wall Street Journal, 9/7).
Washington Post Examines Kenyan Luo Tribe's Resistance to Circumcision
In related news, the Washington Post on Friday profiled the Kenyan Luo tribe, the only major Kenyan tribe that does not traditionally circumcise boys. According to the Post, about one in five Luo adults is HIV-positive, compared with one in 17 throughout Kenya. Robert Bailey, an epidemiologist at the University of Illinois-Chicago who oversaw the Kenyan circumcision trial, said that a well-run circumcision program could reduce HIV prevalence among Luo men from 18% to 8% over 20 years. In addition, women would be less likely to contract HIV because fewer men would have the virus (Timberg, Washington Post, 9/7).
Male Circumcision Doesn't Affect Women's HIV Risk. 24/08/07
Michael Carter, Friday, August 24, 2007
Male circumcision has “little influence” on a woman’s HIV risk, according to a study conducted in Uganda and Zimbabwe published in the August 20th edition of AIDS. However, the study did show that women with high levels of sexual risk were slightly less likely to contract HIV if their partners were circumcised, and the investigators suggest that this finding should be explored in further studies.
Three randomised controlled trials have now shown that circumcised men might have a significantly lower risk of HIV infection than uncircumcised men. It is uncertain, however, if male circumcision has a protective effect against HIV infection for women. The studies that have examined this question have so far yielded conflicting results.
You can read more about this new study here
Making the Foreskin History. 20/6/07
20 June 2007
UNAids is careful in its assessment: "Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a 'magic bullet' -- it does not provide total protection and it does not mean people can stop taking the safe sex precautions they were already using."
The caution is a response to the excitement -- and debate -- triggered by results from three random trials in South Africa, Kenya and Uganda in 2005 and last year, which seemed to demonstrate that circumcision reduced the risk of HIV infection for men by between 50% and 60%.
After the slow slog of behaviour-change messaging, here was a simple medical procedure -- already widely accepted by many African cultures -- that could have a significant impact on HIV acquisition. A broad front of United Nations agencies, key United States-based donors and, recently, African health ministers are rallying around an endeavour to make the foreskin history.
But there are voices of dissent: some argue that there is not enough incontrovertible evidence to rush to scale up circumcision and why, for example in South Africa, there does not seem to be a significant difference in prevalence between communities that circumcise and those that do not.
Frustration over the slow headway made by orthodox Aids programmes has resulted in "a desperation to find something that works, with a growing lobby for biomedical intervention", says researcher Peter Aggleton.
The danger that men will see circumcision as a quick fix -- and ignore the public health exhortations to condomise -- is acknowledged by both sides of the debate. But the dissidents question why any potential dilution of the latex message should be risked when condoms provide close to 90% protection and it has been such a struggle to persuade men to put them on.
For Richard Delate, communications director of the South African health and education programme of Johns Hopkins University, circumcision is just an additional prevention method. "We need to give men a choice ... and circumcision provides an entry point where we can engage men to talk about their penises in relation to sexual and reproductive health."
Circumcision, though, is not just a medical or cosmetic procedure -- for many men it is loaded with meaning around identity and manhood. Social scientists, who feel they have been sidelined in the debate, argue that it is a deeply political act serving as a marker for status, power and social differentiation.
Can a mass roll-out work among men in ethnically mixed societies, where foreskins -- or their absence -- are shorthand for kinship, culture and, inevitably, chauvinism? Delate is clear that culture changes: Zulus were once traditionally circumcised, but obeyed a decree by King Shaka and simply stopped.
But it also boils down to money. Health services in Africa are already overburdened, under-resourced and unable to provide the most basic care. Should circumcision be added to that load?
Circumcision: A Woman's View. 20/6/07
Irin/PlusNews 20 June 2007 11:59
Women's voices have largely gone unheard in the debate on male circumcision as an HIV-prevention method, but informal discussions with women reveal a range of concerns, preferences and views that researchers and governments would do well to consider before drawing up plans for rolling out a national circumcision programme.
In an unscientific poll, Irin/PlusNews found a high degree of ambivalence among wives, girlfriends and mothers about the implications of a mass male circumcision campaign.
"It's going to be an advantage for women who are married to men who are cheating," said Carol Masombuka (19) from Mpumalanga, zeroing in on the fact that even the partial protection circumcision provides could make a difference to women who are powerless to insist on the use of condoms.
Other women were wary of an initiative that could give men one more excuse not to use condoms. "Most women are shy when it comes to things concerning sex. It's always the man who knows better, so he will decide when we have sex and, if he wants to use a condom, he will. Whatever he says goes, so it's going to suppress women even more," said Kgaugelo Khuto (20) a student from Limpopo.
Studies have found higher levels of acceptability for male circumcision among women than among men.
Three clinical trials have demonstrated that circumcision reduces a man's chances of contracting HIV by about 60%. The expected numbers of male HIV infections averted by a large-scale male circumcision programme would translate, eventually, into fewer infections in women. There is also evidence that circumcised men are less likely to harbour the human papilloma virus, which causes cervical cancer -- a major killer of women in sub-Saharan Africa.
A set of guidelines issued by the World Health Organisation and UNAids in March, however, makes it clear that we do not know whether male circumcision, specifically, reduces the sexual transmission of HIV from men to women.
Preliminary results from a study in Uganda suggest that HIV-positive men who resume sex before their circumcision wounds have healed are more likely to infect their female partners. The findings are too small to be conclusive, but they have raised the alarm about the need to inform both sexes about the potential risks and benefits.
One of the greatest of those risks is that circumcised men will misunderstand or exaggerate the degree to which they are protected from HIV and stop using condoms.
The only experience many African women have of male circumcision is as part of a traditional rite of passage that their sons, brothers and male friends go through if they belong to certain ethnic groups.
Women are barred from attending such rituals and men are "not supposed to talk about it with women -- they tell them they can go crazy if they do", said Masombuka.
Several of the women interviewed said they observe a positive change in men who attend traditional circumcision "schools". "Most of the guys who've been through it know how to respect a woman and elders; a person not coming from circumcision school, they're very rude and they use power," said Gloria Mphekgwana (44) from Limpopo, where traditional circumcision is practised.
"They tell them to be faithful to a girl and to marry that girl and not to go 'jolling' [sleeping] around," said Masombuka.
Rachel Jewkes, who heads the gender and health unit of South Africa's Medical Research Council, believes that efforts to introduce male circumcision as an HIV intervention should borrow from traditional approaches that view the procedure as part of a "transformative process".
"If we see it purely as a medical intervention, it'll be a mistake. It's a social intervention," said Jewkes. "I think culture is highly flexible and, to the extent that circumcision has been associated with manhood, I think that gives it enormous potential for equating it with better manhood."
By "better manhood" Jewkes means men who are sexually responsible and more willing to view women as equals. She sees male circumcision programmes as a valuable opportunity to engage men in discussions about safer sex and gender equity.
"The critical thing is that male engagement in HIV prevention must not stop at the surgical knife. Circumcision programmes must be accompanied by gender-transformative approaches to HIV prevention," she said.
Dr Yassa Piere, a virologist who treats HIV-positive patients at the University Teaching Hospital in Lusaka, believes women could play a role in motivating their male partners to be circumcised. The women interviewed cited hygiene as another reason for preferring their sexual partners to be circumcised. "I prefer a guy who's circumcised. I think it's safer and cleaner," said Khuto. "But I wouldn't ask him to do it."
Mothers were much more vocal in their support of medical circumcision. Mphekgwana is under pressure from her former husband to send their son to a traditional circumcision school, but she has read media reports about botched procedures and fatalities and refuses to send her son to one.
"No one wants her kids to go there now, because they don't clean their utensils. They're using only one blade. I want to take him to the hospital [to be circumcised]," she said.
At the male circumcision clinic at the teaching hospital, where about 80 procedures are performed every month, half of the patients are young boys brought to the clinic by their mothers.
"Studies show high acceptability by women of this," said Dr Kasonde Bowa, the clinic's director. "I think they're keen on anything that is healthy for their children and their husbands."
Aids Prevention: UN Gives Green Light to Circumcision. 28/3/07
Mail & Guardian
Paris, France 28 March 2007
United Nations health agencies on Wednesday gave the stamp of approval for including male circumcision in the panoply of arms to fight the spread of Aids, stressing though that its success also depended on safe-sex awareness, sensitivity and resources.
The World Health Organisation (WHO) and the specialised agency UNAids declared that millions of lives could be saved if circumcision is widely and safely practised.
They issued guidelines at a press conference in Paris following a debate among experts, health officials and grassroots groups in Geneva on March 6 to 8.
"The recommendations represent a significant step forward in HIV prevention," said Kevin de Cock, director of the WHO's HIV/Aids department.
"Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention, which can reduce the risk of HIV infection in heterosexual men," said de Cock.
"Scaling up male circumcision in such countries will result in immediate benefit to individuals," he said, adding, however: "It will be a number of years before we can expect to see an impact ... from such investment."
The spur for the recommendation has been two trials conducted in Uganda and a third in South Africa.
These studies found that men who had been circumcised reduced the risk of HIV infection by between 51% and 60% at least, as compared with uncircumcised counterparts.
"The efficacy of male circumcision in reducing female-to-male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention," said the WHO and UNAids.
According to figures published in Public Library of Science Medicine that were cited in the UN document, 5,7-million new cases of HIV infection and three million deaths could be prevented over 20 years if male circumcision is universally practised in sub-Saharan Africa.
The two agencies made these points:
Circumcision reduces, but does not eliminate, the risk of infection for the man in the context of heterosexual intercourse. There is no evidence yet as to whether circumcision has any impact on the risk of infection for the woman, on the risk among men who have sex with other men, or on the risk for heterosexual anal intercourse.
- Circumcision should be a part of a prevention package that also includes safe-sex counselling and access to condoms for both partners. "Communities, and particularly men opting for the procedure and their partners, require careful and balanced information and education materials that underline male circumcision is not a 'magic bullet' for HIV prevention but is complementary to other ways of reducing risk of HIV infection," the guidelines warn.
- Circumcision has to be carried out with confidentiality and the informed consent of the male and without coercion or discrimination. Countries should also emphasise that male circumcision has no connection with female genital mutilation, a practice with many adverse physical and psychological impacts and with no demonstrated medical benefits.
- Circumcision should be promoted "with full adherence to medical ethics" but in a "culturally appropriate manner". For instance, traditional practitioners who carry out circumcision in a ritual to symbolise a child's transition to adulthood should be consulted to help ensure support for a circumcision campaign.
- Countries should carefully assess their needs in funding, trained personnel and medical equipment before promoting a circumcision campaign, to avoid botched operations.
More than 25-million people have died of Aids since the disease was first detected in 1981. At the end of 2006, an estimated 39,5-million people had Aids or HIV, and 4,3 million became newly infected with the virus that year.
The clinical reason for circumcision's preventive effect is still being investigated.
One theory is that the foreskin has a very thin lining and suffers minor abrasions during intercourse, making it easier for the human immunodeficiency virus (HIV) to enter the man's bloodstream. Another is that the foreskin is rich in Langerhans cells, whose surface is configured in such a way that the Aids virus readily latches on to them. -- AFP
Male Circumcision is 'Real-World Equivalent' to AIDS Vaccine, Opinion Piece Says. 16/1/07
Kaiser Daily HIV/AIDS Report
Tuesday, January 16, 2007
Male circumcision in "some ways" is "closer to the fantasy" of "the magic bullet" that would end the HIV/AIDS pandemic than a "real" vaccine might be, and it "would be given more weight if the world recognized that it is, in fact, the real-world equivalent of an AIDS vaccine," Tina Rosenberg, a contributing writer for New York Times Magazine, writes in an opinion piece. Last month, two NIHstudies "confirm[ed] ... what scientists had long suspected: circumcision helps protect men from" HIV transmission, Rosenberg writes (Rosenberg, New York Times Magazine, 1/14). The studies, which took place in Kenya and Uganda, found that routine male circumcision could reduce a man's HIV infection risk through heterosexual sex by about 50%. Researchers monitored 4,996 men ages 15 to 49 living in Uganda and 2,784 men ages 18 to 24 living in Kenya -- half of whom were randomly assigned to be circumcised and the other half served as a control group -- to determine if circumcision reduced HIV infection. All participants in both studies received counseling on HIV risk reduction and were advised to use condoms. The results of the studies were so overwhelming that NIH stopped the trials early and offered circumcision to all participants. The researchers also found no evidence that the circumcised men in the studies adopted higher-risk sexual behaviors, including sex with multiple partners and unprotected sex (Kaiser Daily HIV/AIDS Report, 12/14/06).
According to Rosenberg, men must be encouraged to come to clinics, countries will need to equip clinics and train counselors and medical professionals, and the procedure must be provided at no cost. Circumcision and a vaccine with an efficacy rate of 50% to 60% "might be enough to stop AIDS," but "behavior change, microbicides, fighting malaria, treating genital herpes and other interventions we don't even know about yet" also must be implemented to help curb the pandemic, Rosenberg writes. "Research on an AIDS vaccine is more crucial than ever," Rosenberg writes, adding, "But we must not let our hope for a thunderbolt prevent us from racing ahead with circumcision now." She concludes, "For the biggest difference between circumcision and a vaccine is this: only one of them exists" (New York Times Magazine, 1/14).
Routine Male Circumcision Could Prevent 6M New Infections. 14/7/06
Routine Male Circumcision In Sub-Saharan Africa Could Prevent 6M New HIV Infections, 3M Deaths Over 20 Years, Report Says
Medical News Today
Routine male circumcision across sub-Saharan Africa could prevent up to six million new HIV infections and three million deaths in the next two decades, according to a report published in the July 11 edition of PLoS Medicine, Toronto's Globe and Mailreports. The report is based on an analysis of findings from a recent study in South Africa that indicates that male circumcision significantly reduces HIV transmission (Gandhi, Globe and Mail, 7/11).
According to the South Africa study, which was published in the November 2005 issue of PLoS Medicine, male circumcision might reduce by about 60% the risk of men contracting HIV through sexual intercourse with women. The randomized, controlled clinical trial enrolled more than 3,000 HIV-negative, uncircumcised men ages 18 to 24 living in a South African township. Half of the men were randomly assigned to be circumcised and the other half served as a control group, remaining uncircumcised. For every 10 uncircumcised men who contracted HIV, about three circumcised men contracted the virus. Researchers believed the findings were so significant they deemed it was unethical to proceed without offering the option to all males in the study. Two similar studies examining the effect of male circumcision on HIV transmission currently are underway in Kenya and (Kaiser Daily HIV/AIDS Report, 6/29).
For the report published Tuesday, researchers looked at data on HIV and male circumcision across Africa and used mathematical modeling to predict the impact of circumcision on HIV transmission over the next 10 years (BBC News, 7/10). The team, which included researchers from the World Health Organization, UNAIDS and universities and research centers in France, South Africa and the U.S., found that if all men in sub-Saharan Africa were circumcised over the next decade, roughly two million new infections and 300,000 deaths could be averted. An additional 3.7 million new HIV infections and 2.7 million deaths could be avoided in 20 years, with one in four of all prevented cases and deaths in South Africa, the study finds (Williams et al., PLoS Medicine, 7/11). The researchers found that the reduced risk of HIV transmission might be related to the structure of the foreskin, which is covered in cells that the virus can infect easily. In addition, the virus' chances of survival might be higher in a warm, wet environment like the one under the foreskin, Reuters U.K.reports (Fox, Reuters U.K., 7/11).
Next Steps, HIV Prevention Implications
The researchers said if the results of the studies in Kenya and Uganda when they are released in mid-2007 are as positive as the South Africa study, advocates might immediately call for a change in HIV prevention strategies. The team said circumcision would have to be promoted in tandem with other prevention methods, including condom use and faithfulness, as well as counseling to emphasize that circumcision will not provide complete protection against HIV.
The researchers cautioned that adult male circumcision procedures can be risky, especially if performed by people without proper medical training (Globe and Mail, 7/11). Catherine Hankins, a chief scientific adviser to UNAIDS who cowrote the study, said the researchers need more data from the ongoing trials to further refine the mathematical model that was used.
"Safety, acceptability and cost of male circumcision will also be important beyond just modeling this impact, because if you do not get increased uptake you will not see any of these effects," Hankins said. According to BBC News, the reduction in the number of new HIV cases with increased male circumcision would be greatest among men and would then have a "knock-on effect for women" (BBC News, 7/10). UNAIDS is collecting data on circumcision rates and its social acceptability to help nations decide if they want to include circumcision in their HIV prevention efforts, Hankins said (Shimo, Globe and Mail, 7/10). According to acceptability studies conducted in Kenya, South Africa, Uganda and other countries, between 50% and 75% of uncircumcised men would opt to have themselves and their sons circumcised if the procedure was proven to reduce the risk of HIV transmission, Bertran Auvert, who coordinated the South Africa study for France's National AIDS Research Agency, said (Globe and Mail, 7/11).
Circumcised Men Less Likely to get HIV Says SA Study. 04/7/05
Marina Lemle and James Njoroge.
Mail & Guardian Online.
04 August 2005 03:00
Heterosexual men who are circumcised are less likely to contract HIV/Aids from their female partners, according to ground-breaking South African research.
In 2002, the scientists recruited more than 3 000 uncircumcised heterosexual men aged 18 to 24 from Orange Farm, a Johannesburg slum where about 32% of women have HIV.
Half these men were then circumcised.
Three years later, 51 of the uncircumcised men were diagnosed with HIV, compared with just 18 of those who had been circumcised.
"It means we prevented six or seven out of a possible 10 infections," says Bertrand Auvert of the French National Institute of Health and Medical Research (Inserm), who worked with Dirk Taljaard of the Progressus Research and Development Consultancy in Johannesburg. Their work has just been presented at the 2005 International Aids Society conference in Rio de Janeiro, Brazil.
Because of the marked difference between the two groups, and following the advice of the Data Safety and Monitoring Board, part of the Create consortium against TB and Aids funded by Microsoft founder Bill Gates, the trial was stopped and all participants were offered circumcision.
Two similar trials are currently underway in Kenya and in Uganda. Together, they involve another 8 000 men. According to Auvert, an uncircumcised penis is more likely to be infected because the moist environment underneath the foreskin helps the virus -- and other organisms that cause sexually transmitted diseases -- survive and reproduce.
The Joint United Nations Programme on HIV/Aids says the results of these trials are important to clarify the relationship between circumcision and HIV.
UNAids adds that the results of the South African trial "must be considered in the context of the cultural acceptability of promoting circumcision, the risk of complications from the procedure, the additional risk associated with circumcisions performed under unhygienic conditions, and the potential to undermine existing protective behaviours and prevention strategies that reduce the risk of HIV infection."
In a joint statement, three UN bodies, including UNAids and the World Health Organisation warned that even if male circumcision is confirmed to reduce the risk of acquiring HIV, this does not mean that circumcised men are risk-free.
Charles Gilks, of the WHO's HIV/Aids department, says he is concerned that men might rush to get circumcised in unsafe procedures and subsequently abandon other precautions in sexual intercourse, such as using condoms.
Also at the IAS conference, Rebecca Stallings, of the US Macro International Research Corporation, presented a study of female circumcision.
The trial involved 7 154 HIV positive women in Tanzania. According to Stallings, female circumcision appears to increase the risk of women being infected with HIV.
She says this is because the surgery itself increases the vulnerability of the genital skin.
In addition, says Stallings, circumcised women are more likely to have anal intercourse, which also increases the chances of infection.
The British-based Lancet medical journal last year published the results of a study in India that suggested there was a link between circumcision and lower HIV infection rates as "Aids risk 'cut by circumcision'."
Unlike the South African trial however, the Indian study did not randomly circumcise half the participants. Rather, the researchers observed whether already circumcised men were more or less likely to become infected with HIV.
The Lancet decided against publishing the South African study. According to a report in The Wall Street Journal online, this was "for reasons unrelated to the data and scientific content". The Lancet, following its standard policy, declined to explain it chose not to publish the study.
Meanwhile, efforts to treat and prevent HIV/Aids will fail if the gap between scientific discovery and health policy is not narrowed, said researchers at the same conference. Delegates at the 2005 International Aids Society conference were told that responses to the pandemic should be modified quickly in line with new research.
"Scientific findings presented at this conference highlight the urgency of applying what we learn," said Craig McClure, executive director of the International Aids Society. "This is a rapidly evolving virus and epidemic and we need to stay ahead of it."
IAS president Helene Gayle added that "scientific knowledge alone will not end the pandemic, we need bold political leadership to translate science into policy, and policy into practice".
These sentiments were echoed by Stephen Lewis, the UN Special Envoy for HIV/Aids in Africa, who said: "Despite important progress in recent years, we have failed to ensure that the benefits of science ... in particular, state-of-the-art treatments and effective prevention services, reach the most impoverished areas of the world."
Charlie Gilks, of the World Health Organization's HIV/Aids department called for a new alliance between the scientific community and those living with HIV/Aids, as well as between companies that develop new drugs and those that make 'generic' versions of existing ones.
"We need to move new products and approaches into the field very quickly," said Gilks.
He noted that HIV/Aids was a huge challenge, but that there was a growing body of science to help to combat it.
"There is no other field where the opportunities to translate evidence into action are so great," said Gilks.
"Not only can researchers directly impact on policy and practice, they have a real opportunity to reduce the inequity between those who usually benefit from science and those who do not."
Mauro Schechter, who heads the Aids programme at Brazil's Federal University of Rio de Janeiro and is co-chairing the conference, said that increasing access to life-saving HIV drugs in developing countries had emerged as a global imperative.
"Equally important are the goals of ensuring access to proven prevention methods and disseminating important scientific research that is taking place all over the world, including here in Brazil," he added.
Circumcision Can Prevent HIV Infection. 26/7/05
Last Updated: 2005-07-26 14:10:09 -0400 (Reuters Health)
RIO DE JANEIRO (Reuters Health) - The longstanding observation that circumcision protects against HIV infection to some degree has been confirmed in a randomized trial.
Circumcision in adult heterosexual men is as effective in preventing new HIV infections as a vaccine that is 65 percent effective rate, according to the results presented here at the 3rd International AIDS Society (IAS) Conference on HIV Pathogenesis and Treatment.
The report is based on a study of more than 3,000 sexually active men living near Johannesburg, South Africa, who described themselves as heterosexual. Researchers randomly assigned the men to one of two groups: those who accepted circumcision immediately, and those who agreed to wait 20 months for the procedure.
After 21 months, the researchers diagnosed 69 new HIV cases -- 51 in the uncircumcised group and 18 in the circumcised group -- said Dr. Bertran Auvert of the University Versailles Saint-Quentin in France. He calculated the efficacy of circumcision to be 65 percent.
Rolling Out Male Circumcision Requires Community Engagement, Task Shifting and Streamlined Procedures. 21/7/10
It’s feasible and safe for a team of five to circumcise ten men in an hour
By Roger Pebody
21 July 2010
It’s feasible and safe for a team of five to circumcise ten men in an hour, researchers told the Eighteenth International AIDS Conference in Vienna on Tuesday. To achieve this, tasks are shared between doctors and nurses, and the procedures have been refined to use time as efficiently as possible.
The conference heard the experiences of people working in Orange Farm, South Africa (where the first randomised controlled trial demonstrating circumcision’s impact on HIV infection was carried out); Kenya (including the city of Kisumu, where a circumcision trial took place); and in Zimbabwe.
Speakers from Orange Farm and Kenya emphasised the importance of community engagement and communication. Much of this had already begun as part of the research trials, but roll-out in Orange Farm has been supported by visits to each household in the area, radio shows, and separate meetings for men and women. In the Kenyan experience, women play an influential role in men’s decisions about circumcision and should be a priority audience for communications.
Kenya has rolled circumcision out nationally (the largest programme in Africa), requiring engagement with a large number of political, community and social leaders. There has been high-level political support and the involvement of a wide range of government departments and professional bodies.
The Kenyan programme aims to achieve significant population coverage quickly in order to reduce HIV incidence. Starting in October 2008, over 130,000 have been circumcised, with the aim of reaching 860,000 by 2013. Teenagers have been much keener to take up the offer than men over the age of 25.
Circumcision is not a national priority for South Africa, but the clinic in the township of Orange Farm offers free medical circumcision to all male residents aged 15 or over. Between January 2008 and November 2009, 14,011 men took up the offer, which is equivalent to 39% of men in the community.
There were no permanent injuries or deaths, but 1.8% had some adverse events (for example, bleeding). A satisfaction survey of over 1000 men found that 92% rated the service as good or very good.
Although the researchers say that up to 150 men can be circumcised in a day, the monthly average is in fact 740. These high rates were achieved by working in three teams, each composed of one medical circumciser and five nurses.
The practical details of this kind of team working were described in more detail by Karin Hatzold, based on her experience in Zimbabwe. The goal there is to circumcise 80% of men aged 15 to 29 – in other words, 1.3 million men.
In an open-plan operating room, divided by curtains, a team of five works on the circumcisions of four men at a time. This reduces idle time between procedures (for example, while the local anaesthetic is taking effect) and allows staff to move quickly from one patient to another and communicate easily with each other.
As many tasks as possible are delegated to nurses. However, under Zimbabwean law the circumcision itself must be performed by a doctor, so the team is made up of two doctors and three nurses.
The forceps-guided method is used, which the researchers say is the quickest and easiest to learn and use. Wounds are sealed with diathermy (a procedure using electrical heat) rather than stitches. Most of the equipment used is disposable.
One team can now perform between eight and ten circumcisions an hour, rather than one or two before the new systems were introduced. The time the doctor spends on a man has reduced from 25 to 30 minutes to 7 to 10 minutes.
Hatzold was asked if there are any downsides to these procedures. She said that the number of side effects has not increased. On the other hand, the work can be tiring and repetitive. Moreover, to return to the issue of community engagement, the system can only work efficiently if there are enough men who want to be circumcised.
Study: Circumcision Lowers HIV and Bacterial Infection Risks. 06/1/10
January 6, 2010
Circumcision not only reduces the risk of HIV transmission in men, but also drastically changes the bacteria on the penis, reducing the risk of HIV and bacterial infection transmission to female partners, suggests a study published in PloS ONE and reported on by United Press International. The study was part of a larger initiative by the National Institutes of Health to examine the “human microbiome,” or microbes that exist on and within the human body.
“Our randomized trials have shown that male circumcision prevents HIV infection in men and protects their female partners from vaginal infections, especially bacterial vaginosis,” said senior author Ronald H. Gray, MD, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health.
After circumcision, the glans of the penis is exposed to more air and, specifically, oxygen, according to the article. This is important, Gray explained, because “[anaerobic] bacteria, which cannot grow in the presence of oxygen, have been implicated in inflammation and a number of infections affecting both men and women.”