Male Circumcision

Thursday, July 26, 2007

Economic Analysis Supports Adult Male Circumcision for HIV Prevention in Sub-Saharan Africa

Emma Hitt, PhD

July 25, 2007 (Sydney) — Male circumcision has been shown to reduce HIV acquisition in studies conducted in countries in sub-Saharan Africa; the cost of the approach appears to be justified given the savings that will result from the expected health benefits, according to new research.

Three randomized controlled trials demonstrated recently that adult male circumcision could reduce the acquisition of HIV in sub-Saharan Africa by 50% or more. The current analysis, by Bertran Auvert, MD, from the INSERM U687, Saint-Maurive, France, and colleagues sought to evaluate the cost effectiveness of this approach.

The researchers presented their findings here today in an oral presentation at the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention.

Using a "costing tool" to reflect the economic effect of adult male circumcision in this setting, the researchers found that the cost of a roll-out over an initial 5-year period would be $1036 million ($748 – $1319 million) and $965 million ($763 – $1301 million) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively.

After adjustment for averted HIV medical costs, the researchers determined that the program would result in a net savings of about $2 per adult per year over the first 20 years of the program.

Demographic and HIV transmission models were integrated into the analyses and applied to 16 countries in which HIV prevalence was more than 5% and in which fewer than 80% of the men had undergone circumcision. The analysis also assumed that 85% of uncircumcised men would agree to undergo the procedure.

"Our findings suggest that this approach is economically feasible and worth the expense," Dr. Auvert told Medscape. "At this point, it would be unethical not to offer free and safe male circumcision to all males and newborn in Africa," he added.

According to Dr. Auvert, some of the hurdles to overcome "include political issues, issues of communication, and the need to train healthcare workers in the procedure."

Another study presented at the same session indicated that postcoital penile cleansing, a strategy that has been promoted as an alternative to male circumcision in rural populations in Africa, may in fact increase the risk of HIV transmission.

"This finding was contrary to what we would have expected," said study author Fred E. Makumbi, PhD, a researcher from Makerere University, Institute of Public Health, Kampala, Uganda. "Circumcision has been proven to be protective against male HIV acquisition and is recommended by the World Health Organization for HIV prevention," he told Medscape. "This should be our priority."

Session moderator David Serwadda, MMed, also from Makerere University, told Medscape that a potential issue that needs to be surmounted is that circumcision may generate "a false confidence that may undo some of the gains that have been attained with health education, condom use, abstinence, and other preventive measures." He added that "circumcision should be viewed as just another measure on top of other forms of prevention."

The researchers and moderator report no relevant financial relationships. The study by Dr. Makumbi and colleagues was funded by the National Institutes of Health.

4th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention: Abstracts WEAC1LB and WEAC105. Presented July 25, 2007.

Wednesday, July 25, 2007

UNAIDS: Male Circumcision: Part 3

Moving forwards: UN policy and action on male circumcision
02 March 2007

In the final part of a special series on the issue of male circumcision and its links to the reduction of HIV acquisition, discusses expected upcoming action and developments from the United Nations on male circumcision through a special interview with UNAIDS Chief Scientist, Dr Catherine Hankins

From 6-8 March 2007, public health experts from the World Health Organization, UNAIDS and other partner organizations will gather in Montreux, Switzerland, to discuss the topical and often thorny issue of male circumcision and its links to HIV prevention, and to define future United Nations guidance to countries on the policy and programming implications of recent research findings.

As the consultation approaches, UNAIDS’ Chief Scientific Adviser, Dr Catherine Hankins gives a preview of the different issues that may be raised, and an insight into considerations for potential outcomes and action for the United Nations. Dr Hankins, you’ve been involved in the issue of male circumcision and its impact on HIV for many years—how do the current findings corroborate scientists’ claims that there is a link between circumcision and reduced HIV infections?

CH: For many years, researchers and scientists have noted that parts of Sub-Saharan Africa where circumcision is common, such as countries in West Africa, have much lower levels of HIV infection, while those in southern Africa, where circumcision is rare, have the highest. Before the availability of data from these three randomised controlled trials, multiple observational studies indicated that male circumcision carried with it a reduced risk of HIV infection. The latest findings from the three trials indicate that male circumcision provides a protective benefit against HIV infection of 50% to 60%

A further trial, led by researchers at Johns Hopkins University, to assess the impact of male circumcision on the risk of HIV transmission to female partners is currently under way in Uganda, with results expected in 2008. What is the United Nations doing about this latest evidence that male circumcision reduces risk of HIV acquisition?

CH: Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the United Nations agencies involved in this work absolutely underline that it does not provide complete protection against HIV infection- we need to make sure that men and women understand that circumcised men can still become infected with the virus and if HIV-positive, can infect their sexual partners.

Next week, WHO, the UNAIDS Secretariat and their partners will review the trial findings in detail at a consultation which will define specific recommendations for expanding and/or promoting male circumcision. These recommendations will need to take into account a number of key issues including the cultural and human rights considerations associated with promoting male circumcision; the risk of complications from the procedure performed in various settings; the potential of male circumcision to undermine or to work in synergy with existing protective behaviours and prevention strategies that reduce the risk of HIV infection; and the financial and human resource implications of male circumcision in different service delivery settings.

In order to support countries or institutions that decide to scale up male circumcision services, with our partners we are developing technical guidance on ethical, rights-based, clinical and programmatic approaches to male circumcision. We are also developing guidance on training, standard setting and certification procedures. What are some of the key concerns about increasing male circumcision practice that will be discussed at the consultation?

CH: A number of thorny issues arise related to promoting male circumcision as a public health intervention for HIV prevention. Adult male circumcision has a higher risk of adverse effects than infant male circumcision, and should be undertaken by trained health workers in safe, adequately equipped and sanitary conditions with appropriate pre and post-surgical counselling and follow-up. There is a real need to ensure that male circumcision interventions for health benefits are differentiated from female genital mutilation which the UN opposes and is considered to have no health benefits and potentially severe consequences for women and girls.

We also have to take into account the cultural issues- within cultures and faith traditions in which male circumcision is not considered acceptable, promoting it may or may not prove challenging. Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’- it doesn’t provide total protection and it doesn’t mean people can stop taking the safe sex precautions they were already using, such as use of male or female condoms, delaying sexual debut, avoiding penetrative sex and decreasing the number of sexual partners. We must continue to promote combination prevention and ensure that male circumcision is perceived as an additional benefit but one that should be in combination with other strategies to prevent sexual transmission of HIV. We don’t want increased risk behaviour to offset the benefits.

If the United Nations moves forward with guidance to countries on male circumcision as a public health intervention for HIV prevention, it will be promoted as an ‘additional’ intervention to current HIV prevention packages; not an alternative.

Effective communication on male circumcision will be critical and will be an opportunity to reinforce messages on the need for a comprehensive approach to prevention that encourages people to use more than one of the prevention choices available to them. Would male circumcision be part of the HIV prevention response for all settings?

Countries with high HIV prevalence and low male circumcision levels may be among the first to consider the potential for male circumcision to play a role in their HIV prevention programming. Other countries may decide to provide male circumcision services to particular populations who could benefit from the additional protection that male circumcision can afford.

The UN and its partners are fully aware that male circumcision may raise cultural and religious issues – it should never be imposed and, if it is promoted, must be done in a culturally acceptable manner in settings where it is not traditionally practised. What are the risks of male circumcision?

CH: Like all types of surgery, circumcision is not without risk. Circumcision by unqualified individuals under unsanitary conditions with poorly maintained or sub-optional equipment can lead to serious, immediate and long-term complications, or even death. Where health professionals have been trained and equipped to perform safe male circumcisions, however, the rate of post-operative complications is less than 5% and the large majority of these resolve with simple, appropriate post-operative care.

Anecdotal accounts of serious complications, including penile amputation and death after male circumcision in traditional settings have been reported. It is difficult to give overall figures for adverse events in all settings, in part because well-documented studies of complication rates in low-and-middle income countries are rare. Is there a need to improve male circumcision practices?

CH: Absolutely. Action is required now to improve circumcision practices in many regions, and to ensure that health-care providers and the public have up-to-date information on the health risks and benefits of male circumcision. Many boys and men wishing to be circumcised do not have access to safe circumcision services nor to post-circumcision care if they do suffer from complications. Regardless of the HIV prevention benefits, it is now increasingly important to make existing practices safer. Where circumcision is legal, authorities need to ensure that practitioners are properly trained and licensed to do this procedure. Monitoring should also be done to ensure that procedures are performed safely and that untrained practitioners do not continue to perform unsafe circumcisions. Does male circumcision raise human rights issues?

CH: Yes, as is the case with all medical and health procedures. In line with internationally accepted ethical and human rights principles, UNAIDS and WHO are of the view that no surgical intervention should be performed on anyone if it results in adverse outcomes in terms of health or the integrity of the body, and where there is no expectation of health benefit. Nor should any surgical intervention be performed on anyone without informed consent, or the consent of the parents or guardians when a child is not capable of providing consent.

As male circumcision involves surgery and removal of a part of the body, it should only be performed under these conditions: a) participants are fully informed of the possible risks and benefits of the procedure; b) participants give their fully informed consent; and c) the procedure can be performed under fully hygienic conditions by adequately trained and well equipped practitioners with appropriate post-operative follow-up. What effect on the HIV epidemic might we expect if male circumcision were commonly practised where it currently is not?

An international group of experts have carried out a mathematical modelling exercise on the impact on HIV incidence of a programme of universal male circumcision in sub-Saharan Africa, assuming the programme worked as it had in Orange Farm, South Africa and that all men would be circumcised within 10 years. The model predicts that 5.7 million infections and 3 million deaths would be prevented over 20 years among both men and women. There are many unknowns within this model but it does predict that male circumcision would provide a significant, potential benefit, similar to a partially effective vaccine. Importantly though, the model also shows that male circumcision alone cannot eliminate the HIV epidemic in sub-Saharan Africa. Could male circumcision eliminate the risk of HIV infection?

CH: No. Male circumcision alone certainly does not prevent men from becoming infected with HIV. Nor does it prevent women from being infected with HIV by men who have been circumcised. Circumcision needs to be seen as one of the range of methods to reduce the risk of HIV—including avoidance of penetrative sex, delaying sexual debut, reduction in the number of sexual partners, and correct and consistent male or female condom use. Male circumcision reduces the risk of HIV infection during vaginal intercourse, but is unknown whether it would have an effect on other routes of sexual HIV transmission: the receptive partner in anal intercourse may not have a reduced risk due to the circumcision status of his or her partner and, if male, will not have a reduced risk due to his own circumcision status. It is also not known whether male circumcision reduces the risk of HIV infection for the insertive partner during anal intercourse. Male circumcision has no effect in the case of HIV transmission through injecting drug use. Given all these considerations, is it likely the UN will recommending that adult men become circumcised as a way to protect themselves from HIV?

CH: This is what will be discussed at the consultation, and the partners expect to release information about the discussions and possible next steps at the end of the week’s meeting.

In any and all cases for future direction and action, the UN and its partners will certainly underline that male circumcision does not provide complete protection from HIV. It should therefore never replace other known effective preventive methods, such as delay in onset of sexual activity, abstinence from penetrative sex, correct and consistent use of condoms, and reductions in the number of sexual partners.

It’s very important that we stress that circumcised men, if HIV positive, can still infect their sexual partners if they do not use condoms during penetrative sexual intercourse.

Penile washing after sex not a substitute for circumcision

Michael Carter & David McLay, Wednesday, July 25, 2007

Cleaning the penis after vaginal sex does not protect a man from infection with HIV, according to a study conducted in Rakai, Uganda and presented as a ‘late breaker’ in the circumcision session at the Fourth International AIDS Society Conference in Sydney on July 25th.

Dr Fredrick Makumbi of Makerere University Institute of Public Health, Uganda, who presented the study, said that his study team had been surprised by this finding given that genital hygiene has long been thought to be protective against sexually transmitted infection. He emphasised that men who washed using soap, or a few minutes after intercourse had the highest risk of infection with HIV.

He speculated that this could be because washing with soap and failure to dry resulted in wetness, increasing the chance of cells becoming inflamed and thus more vulnerable to infection with HIV. Dr Makumbi also suggested that washing soon after sex could remove enzymes in vaginal fluid that help neutralise HIV.

Three randomised controlled trials in Africa have shown that men who are circumcised have a lower risk of becoming infected with HIV. However, circumcision is not universally possible or acceptable, and genital hygiene has been suggested as an alternative.

Therefore, investigators from the large Rakai circumcision trial analysed data from 2,552 uncircumcised, HIV-negative men to establish if post-coital washing helped to protect men against infection with HIV.

Investigators interviewed men about their cleaning habits after they have sex. This was correlated to the incidence of HIV seroconversion during the study.

During a total of 4,378 follow-up interviews, 83.0% of men reported cleaning after each time they had sexual intercourse. The HIV incidence in this group was not significantly different to that in the group who never cleaned, 1.69 per 100 patient years versus 1.22 per 100 patient years, respectively.

When men who cleaned were asked how soon after intercourse they usually cleaned, almost half (49.2%) responded that they clean within three minutes.

In this group of men, HIV incidence was 2.32 per 100 patient years. This was significantly higher than the incidence of 0.39 per 100 patient years among men who waited at least 10 minutes after sex before cleaning. That is to say that waiting 10 minutes before cleaning decreased the HIV incidence to less than 20% of that among men who washed right away.

Differences were also noted in HIV incidence depending on what cleaning method was used. Washing only, reported in 46.9% of interviews, was associated with an incidence of 2.20 per 100 patient years. Using a cloth and washing was used in 40.6% of cases and was associated with an incidence of 1.04 per 100 patient years. And using only a dry cloth, 12.4% of cases, was associated with the lowest incidence, 0.55 per 100 patient years (p = 0.0442).

In conclusion, the authors noted that while cleaning the penis after sex is common in this rural Ugandan population, caution should be taken in promoting it as an alternative to circumcision.


Makumbi FE et al. Male post-coital penile cleansing and the risk of HIV-acquisition in rural Rakai district, Uganda. Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, abstract WEAC1LB, Sydney, 2007.

South Africa: Male Circumcision 'Could Cut Soweto HIV 40 Percent'

Business Day (Johannesburg)

25 July 2007
Posted to the web 25 July 2007

Tamar Kahn
Sydney, Australia

HIV prevalence in Soweto could be reduced by close to 40% if half the number of uncircumcised men in the Johannesburg suburb underwent the procedure, an international Aids conference heard yesterday.

SA, with about 5,5-million infected people, has one of the worst HIV/Aids epidemics in the world, but it has yet to develop a policy on male circumcision.

A leading researcher told the conference that international HIV agencies had been slow to promote male circumcision as an anti-Aids strategy because, unlike medicines, no one stood to make money out of it .

"If it were a drug or ... a shot with a fancy label, international agencies and donors would have been fighting to be the first to make it available many months, even years, ago. But no one stands to profit from male circumcision -- no one that is but the 4000 men in Africa who will be newly infected tomorrow, and their partners, and their children," Prof Robert Bailey, an epidemiologist from the University of Illinois, said during his plenary address.

Three recent African studies, including one conducted in SA, have shown that circumcision reduces the risk that a man will contract HIV from an infected female partner by about 60%.

These studies come in the wake of about two dozen small observational studies that noted HIV was less common among men who had been circumcised than among men who had not.

Bailey, who was involved in two recent studies in Uganda and Kenya, urged countries battling large HIV epidemics to stop stalling, and begin offering the procedure to men who had not had their foreskins removed.

"If we had a vaccine that was 60% effective, we would be rolling it out as fast as we could," he said.

In March, the World Health Organisation (WHO) recommended that countries with low male circumcision rates and high HIV prevalence devise policies to provide the procedure, but few countries have taken action.

"Until it is endorsed by local communities and governments it will be difficult for donors (to assist)," said Bailey.

If all men were circumcised, 2-million new HIV infections and 300000 deaths could be averted over the next decade, he said.

Scientists believe the procedure helps protect men from HIV because the foreskin contains langerhans cells that are especially vulnerable to invasion by the virus. There is no evidence so far that circumcision protects women from HIV directly.

Bailey said male circumcision policies should include clear communication programmes to ensure people continued to use condoms, as circumcision offered only partial protection against HIV, which causes Aids.

The conference also saw the launch of a global initiative by the Foundation for Aids Research to combat HIV among men who have sex with men in the developing world. Fewer than 5% of men who had sex with men had access to HIV prevention, treatment and care, the organisation said.

"In many parts of Asia, Africa, eastern Europe and Latin America, stigma, criminalisation, and lack of access to health services have sparked alarming epidemics that threaten to devastate communities of men who have sex with men, mirroring the HIV pandemics that ravaged gay communities in North America and western Europe in the 1980s," the organisation said.

About a third of South African males are circumcised, according to a 2002 study by the Human Sciences Research Council, most as a rite of passage into manhood.

Models predict costs and benefits of circumcision programmes

Keith Alcorn & Michael Carter, Wednesday, July 25, 2007
Although circumcision programmes will involve significant initial costs, they will save billions of dollars in the long-term, according to a mathematical model presented to the Sydney International AIDS Society Conference on July 25th.

A separate mathematical model also presented to the conference, showed that universal circumcision would have the greatest impact on HIV incidence, but that targeting circumcision at men with the most sexual partners, and those aged between 20 – 30-years would be the most effective way of reducing HIV prevalence.

The rapid roll out of circumcision as an HIV prevention measure would require high uptake and substantial funding in the first few years if it is eventually to be cost-effective, according to a costing model developed by French circumcision researcher Bertran Auvert and colleagues in France, South Africa and the United States.

Using demographic data from 14 African countries with a circumcision prevalence of less than 80% and adult HIV prevalence of more than 5%, the researchers modelled the cost for individuals and the public sector of a rapid roll out of medical circumcision for adult males.

The cost was calculated over a ten year period, and then adjusted to take into account the amount the researchers estimate would be saved if HIV infections were averted and antiretroviral therapy was not needed.

Rolling out circumcision in the 14 countries would cost the public sector between $315 and $532 million during the first five years, but a much greater cost would be borne by the private sector, particularly by individuals paying fees for circumcision operations. Private expenditure on circumcision might top $1.2 billion.

Although considerable investment would be required in the first five years of a circumcision roll-out programme, Dr Auvert calculated that over 20 years between $3 - $4 billion would be saved in HIV treatment and care costs.

Dr Auvert also calculated that the cost of circumcision per infection prevented would be between $113 - $375 and that, in the first 20 years, it would be necessary to circumcise between four and nine men to prevent each new HIV infection.

Although Dr Auvert acknowledged that the costs of a mass circumcision programme would be “expensive”, it would ultimately be worth the cost given the long-term savings in treatment and care costs.

Modelling data on the effects of circumcision on HIV prevalence and incidence between now and 2020 were also presented, by Gregory Londish of the University of New South Wales, Sydney.

His simulations predict that complete male circumcision in an average country could reduce HIV prevalence in 2020 from 8.3% to 5.3% and incidence from 13.5 seroconversions per thousand to 7.3 per thousand.

Targetting only 20 to 30 year old men or men with greater sexual activity produced the most cost-effective reduction in HIV prevalence, 2.0% and 1.1% respectively.

But the benefits would be smaller with increasing sexual activity in men who have been circumcised, and would be completely eliminated if more than 40% of circumcised men increased their sexual activity.

Another sophisticated model, developed by Timothy Hallett of Imperial College, London, presented at last month’s 2007 HIV Implementers’ Meeting in Kigali, Rwanda, highlighted the uncertainties inherent in current assumptions about circumcision’s efficacy.

He pointed out that although all three randomised studies of circumcision had shown a similar efficacy for the intervention – around 60% - the confidence intervals for the efficacy estimates were wide.

“If 60% represents the upper bound of effectiveness, once you get down to 40% efficacy and little or no impact on male to female transmission, if there is disinhibition you may get an increased infection rate,” he said.

However Professor Robert Bailey of University of Illinois, Chicago, School of Public Health, speaking during a plenary session at the conference, pointed out that in the Kisumu study of medical circumcision, risk behaviours by circumcised men fell during the 12 months following circumcision.

He also noted that general circumcision programmes in countries outside Africa with low HIV prevalence (< 2%) are unlikely to prove cost-effective and may avert few HIV infections. Instead more targeted programmes to high-risk heterosexual men should be explored.

Circumcision services should be made available as soon possible in high prevalence settings, he said, highlighting a modelling study looking at the effect of differing paces of circumcision scale-up in South Africa.

“If we delay, at the end of 8 years we will have averted 16.4% fewer HIV infections and the cost per infection averted will be greater. Not delaying in putting our best efforts to providing services now will save lives and save money.”


“All the indications are that they will come and they’ll come in large numbers, as they did in the trials and as they are doing now to the few small projects offering circumcision,” said Prof. Bailey

Diagnosis and treatment for sexually transmitted infections should also be available as part of circumcision services, he went on.

“Special behavioural counselling will be required to communicate the concept of partial protection and the dangers of resuming sex activity before full wound healing.”

Circumcision programmes are also a “superb opportunity to gain access to the sex partners of the men, who because they are sexually active in a high HIV prevalence community, are vulnerable and can gain from comprehensive reproductive services.”

Circumcision should not be considered a stand-alone medical procedure, but must be integrated with the wider spectrum of HIV prevention measures.

Innovative means will be needed to reach men, inclduing mobile circumcision clinics, large medical missions and circumcision weekends, he concluded.


Auvert B et al. Cost of the roll-out of male circumcision in sub-Saharan Africa. Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, abstract WEAC105, Sydney, 2007.

Londish B et al. Mathematical modelling of male circumcision in sub-Saharan Africa predicts significant reduction in adult HIV prevalence even when it is limited to certain age groups. Fourth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, abstract WEAC104, Sydney, 2007.

Tuesday, July 24, 2007

Circumcision, Fidelity More Effective HIV Prevention Methods Than Condoms, Abstinence

Promoting male circumcision and fidelity to one partner seems to be more effective at curbing the spread of HIV than promoting abstinence and condom use, USAID researcher and technical adviser Daniel Halperin said last week, the Chicago Tribune reports. As Halperin and other researchers analyze 20 years of studies on HIV/AIDS throughout Africa, they have tried to "put aside intuitions, emotions, ideologies and look at the evidence in as coldhearted a way as we can," Halperin said.

During a speech at a meeting of the Southern African HIV Clinicians Society in Johannesburg, South Africa, Halperin said he and his colleagues discovered that regular sex partners rarely use condoms, and abstinence merely delays HIV infection among young people by one or two years. For example, condom use in Ghana and Senegal seems to have helped in the reduction of the spread of the HIV, which in those countries is particularly prevalent among commercial sex workers and their partners.

However, condom use in South Africa and Botswana has had little effect in reducing those countries' HIV epidemics -- which have reached the general population -- because regular sex partners rarely use condoms consistently. In comparison, faithfulness to one partner has worked at reducing HIV prevalence in Uganda and Kenya, according to Halperin. Because a person is more likely to transmit HIV during the first three weeks of contracting the virus, an HIV-positive person who has just one partner during that time is likely to pass the disease to that one person. But if an HIV-positive person in the highly infectious stage has many sexual partners at a time, "the virus spreads like wildfire" as those people in turn have sex with other people, Halperin said.

In addition, circumcision has been shown to reduce male-to-female HIV transmission by 60% to 75% (Goering, Chicago Tribune, 4/23). A study published in the November 2005 issue of PLoS Medicine of men living in South Africa finds that male circumcision might reduce the risk of men contracting HIV through sexual intercourse with women by about 60%. Male circumcision might also reduce the risk of HIV transmission from HIV-positive men to their female partners, according to a study of couples in Rakai, Uganda (Kaiser Daily HIV/AIDS Report, 2/9).

Circumcision: the kindest cut

The results of three recent studies on male circumcision provide strong evidence that this simple surgery could save millions of lives.

Robert Bailey, Professor of Epidemiology at the University of Ilinois at Chicago, speaking at today's plenary session at the 2007 Internationl Aids Society Conference on HIV Pathogenises, Treatment and Prevention, says that male circumcision has been likened to a vaccine.

"Not a perfect vaccine, but an effective one - about 60% effective in preventing new HIV infections in adult heterosexual men," says Bailey.

Oldest surgery in the world
Bailey points out that circumcision is hardly a new health-related intervention: the ancient Egyptians performed the procedure over 4 300 years ago, and it developed independently in several different cultures around the world.

It is likely the oldest and most common surgery ever performed.

Today, about 30 - 35% of men are circumcised. When performed under antiseptic conditions by a trained practitioner, says Bailey, it is a simple, low-risk procedure.

Trials stopped because so effective
The most persuasive evidence to date of circumcision's efficacy in reducing HIV infection has come from three randomised controlled trials conducted in South Africa, Uganda and Kenya.

The trials were all stopped before going to full completion. Bailey explains: "This was because the protective effect of circumcision was so strong there was miniscule statistical doubt it was effective, and it wouldn't have been ethical to continue to withhold the procedure from uncircumcised men in the trials."

The trials showed a reduction of HIV incidence in circumcised men of 57%. "One would be challenged to find any public health intervention with such a strong and consistent efficacy. Certainly, we have nothing else like this in the field of HIV prevention," says Bailey.

In the light of the trial results, the World Health Organization (WHO) and the United Nations Programme on HIV/Aids (UNAIDS) issued a joint statement in which they strongly endorse male circumcision as a means of HIV prevention, asserting that its efficacy "has been proven beyond reasonable doubt" and that it "should be considered as part of a comprehensive HIV prevention package."

Not just HIV
In addition to HIV, circumcision offers protection against several other conditions, says Bailey, including urinary tract infections in baby boys, and penile cancer, chancroid and human papillomavirus in adult men.

Female sexual partners of circumcised men benefit too, experiencing lower rates of cervical cancer and chlamydia.

6 years, $23 million, 1 million deaths later
Bailey laments the fact that, even as early as 2000-2001, there was already ample evidence - admittedly from less rigorous studies - that an uncircumcised man was far more likely to be HIV-infected than a circumcised man.

"We've come to the same conclusion that was staring us in the face then," says Bailey. "Six years, 23 million dollars and probably a million new preventable infections later.

"Only a handful of scientists, and no policy makers, were persuaded that circumcision should be considered as a new HIV prevention strategy. Randomised control trials had to be done before the international health community could be persuaded to move.

"It raises the question: have we raised the bar too high for converting evidence to action in the face of a crippling pandemic?

"One can't help but contemplate that if it were a drug or a compound or a shot with a fancy label, international agencies and donors would have been fighting to make it available many months, even years ago.

"But no one stands to profit from male circumcision - except the 4 000 men in Africa who will be newly infected tomorrow, and their partners and children."

Won't circumcised men take more risks?
Concerns have been raised that if circumcision were promoted as preventing HIV, circumcised men may feel protected and take more risks, a phenonemnon known as "sexual disinhibition". Bailey quotes one circumcised man as saying: "Ah, I have a natural condom."

However, Bailey reports that data from the three trials suggest that sexual disinhibition did not occur. The level of risk behaviour of both circumcised and uncircumcised men came out about equal; overall risk behaviour and sexually transmitted diseases (STIs) declined for all participants in the trial.

Bailey further points out that: "All the highest HIV prevalence countries are those where circumcision is little practised. No country with nearly universal circumcision coverage has ever had an adult HIV prevalence higher than 8%."

He adds that, in addition to its high efficacy, circumcision is also cost effective - more so the faster countries act. "The faster we scale up, the more infections we can prevent - and each infection averted costs us less."

Will men agree to get circumcised?
Bailey believes that, if the large numbers of people who came to participate in the trials are anything to go by, then men are highly likely to find circumcision initiatives acceptable.

A circumcision programme should also engage women in its planning, because they, as sex partners and mothers, will be instrumental in encouraging male circumcision. In previous studies on circumcision acceptability, women particularly were in favour of their sons getting circumcised, and felt that circumcised men were cleaner and less likely to be carrying an STI.

Why a foreskin increases risk
The outer surface of the foreskin and the penile shaft are covered by a relatively thick layer, which provides a protective barrier against HIV.

By contrast, the inner mucosal layer of the foreskin is very thin, and allows HIV and other pathogens easy access to target cells lying near the surface.

During heterosexual intercourse, in an uncircumcised man the foreskin is pulled back down the shaft of the penis, and the whole inner surface of the foreskin is exposed to vaginal secretions, providing a large area where HIV transmission could take place.

- Olivia Rose-Innes, Health24, July 2007

Additional information source for this article:
Szabo, R and Short, RV. How does male circumcision protect against HIV infection? BMJ 2000;320:1592-1594,41252.asp

Kampala supports circumcision against Aids



the majority of people in Kampala believe that circumcising all new born baby boys will significantly reduce HIV infection rates, a report has shown.

This follows the government's planned nationwide campaign to have new born babies circumcised to reduce the HIV prevalence rate from the current 6.3 per cent.
Arising from a July 14 -15 survey, a report titled "the Social Political Economic & Cultural (SPEC) Barometer" shows that 53 per cent of Kampalans support the move.

About 500 respondents, aged 21-51, were carefully picked from the five administrative divisions that make up Kampala District. The report was compiled by Steadman Group, a research agency that specialises in sampling public opinion on topical issues.
Forty eight per cent of the respondents were reportedly women and 52 per cent men whose education background ranged from the 'never gone to school' category to holders of post university qualifications.

The proposal for massive circumcision- as a strategy against HIV/Aids- gained unprecedented momentum in May when officials in the Ministry of Health and other government departments showed great support for the idea.

Proponents have since suggested that another C-for Circumcision-be added on to the ABC (Abstinence, Be faithful or use Condom) strategy to make it ABCC.
At a conference on HIV/Aids in Sydney, Australia, over the weekend, world experts on fighting the HIV pandemic called for more research on the effectiveness of circumcision as a strategy against HIV/Aids.

Africa: Mass Male Circumcision - What Will It Mean for Women?

UN Integrated Regional Information Networks

24 July 2007
Posted to the web 24 July 2007


Women's voices have gone largely 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, a Sesotho woman from Mpumalanga Province, in South Africa, zeroing in on the fact that even the partial protection circumcision provides could make a difference to women who are powerless to insist on condom use.

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, and whatever he says goes, so it's going to suppress women even more," said Kgaugelo Khuto, 20, a student from South Africa's Limpopo Province.

"Women should be informed so they do not get fooled by the men, because some girls might get told by the men that because he's circumcised she can't be infected," said Masombuka.

Gloria Mphekgwana, 44, a receptionist and single mother of two, who lives in a Johannesburg township and has watched a number of her relatives succumb to AIDS-related illnesses, was strongly in favour of male circumcision. "Women should fight for this," she said. "They can refuse to have sex unless their man goes for circumcision."

The evidence, or lack of it

Studies have found even higher levels of acceptability for male circumcision among women than among men. This is despite the fact that very little is known about how a large-scale male circumcision campaign would affect women.

Three clinical trials have demonstrated that circumcision reduces a man's chances of contracting HIV by about 60 percent. The expected numbers of male HIV infections averted by a large-scale male circumcision programme would eventually translate into fewer infections in women. There is also evidence that circumcised men are less likely to harbour the human papilloma virus (HPV), which causes cervical cancer - a major killer of women in sub-Saharan Africa.

However, a set of guidelines issued by the World Health Organisation and UNAIDS in March 2007 makes it clear that we do not know whether male circumcision, specifically, reduces sexual transmission of HIV from men to women.

Preliminary results from a study underway 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 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; no one knows how real this risk is or to what extent it could be offset by education campaigns and individual counselling.

A route to "better manhood"?

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 not only barred from attending such rituals, men are also "not supposed to talk about it with women - they tell them they can go crazy if they do", said Masombuka.

Several of the women IRIN/PlusNews spoke to said they could observe a positive change in men who had attended 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 Mphekgwana, who is from Limpopo Province, where traditional circumcision is practiced.

According to Masombuka, "They tell them to be faithful to a girl, and to marry that girl, and not to go 'jolling' [sleeping] around."

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 very 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 more 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 as well as gender equity.

"The critical thing is that male engagement in HIV prevention must not stop at the surgical knife, but that circumcision programmes must be accompanied by gender-transformative approaches to HIV prevention," she stressed.

What role for women?

Although public health experts have paid lip service to the idea of involving women in efforts to roll out national male circumcision programmes, details of what form such involvement would take are sketchy.

Dr Yassa Piere, a virologist who treats HIV-positive patients at the University Teaching Hospital in Lusaka, Zambia's capital, believes women could play a role in motivating their male partners to be circumcised.

He pointed to evidence that circumcised men experience slightly less sensation during sexual intercourse, a side effect some women might consider an advantage. The latest research contradicts this, but according to Piere, "some women prefer circumcised men because they last longer."

The women IRIN/PlusNews spoke to were more likely to cite hygiene as a reason for preferring their sexual partners to be circumcised. "I prefer a guy who's circumcised, I think it's safer and cleaner," said Kgaugelo Khuto, the student from Limpopo. "But I wouldn't ask him to do it."

Mothers were much more vocal in support of medical circumcision. Gloria Mphekgwana is under pressure from her ex-husband to send their son to a traditional circumcision school, but she has read media reports about botched procedures and even 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 Lusaka's University Teaching Hospital, where around 80 procedures are performed every month, about half of the patients are young boys brought to the clinic by their mothers.

"Studies show high acceptability of women for this," said Dr Kasonde Bowa, the clinic's director. "I think they're very keen on anything that is healthy for their children and their husbands."

Australian Doctors Soften Anti-Circumcision Stance on HIV Risk

By Jason Gale

July 25 (Bloomberg) -- Australia health officials may want to encourage greater use of circumcision for infant boys as research shows the procedure can help prevent the spread of HIV, the country's top AIDS expert said.

Studies have shown the surgical procedure performed on adult men in Africa reduced their chances of getting HIV through heterosexual intercourse by as much as 60 percent, according to the World Health Organization. The finding is encouraging doctors in Australia to rethink their opposition to the practice, said David Cooper, director of the National Centre in HIV Epidemiology and Clinical Research in Sydney.

``I think the stance will be softened and that pediatricians and obstetricians will explain to parents a more balanced view of the advantages and disadvantages'' of circumcision, Cooper said in an interview at an AIDS conference in Sydney yesterday. Physicians are ``looking at it with less distain than they did several years ago.''

After the Second World War, Australia conducted routine circumcision of all newborn boys, partly to avoid hygiene problems related to germs that can linger in unwashed foreskins. The millennia-old technique fell out of favor in the mid-1970s as doctors concluded that the risks of surgery outweighed the benefits. Data collected in 2004 showed fewer than one in eight Australian males are circumcised by six months of age.

``There is always going to be a controversy about whether to be cut or uncut,'' said Cooper, who is also a professor of medicine at the University of New South Wales. ``It's now pretty clear that it's a low risk procedure and does have a lot of benefits in addition to protecting against HIV.''

Studies published in The Lancet last February helped doctors understand the link between circumcision and HIV prevention, ``a breakthrough'' in the fight against AIDS, Anthony Fauci, the director of the U.S. National Institute on Allergy and Infectious Diseases told reporters at the Sydney conference.

Circumcision could save millions from AIDS

Scientific American
24 July 2007

By Jane Lee

SYDNEY (Reuters) - Millions of new HIV infections in Africa could be avoided if more men were circumcised, an International AIDS Society conference was told on Tuesday.

Studies in Africa have found that male circumcision, the world's oldest surgical procedure dating back to 2300 BC, reduces HIV transmission from females to males by 60 percent.

Universal circumcision could avert 2 million new infections and 300,000 deaths in sub-Saharan Africa over 10 years, said Professor Robert Bailey from the School of Public Health at the University of Illinois in Chicago.

"If we had a vaccine that was 60 percent protective we would be very happy and rolling it out as fast as possible," Bailey told the IAS conference in Sydney.

"But no one stands to profit from male circumcision -- no one but the 4,000 in Africa who will be infected tomorrow."

Africa is the epicenter of the AIDS epidemic. South Africa has an estimated 5.5 million people with HIV and is struggling to stem the spread of the disease in the general population.

But African nations such as Cameroon and Nigeria, where circumcision is common, have a much lower rate of HIV infection than Zimbabwe and Swaziland where there is little circumcision.

The idea of using circumcision as a weapon against AIDS emerged after studies in Uganda, Kenya, Malawi, Zambia and the United States found the potential to significantly reduce infections, said Bailey, adding the World Health Organisation has now endorsed circumcision as a disease prevention method.

"The challenge ahead for us is how to roll out circumcision safely ... and to persuade leaders in countries that it is going to help their populations," Bailey told a news conference.

"Circumcision is not just simply a surgical procedure. Its tied up in a complex web of cultural and religious practices and beliefs," he added.

"It's not easy for politicians and ministers of health to quickly come out in favor of circumcision in countries where circumcision is not traditionally practiced."

Bailey said aid organizations would not offer the service until local governments endorsed it, for fear of being seen as culturally insensitive.


Women in African nations are expected to be the drivers behind using circumcision to stop HIV infection as they are traditionally associated with ensuring hygiene in communities.

"Women, more than men, equate circumcision with improved hygiene," said Bailey.

"It's often up to women to provide the water, the soap and the materials for men to bathe and cleanse themselves. Many of the women complain the men are not as clean as they could be."

Circumcision should not be seen by men as their only preventative measure against HIV and must still be combined with safe sex practices. Condom use should still be encouraged.

"It's very important not to view this as a standalone surgical procedure," said Bailey.

Many Africans were already seeking circumcision to try and stop the spread of HIV, but many were suffering medical complications because of poor procedures.

There also was some evidence that circumcision may help prevent infection between homosexual men, with one study in Uganda showing a 30 percent reduction in infection.

Male circumcision key to slowing AIDS epidemic

Published: Monday, July 23, 2007 | 11:06 PM ET
Canadian Press: MERAIAH FOLEY

SYDNEY, Australia (AP) - An American health official urged international agencies Tuesday to step up their promotion of circumcision to slow the spread of HIV, saying that men without the procedure face greater risk of contracting the virus from infected female partners.

The World Health Organization says male circumcision reduces the risk of female-to-male transmission of the disease by around 60 per cent. But only 30 per cent of men worldwide have had the procedure, mostly in countries where it is common for religious or health reasons.

Robert Bailey, a professor of epidemiology at the University of Illinois, said uncircumcised men are 2-½ times more likely to contract the virus from female partners, based on testing in parts of Africa hardest-hit by the epidemic.

Bailey told a major international AIDS conference in Sydney, Australia, that world health agencies should be aggressive in implementing the procedure in light of mounting evidence of its effectiveness in preventing new HIV infections.

"Circumcision could drive the epidemic to a declining state toward extinction. ... We must make safe, affordable, voluntary circumcision available now," he said.

"But no one stands to profit from male circumcision - no one but the 4,000 in Africa who will be infected tomorrow," said Bailey, who has conducted circumcision-related studies in Uganda, Kenya, Malawi, Zambia and the United States.

The World Health Organization issued a statement in March urging heterosexual men to undergo the procedure because of compelling evidence that it reduces their risk of getting the disease.

However, it cautioned that male circumcision is not a complete protection against HIV, and said men should still use condoms and take other precautions such as abstinence, delaying the start of sexual activity and reducing the number of sexual partners.

UNAIDS: Male Circumcision: Part 2

Male Circumcision and HIV: the here and now
28 February 2007

In the second of a special three-part series on the issue of male circumcision and its links to the reduction of HIV acquisition, 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.

In scientific circles, the perceived links between male circumcision and HIV infection are nothing new. For years, AIDS researchers have observed that many African tribes that circumcise boys or young men had lower HIV rates than those that do not, and that Africa's Islamic nations, where circumcision is near universal, had far fewer AIDS cases than predominantly Christian ones.

Now, trials in Kenya, Uganda and South Africa have all shown that male circumcision significantly reduces a man’s risk of acquiring HIV. The three sets of trials have shown circumcised men are up 50 to 60% less likely to acquire HIV during heterosexual intercourse.

Research findings

The first research proof came in 2005, when a study in South Africa, supported by the French agence nationale de recherches sur le sida (ANRS) and known as the 'Orange Farm Intervention Trial', was stopped early in the face of evidence that the men who had been randomly assigned to be circumcised were getting 60% fewer HIV infections than the men assigned to the control group.

In December 2006, on the recommendation of their Data and Safety Monitoring Board (DSMB), two similar studies in Uganda and Kenya were halted early by the United States National Institutes of Health (NIH) because the interim results showed a significant effect of male circumcision in preventing HIV acquisition in men.

The trial carried out in Kisumu, Kenya by researchers from the University of Nairobi, University of Illinois at Chicago, the University of Manitoba, and RTI International involving 2,784 men aged 18 to 24 showed a 53% reduction of HIV infections in circumcised men compared to uncircumcised men.

In Uganda, the trial, carried out in Rakai by researchers from Makerere University, the Uganda Virus Research Institute, Johns Hopkins University, and Columbia University New York, involved 4996 men aged 15 to 49 years old and showed that adult male circumcision reduced by 51% the risk of becoming infected with HIV.

Dr. Anthony Fauci, director of the NIH's National Institute of Allergy and Infectious Diseases, said the institute ended both trials early and offered circumcision to all men involved in them. The trials began in 2005 and were due to go until mid-2007.

The biology

Male circumcision involves the surgical removal of the foreskin, the tissue covering the head of the penis. Previous research shows that removing the foreskin is associated with a variety of health benefits including lower rates of urinary tract infections in male infants who are circumcised and reduced risk of certain inflammations and health problems associated with the foreskin.

Scientists say male circumcision probably reduces the risk of HIV infection because it removes tissue in the foreskin that is particularly vulnerable to the virus, and because the area under the foreskin is easily scratched or torn during sex. “Uncircumcised men may also be more vulnerable to sexually transmitted diseases, which in turn increase the risk of contracting HIV, because the region under the foreskin provides a moist, dark place in which germs can thrive,” said UNAIDS Chief Scientific Adviser, Dr Catherine Hankins.

No ‘magic bullet’

The results of the trials in South Africa, Uganda and Kenya indicate that in certain settings, adult male circumcision could become an important addition to an HIV prevention strategy for men. “The trials indicate that male circumcision can lower both an individual's risk of infection and hopefully the rate of HIV spread through the community," NIH’s Dr Fauci said.

But experts— including the United Nations bodies working on the issue—caution that circumcision is no cure-all. Male circumcision does not provide complete protection against HIV infection; it only lessens the chances that a man will acquire the virus.

Circumcision is "not a magic bullet, but a potentially important intervention," said Dr. Kevin M. De Cock, director of the World Health Organization’s AIDS department.

“Men and women must understand that circumcised men can still become infected with the virus and if HIV-positive, can infect their sexual partners,” said UNAIDS’ Dr Hankins

“ Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive HIV prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and abstaining from penetrative sex”, she said.

Safety, sanitation and communication

To ensure safe and clean operations, male circumcision should only be performed by well-trained practitioners in sanitary settings under conditions of informed consent, confidentiality, proper counseling and safety. “If male circumcision is to be promoted, this should be done in a culturally appropriate manner and people should be provided sufficient and correct information on HIV prevention to prevent them from developing a false sense of security and engaging in risky behavior,” said Dr Hankins.

These considerations and others in relation to the AIDS response, including the fact that male circumcision has the potential to be an expensive intervention, that more research is needed to address whether male circumcision reduces risk of transmitting HIV-particularly for female partners, and the different ethical and human rights issues raised by male circumcision, will form discussions of the United Nations consultation on male circumcision that will take place in Geneva from 5 March. Here, WHO, the UNAIDS Secretariat and their partners will review the detailed trial findings and will, if deemed appropriate, then define specific policy recommendations for expanding and/or promoting male circumcision.

“Male circumcision is a complicated issue which involves sometimes difficult discussion on issues of culture, tradition, religion, ethnicity, human rights and gender. The consultation will provide an excellent arena for moving the discussion and policy forward within the United Nations,” said Dr Hankins.

Monday, July 23, 2007

Sensation and Sexual Arousal in Circumcised and Uncircumcised Men.

Payne K, Thaler L, Kukkonen T, Carrier S, Binik Y.

Riverside Professional Center, Ottawa, Canada;

Introduction. Research, theory, and popular belief all suggest that
penile sensation is greater in the uncircumcised as compared with the
circumcised man. However, research involving direct measurement of
penile sensation has been undertaken only in sexually functional and
dysfunctional groups, and as a correlate of sexual behavior. There are
no reports of penile sensation in sexually aroused subjects, and it is
not known how arousal affects sensation. In principle, this should be
more closely related to actual sexual function.

Aim. This study therefore compared genital and nongenital sensation as
a function of sexual arousal in circumcised and uncircumcised men.

Methods. Twenty uncircumcised men and an equal number of age-matched
circumcised participants underwent genital and nongenital sensory
testing at baseline and in response to erotic and control stimulus
films. Touch and pain thresholds were assessed on the penile shaft,
the glans penis, and the volar surface of the forearm. Sexual arousal
was assessed via thermal imaging of the penis.

Results. In response to the erotic stimulus, both groups evidenced a
significant increase in penile temperature, which correlated highly
with subjective reports of sexual arousal. Uncircumcised men had
significantly lower penile temperature than circumcised men, and
evidenced a larger increase in penile temperature with sexual arousal.
No differences in genital sensitivity were found between the
uncircumcised and circumcised groups. Uncircumcised men were less
sensitive to touch on the forearm than circumcised men. A decrease in
overall touch sensitivity was observed in both groups with exposure to
the erotic film as compared with either baseline or control stimulus
film conditions. No significant effect was found for pain sensitivity.

Conclusion. These results do not support the hypothesized penile
sensory differences associated with circumcision. However, group
differences in penile temperature and sexual response were found.

There is a lot of disinformation about the foreskin on the net and this site goes someway to Debunking Myths about the Foreskin relating to a supposed sexual function.

UNAIDS: Male Circumcision: Part 1

Male Circumcision: context, criteria and culture
26 February 2007

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, takes a closer look at the historical, traditional and increasingly social reasons behind the practice of male circumcision across the world.

Male circumcision is one of the oldest and most common surgical procedures known, traditionally undertaken as a mark of cultural identity or religious importance.

Historically, male circumcision was practised among ancient Semitic people including Egyptians and those of Jewish faith, with the earliest records depicting circumcision on Egyptian temple and wall paintings dating from around 2300 BC.

With advances in surgery in the 19th century, and increased mobility in the 20th century, the procedure was introduced into some previously non-circumcising cultures for both health-related and social reasons.

According to current estimations, approximately 30% of all males across the world— representing a total of approximately 670 million men — are circumcised. Of this number, about 68% are of Islamic faith, less than 1% of Jewish faith, and 13% are non-Muslim, non-Jewish Americans.

“With the recent findings that male circumcision significantly reduces a man’s risk of acquiring HIV the practice is receiving renewed interest as the world looks to understand what this will mean for HIV prevention,” said UNAIDS Chief Scientific Adviser, Dr Catherine Hankins. “Looking at the determinants of male circumcision, and the acceptability of male circumcision in non-circumcising societies give a better picture of how to take the latest research findings forward.”

Religious practice

In the Jewish religion, male infants are traditionally circumcised on their eighth day of life, providing there is no medical contraindication. The justification, in the Jewish holy book the Torah, is that a covenant was made between Abraham and God, the outward sign of which is circumcision for all Jewish males. The Torah states: “ This is my covenant, which ye shall keep, between me and you and thy seed after thee: every male among you shall be circumcised " (Genesis 17:10). Male circumcision continues to be almost universally practiced among Jewish people.

Islam is the largest religious group to practice male circumcision. As an Abrahamic faith, Islamic people practice circumcision as a confirmation of their relationship with God, and the practice is also known as ‘tahera’, meaning purification. With the global spread of Islam from the 7th century AD, male circumcision was widely adopted among previously non-circumcising peoples. There is no clearly prescribed age for circumcision in Islam, although the prophet Muhammad recommended it be carried out at an early age and reportedly circumcised his sons on the seventh day after birth. Many Muslims perform the rite on this day, although a Muslim may be circumcised at any age between birth and puberty.

The Coptic Christians in Egypt and the Ethiopian Orthodox Christians— two of the oldest surviving forms of Christianity— retain many of the features of early Christianity, including male circumcision. Circumcision is not prescribed in other forms of Christianity. In the New Testament, St. Paul wrote: "in Christ Jesus neither circumcision nor uncircumcision count for anything" (Galatians 5:6) and a Papal Bull issued in 1442 by the Roman Catholic Church stated that male circumcision was unnecessary: “Therefore it strictly orders all who glory in the name of Christian, not to practise circumcision either before or after baptism, since whether or not they place their hope in it, it cannot possibly be observed without loss of eternal salvation,” it stated. Focus group discussions on male circumcision in sub-Saharan Africa found no clear consensus on compatibility of male circumcision with Christian beliefs. Some Christian churches in South Africa oppose the practice, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership and participants in focus group discussions in Zambia and Malawi mentioned similar beliefs that Christians should practice circumcision since Jesus was circumcised and the Bible teaches the practice.


Circumcision has been practiced for non-religious reasons for many thousands of years in sub-Saharan Africa, and in many ethnic groups around the world, including aboriginal Australasians, the Aztecs and Mayans in the Americas, inhabitants of the Philippines and Eastern Indonesia and of various Pacific Islands, including Fiji and the Polynesian islands.

In the majority of these cultures, circumcision is an integral part of a rite-of-passage to manhood, although originally it may have been a test of bravery and endurance. “Circumcision is also associated with factors such as masculinity, social cohesion with boys of the same age who become circumcised at the same time, self-identity and spirituality,” Dr Hankins explained.

The ethnographer Arnold Van Gennep in his 1909 work ‘The Rites of Passage’ , describes various initiation rites which are present in many circumcision rituals. These include a three stage process: separation from normal society; a period during which the neophyte undergoes transformation; and finally reintegration into society in a new social role.

“A psychological explanation for this process is that ambiguity in social roles creates tension, and a symbolic reclassification is necessary as individuals approach the transition from being defined as a child to being defined as an adult. This is supported by the fact that many rituals attach specific meaning to circumcision which justify its purpose within this context,” said Dr Hankins. For example, certain ethnic groups including the Dogon and Dowayo of West Africa, and the Xhosa of South Africa view the foreskin as the feminine element of the penis, the removal of which (along with passing certain tests) makes a man of the child.

Tradition plays a major part for many ethnic groups. Among ethnic groups of Bendel State in southern Nigeria, 43% of men stated that their motivation for circumcision was to maintain their tradition. In some settings where circumcision is the norm, there is discrimination against non-circumcised men. For the Lunda and Luvale tribes in Zambia, or the Bagisu in Uganda, it is unacceptable to remain uncircumcised, to the extent that forced circumcisions of older boys are not uncommon. Among the Xhosa in South Africa, men who have not been circumcised can suffer extreme forms of punishment, including bullying and beatings.

Circumcision as a social statement

Social reasons behind male circumcision are becoming ever more common. “The desire to conform is an important motivation for circumcision in places where the majority of boys are circumcised,” said Dr Hankins.

A survey in Denver, US where circumcision occurs shortly after birth, found that parents, especially fathers, of newborn boys cited social reasons as the main determinant for choosing circumcision (e.g. not wanting the son to ‘look different’ from the father).

In the Philippines, where circumcision is almost universal and typically occurs at age 10-14, a survey of boys found two-thirds of those surveyed choosing to be circumcised simply ‘to avoid being uncircumcised’, and 41% stating that it was ‘part of the tradition’. Social concerns were also the primary reason for circumcision in South Korea with 61% of respondents in one study believing they would be ridiculed by their peer group unless they were circumcised.

The desire to ‘belong’ is also likely to be the main factor behind the high rate of adult male circumcisions among immigrants to Israel from non-circumcising countries (predominantly the former Soviet Union).

In a number of countries, socio-economic factors also influence circumcision prevalence, especially in countries with more recent uptake of the practice such as English-speaking industrialised countries. When male circumcision was first practised in the United Kingdom in the late 19th and early 20th century, it was most prevalent among the upper classes. In the US, a review of 4.7 million newborn male circumcisions nationwide between 1988 and 2000 also found a significant association with private insurance and higher socioeconomic status.

Perceived health and sexual benefits

In more recent times, perceptions of improved hygiene and lower risk of infections through male circumcision have driven the spread of circumcision practices in the industrialised world.

In a study of US newborns in 1983, mothers cited hygiene as the most important determinant of choosing to circumcise their sons, and in Ghana, male circumcision is seen as cleansing the boy after birth. Improved hygiene was also cited by 23% of 110 boys circumcised in the Philippines and in South Korea, the principal reasons given for circumcision were ‘to improve penile hygiene’ (71% and 78% respectively) and to prevent conditions such as penile cancer, sexually transmitted diseases and HIV. In Nyanza Province, Kenya, 96% of uncircumcised men and 97% of women irrespective of their preference for male circumcision stated their opinion that it was easier for circumcised men to maintain cleanliness.

Perceived improvement of sexual attraction and performance can also motivate circumcision. In a survey of boys in the Philippines, 11% stated that a determinant of becoming circumcised was that women like to have sexual intercourse with a circumcised man, and 18% of men in the study in South Korea stated that circumcision could enhance sexual pleasure. In Nyanza Province, Kenya, 55% of uncircumcised men believed that women enjoyed sex more with circumcised men. Similarly, the majority of women believe that women enjoyed sex more with circumcised men, even though it is likely that most women in Nyanza have never experienced sexual relations with a circumcised man. In northwest Tanzania, younger men associated circumcision with enhanced sexual pleasure for both men and women, and in Westonaria district, South Africa, about half of men said that women preferred circumcised partners.

Expected increase in demand

Global estimates in 2006 suggest that about 30% of males — representing a total of approximately 670 million men — are circumcised.

With latest research findings suggesting that circumcised men have a significantly lower risk of becoming infected with HIV, demand for safe, affordable, male circumcision is expected to increase rapidly.

“Since male circumcision is now shown to be effective in reducing the risk of HIV acquisition, care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection,” said Dr Hankins, underlining that these issues will be discussed at the “ Male Circumcision and HIV Prevention Research - Policy and Programme Implications” International Consultation to be held in Montreux from 6-8 March 2007. “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. Just as combination treatment is the best strategy to treat HIV, combination prevention is the best strategy to avoid acquiring or transmitting HIV”, she added.

“Action is also required to improve the safety of circumcision practices in many countries and to ensure that health care providers and the public have up-to-date information on the health risks and benefits of male circumcision,” she said.

Sunday, July 22, 2007

What other benefits does male circumcision confer?

Before the emphasis becomes solely fixed on the HIV protection it may be good to summarise the other benefits which accrue through male circumcision.

Below is a letter listing these benefits and challenging the Australian RACP to review and update their policy with regard to neonatal male circumcision.

RACP's policy statement on infant
Male circumcision is ill-conceived


Objective: To conduct a critical peer-review of the 2004 Policy
Statement on routine male circumcision produced by the Royal
Australasian College of Physicians ( RACP).

Method: Comprehensive evaluation in the context of the research field.

Results: We find that the current Statement downplays the wide-ranging
life-long benefits of circumcision in prevention of urinary tract
infections (UTls), penile and cervical cancer, genital herpes and
Chlamydia in women, HIV infection, phimosis and various penile
dermatoses, and at the same time overstates the complication rate. We
highlight the many errors in the RACP Statement and note that it
sidesteps making a conclusion based on circumcisions well-documented
prophylactic health benefits by instead referring to the status of the
Foreskin at birth. In the era of preventative medicine we view this as

Conclusion: The RACP's Statement on routine male circumcision is not
evidence based and should be retracted.

Implications: In the interests of public health and individual
well-being an extensive, comprehensive, evidence-based revision should
be conducted so as to provide scientifically accurate, balanced
information on the advantages, and also the low rate of mostly minor
complications, associated with this simple procedure, which for
maximum benefits and minimal risk should ideally be performed in the
neonatal period.

(Aust NZ J Public Heath 2006 30: 16-22)

Brian J. Morris
School of Medical Sciences and Institute for Biomedical Research,
University of Sydney, New South Wales

Stefan A. Bailis
Research and Education Association on Circumcision Health Effects,
United States of America

Xavier Castellsague
Servei d'Epidemiologia i Begistre del Cencet, lnstitut Catah d'Oncologia
UHospitalet de Llobregat, Spain

Thomas E. Wiswell
Department of Paediatrics, State University of New York, United States
of America

Daniel T. Halperin
AIDS Research lnstitute/Center for AIDS Prevention Studies,
University of California, United States of America

The Royal Australasian College of Physicians (RACP) Division of
Paediatrics & Child Health (formerly the Australian College of
Paediatrics [ACP]) has produced a Policy Statement on circumcision in
which the summary states (in bold) that "there is no medical
indication for routine male circumcision", i.e. the foreskin of an
infant as it presents at birth has no medical condition that would
mandate its removal." This is often misinterpreted by professional and
lay bodies as saying that the RACP is opposed to circumcision. An
"appeal to authority"' may be the only position they might fall back
on, given their lack of training or time to study the evidence.

Other, now somewhat dated, position statements on circumcision by
paediatric bodies elsewhere have similarly been criticised by academic
experts, including in the case of the American Academy of Pediatrics
(AAP) Statement the former Chair of the AAP Task Force on Circumcision.

The RACP Statement is marred by references to opinion pieces by
extremist anti-circumcision organisations. As an example, in section
2, in the same sentence it lumps misconceptions from Victorian times
in with recent hard scientific evidence, referring to the latter as

When the Statement says that it concurs with a previous conclusion by
the ACP it should be recognised that the 1996 ACP Statement was a
substantially watered-down document emanating from a credible review
of the medical by a working party which reported in 1995 emphasising
the considerable medical benefits at the time in a fair and balanced
manner. In the decade since this somewhat neutral statement the
evidence in favour of circumcision has continued to increase. Yet in
its next Statement in 2002, the RACP failed to address this
adequately, and very few of our substantive criticisms to the RACP
were addressed in devising its 2004 Statement, which remains a non
peer-reviewed internet document.

In this article, we point out the multiple errors in the current
Statement, many of which have serious public health ramifications.

Cervical cancer

A large international collaborative study confirms the lower incidence
of cervical cancer in women with a circumcised male partner. Although
monogamous women whose male partners had six or more sexual partners
and were circumcised had a [5.6-fold] lower risk of cervical cancer
than women whose partners were uncircumcised, the Statement neglects
to mention that women whose partner had an intermediate sexual
behaviour risk index were also protected (OR 0.50). In an accompanying
editorial it was suggested that these findings were probably an
underestimate of the true risk to women.

The RACP Statement goes on to recommend use of condoms in lieu of
circumcision "to inhibit sexual transmission of HPV" (the Causative
agent), despite there being no significant difference in Protection
against cervical cancer between condom users (OR 0.83) and non-users
(OR 0.67). Hunan papillomavirus (HPV) is a highly infectious skin
virus transmissible during foreplay. A more specific study on condom
use per se is, nevertheless, needed.

When the Statement mentions an "increased risk of [HPV] infection in
uncircumcised men who indulged [!] in high-risk [?] behaviours" it may
be referring to uncircumcised men who don't use condoms or perhaps men
who have had sex with more than one woman in their life, either
concurrently or sequentially. The latter casts normal men as
'high-risk', which is unreasonable.

The Statement's speculation on future immunisation against HPV is
premature, despite recent success in Phase III trials of HPV16 and
HPVl8 vaccines. Fifty of the 200 types of HPV are ano-genital.
Although vaccination against the 8 most common is predicted to prevent
89% of cases [XC, unpublished], vaccination could lead to their
replacement bt rarer types not vaccinated against. Vaccination has to
occur prior to sexual debut, and availability, cost, or extent of
participation may also limit effectiveness. HPV vaccines can,
moreover, increase tumour invasiveness.

Herpes and Chlamydia in women

History of intercourse with an uncircumcised man ( ever) is also a
risk factor for herpes simplex type 2 infection in women (OR 2.2, 9 5%
CI 1.4-3 6), and Chlamydia trachomatis (OR 5.5, 95% CI 1.7-20).


The RACP Statement dismisses universal neonatal circumcision as an
AIDS prevention strategy in countries like Australia, saying that
circumcision to reduce transmission is more relevant in Third World
countries. Although lower, lack of circumcision is likely to account
for at least some HIV infections in Australasia. Moreover in a highly
mobile global society, risk cannot be ascribed parochially. In
contrast to what the RACP Statement asserts, the role of the foreskin
in HIV transmission is now compelling. This includes a detailed
meta-analysis, fastidious matching of case and control groups to
eliminate confounding factors, absolute protection in a 30-month study
of men with an infected female partner, 6.7-fold reduction in adjusted
relative risk (0.14; 9 5% CI 0.04-0.62) in another, in agreement with
the 8.2-fold reduction seen in an early prospective study, and
biological data showing that the inner, mucosal lining of the
foreskin, unlike the outer layer and rest of the penis, lacks a
protective keratin barrier, meaning that, for an otherwise healthy
penis, the foreskin is the route of infection of HIV which has been
demonstrated to accumulate rapidly in the abundant Langerhans and
other immune system cells in the inner foreskin epithelium. A Cochrane
review recommended waiting for the outcome of three randomised,
controlled trials. The first results from one of these showed a 76%
reduction, i.e. was more effective as any hoped for HIV vaccine.

Condoms, when always used, reduce infection by about 80-90%. Although
important, they are far from a panacea for HIV prevention and the
foreskin can be exposed to infected fluids prior to condom
application. This also applies to homosexual men, who engage in
'docking',' a source of sexual pleasure rendered impossible by

Since heterosexual transmission was the initial, and still is the
major, mode of transmission world-wide, lack of circumcision would
appear to be a major contributing factor to the AIDS epidemic. Even
though other modes of transmission have taken over in the west,
heterosexual transmission to the male may be reduced by lowering
foreskin prevalence among men, many of whom will visit countries in
which HIV abounds. Moreover, in some, but not other, studies the
effectiveness of circumcision in AIDS risk reduction was greater when
performed prior to puberty or sexual debut.

Penile cancer

The RACP Statement makes penile cancers seem much rarer than jt really
is - to wit, its citing of annual incidence rates of penile cancer of
1 in 100,000. The annual incidence of fatal heart attack -200 in
100,000 also seems small, yet it accounts for 22% of all deaths.
Actual lifetime risk of penile cancer in an uncircumcised man is 1 in
400 to 900, as in Australia. It represents 1-2% of cancer deaths in
men in developed nations and 10-22% of all male malignancies in some
developing countries. Presentation is split equally between carcinoma
in situ and invasive penile cancer. The latter is lethal and the RACP
Statement fails to point out that its incidence is 22 times higher in
uncircumcised men. Notably, men circumcised early in life are afforded
greater protection than if circumcised in adulthood. HPV is the
culprit in basaloid and warty carcinomas, most of which are HPV
positive. Similarly half of all vulvar carcinomas are HPV-positive
(cf. the 99.7%' HPV positivity in cervical cancer).The rate of HPV
infection is, moreover, lo er in circumcised men (OR 0.37). High-risk
HPV is found more frequently in verrucous carcinomas than giant
condylomas (which are caused by low-risk HPV) and keratinising and
verrucous carcinomas are HPV positive in one-third of cases.

As is the case for breast cancer, the sex-related organ is often
surgically removed, so adding to the devastating physical and
emotional impact of penile cancer. And the five year survival rate is

Prostate cancer

The lifetime risk of prostate cancer is 1 in 11 and not mentioned in
the RACP Statement, it is twice as common in uncircumcised men.

Urinary tract infections

In contrast to what the RACP Statement says, infections of the urinary
tract are regarded as common in the paediatric population. Rather than
the increased rate in uncircumcised boys being 3-12 fold it is really
5-89 fold (95% CI 11-14), averaging 12-fold in a large meta-analysis.
The RACP's underestimate (' 5-fold') arises from inappropriate
averaging of small and large studies.

The >90% effectiveness of newborn circumcision in preventing UTI makes
it as protective as vaccination of children in disease prevention.

By way of biological support, the strains of Escherichia coli and
Proteus mirabilis present are fimbriated, which facilitates their
adherence to the inner lining of the foreskin and subsequent colony
formation; these are pathogenic to the urinary tract and
pyelonephritogenic. Pathogenic bacteria were found in the periurethral
region of 64% of boys, without phimosis, prior to circumcision, but in
only 10% 4 weeks afterwards; for the glanular sulcus these figures
were 68% and 8% respectively. This study concluded that the
periurethral flora originate from deeper preputial regions and
emphasised the beneficial role of circumcision.

The RACP Statement says UTI incidence in uncircumcised boys is 1-2%.
It then presents a trade-off analysis using the lowest end of this
range (l%) against an inflated figure for serious complications
(haemorrhage and infections) of 2% to say there would be 2.5
complications for every UTI prevented. However, more credible analyses
involving 100,000 and 325,297 US male infants each found the
complication rate was 0.2%.

The latter then calculated that 6 UTIs could be prevented for every
circumcision complication. The RACP Statement cites this reference,
but not these data, merely saying that "other figures can be used to
come to a different conclusion".

A study in western Sydney by the Statement's co-author J.C. noted a
UTI rate of 6% in uncircumcised boys aged 0-5 years.

The RACP Statement does not mention that the highest prevalence and
the greatest severity of UTI' is prior to six months of age. It is,
moreover, misleading for their Summary to state that, "In Australia
and New Zealand the circumcision rate has fallen considerably in
recent years and it is estimated that currently only 10-20% of male
infants are routinely circumcised. In reality, the fall from 90% to
10% took place 30 years ago and is now reversing. Medicare statistics,
which relate only to rebate claims for circumcision, and are thus
underestimates, show a circumcision rate of 17% Australia-wide,
implying an actual rate higher than this. For boys aged <6>100: l. Even more
when conditions caused in women are taken into account.


The RACP Statement cites a rate of circumcision in the USA of 60%,
whereas National Center for Health Statistics (NCHS) data for the past
20 years exceed this value, the most recent being 65.3%. NCHS figures
are based on hospital records, but many US hospitals do not record
circumcisions. Moreover, the rate amongst the traditionally
non-circumcising Hispanic groups is increasing (not decreasing as the
Statement asserts in section 2) as subsequent generations adopt local
practice. Among Anglo-Celtic whites and blacks the rate is close to
90%, any lower overall figure being a dilutional effect o Hispanic,
Asian and European immigrants. Moreover, the newborn rate is
increasing by 6.8% per year in the US.

In the UK, a rate of 6% is suggested. However, publications give:
7-10% for boys aged <15 n =" 1,874,">6 months there
were 5,455 claims, of which 2,064 were for boys aged 6 months to 4
years. Thus most involve younger infants. As stated earlier, the
actual rate is higher than Medicare claim data. Only physical
examination would reveal this. Doing so in adults showed 62% of
attendees at Sydney STI Centre were circumcised being similar in older
and younger men. In Adelaide rate was 63% and 55%, respectively in
each, and in Dunedin was 40% in a 1973 birth cohort. Moreover, in
contrast to the comment in the RACP summary it is for religious
reasons in only 3% of cases.

Although the RACP Statement mentions that either a local or a general
anaesthetic can be used, it fails to alert the reader to the latter
being the norm after 6 months of age. Thus risk from general
anaesthetic must be emphasised should circumcision be delayed.


Curiously, even though circumcision in the newborn period is more
common than later, the Statement only discusses the free-hand or
sleeve-resection technique used in older children – including mention
of sutures, blood vessels, etc. It is imperative that the relatively
easy methods used for newborn circumcision are included, i.e. the
Plastibell, Gomco and Mogen procedures. Training in these, as well as
safe, easy, effective local anaesthetic methods involving EMLA cream,
dorsal penile nerve block or ring block is imperative. Vigilance for
abnormal anatomy or bleeding disorders, necessitating referral to a
paediatric urologist, should also be mentioned.


The RACP Policy Statement on circumcision is marred by many serious
errors. Far more accurate accounts can be found in recent extensive
reviews and credible websites such as by the former AAP Task Force
Chair. There are so many benefits of circumcision that the RACP should
be taking a leadership role in promoting awareness of these, as well
as fostering good surgical technique in conjunction with the RACS.
Just as with childhood immunization there is an overall benefit to
public health and individual well-being accompanied by a very low risk
of any serious adverse consequence (Table 1). Parents also have a
legal right to authorise it.

Thus, to summarise the RACP's "Where we stand: Paediatric policy on
circumcision is misleading, inaccurate and, in places, incorrect. It
amounts to thinly disguised propaganda. A new Statement that has as
its basis evidence-based medicine, not lip service to the same, needs
to be produced as a matter of urgency to assist medical practitioners
in giving accurate advice to parents, as well as in clinical
decision-making. The Statement should contain a conclusion that we the
authors see as being in harmony with the medical literature: "The net
benefits of routine infant male circumcision in prevention of a wide
range of medical and health problems over the lifetime, together with
the small risks associated with this procedure should be explained by
medical practitioners to all parents of infant boys in order to assist
them in arriving at an informed decision about what is best for their
newborn son".

Table 1 can not be included in this document to read it see at:

Saturday, July 21, 2007

Male circumcision can reduce HIV infection

SYDNEY: Scientific studies have confirmed a long-standing belief that male circumcision can reduce human immunodeficiency virus (HIV) infection rates in men by 60 percent, an international Acquired Immune Deficiency Syndrome (AIDS) conference will be told next week.

David Cooper, the co-chairman of an International AIDS Society (IAS) conference to be held in Sydney from July 22-25, said research on male circumcision represented a major development in HIV prevention.

“We always knew that if you went into any particular African country, the HIV rates among Muslim men were much lower,” Cooper said. “But we were never sure that the Muslim men had lower numbers of partners than non-Muslim men, so people always doubted it,” he added.

Cooper said the only way to ensure that the link between lower HIV rates and circumcision was not because of cultural factors was to carry out random trials, the results of which will be presented at the Sydney conference.

He said three trials were conducted in South Africa, Kenya and Uganda, each involving more than 2,000 heterosexual men, half of whom were circumcised.

“The reduction in HIV infection was about 60 percent, so clearly it works,” said Cooper, who is also the director of Australia’s National Centre for HIV Epidemiology and Clinical Research.

Cooper said the studies showed circumcision could be a powerful tool in helping curb HIV infection in sub-Saharan Africa, where infection rates in some countries are up to 40 percent of the adult population.

He said, however, that any introduction of widespread male circumcision in developing countries needed to be carried out with an education campaign that reinforced a safe sex message. afp