Thursday, July 19, 2007

Quickly Achieving High Coverage Male Circumcision

David Griffith, Benjamin Bellows and Malcolm Potts
J. Epidemiol. Community Health 2007;61;612-

Three randomised control trials on male circumcision (MC)in South
Africa (November 2005), and in Uganda and Kenya (December 2006), have
now confirmed what a growing body of evidence has indicated for more
than 15 years: MC reduces human immunodeficiency virus (HIV) infection
by around 50%.

In 1999, Halperin and Bailey4 published an article, ``Male
circumcision and HIV infection: 10 years and counting''. Over the
preceding decade, considerable evidence had accumulated that MC
reduces the risk of HIV acquisition in previously uninfected men. In
the eight years since that article, additional studies have only
underscored this relationship. However, no large-scale, systematic
effort has yet taken up the challenge to translate this science into
preventive strategies.

Are there barriers to roll out MC? MC is cost effective. Kahn et al 5
estimate that, in a South African adult population, MC costs $181
(£90.52; J133.43) per HIV infection averted, which compares favourably
with treatment for sexually transmitted infections for HIV prevention,
and voluntary counselling and testing services.

Predictably, MC arouses strong emotions. As with condoms to protect
against HIV, or oral contraceptives to prevent unwanted pregnancy, the
accusation is always made that the introduction of a new method of
protection will lead to increased sexual licence. The evidence
suggests otherwise. Kawango et al2 conducted a study among 324
recently circumcised men and 324 uncircumcised men in Kenya to
determine the effect of circumcision on sexual behaviour. The
researchers found that, during the first month after circumcision, men
were 63% less likely to report having 0–0.5 risky sexual acts weekly
than uncircumcised men. The differences in sexual risk disappeared
during the remainder of the follow-up period, and the researchers
concluded that, during the first year, circumcised men did not report
an increased number of risky sexual acts compared with uncircumcised men.

While the world waits to act, patients from Uganda to Swaziland who
can afford the operation are seeking this biological ``vaccine''.6 7
The result is that men who can afford it are already protecting
themselves, whereas the poor either cannot access MC or are going to
unsafe and untrained providers.

We think an efficient and socially equitable way to make this
intervention available across large geographical areas, while ensuring
that the poorest men could participate, would be to use an
output-based aid (OBA) voucher programme. The OBA approach contracts
providers at agreed prices for clearly stipulated outputs, and then
sells vouchers to clients for, in this case, MC services. The voucher
is marketed at a nominal price, and entitles the client to treatment
at no additional cost from approved providers. The provider is paid
according to the number of clients served. The payment represents a
realistic unit cost for the procedure covering staff fees and the
costs of drugs and materials.

An independent voucher management agency is appointed to run the
system, and its activities include identifying, training and approving
service providers, marketing and distributing the vouchers, claims
processing and payments, and maintaining the quality of the service,
as well as monitoring and evaluating the system. An entirely new cadre
of MC specialists may not be needed. Given the simple surgical
procedures, it is reasonable to assume that a variety of paramedical,
and even non-medical, operators may be able to provide safe MC under
OBA. In many parts of the world, MCs are not done by highly trained
doctors, but by religious and traditional leaders. Serious
consideration could be given to including them in a well-controlled
OBA scheme.

Voucher schemes are already functioning for treatment of sexually
transmitted infections in Uganda and for safe motherhood and family
planning in Kenya. In both these programmes, vouchers for MC could be
added, and the appropriate providers contracted and trained within a
few months.

Given the results of the randomised control trials, it is now high
time to make MC available to the poor in countries with high HIV
prevalence. A voucher scheme would be the most efficient way to do
this quickly.

David Griffith - Health Consultant, Heidelberg, Germany
Benjamin Bellows - School of Public Health, University of California
at Berkeley, Berkeley, California, USA
Malcolm Potts - School of Public Health, University of California at
Berkeley, Berkeley, California, USA

1 Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV
prevention in men in Rakai, Uganda: a randomised trial. Lancet
2 Agot K, Kiarie J, Nguyen H, et al. Male circumcision in Siaya and
Bondo districts, Kenya: prospective cohort study to assess behavioral
disinhibition following circumcision. J Acquir Immune Defic Syndr
3 Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled
intervention trial of male circumcision for reduction of HIV infection
risk: the ANRS 1265 trial. PLoS Med 2005;2:e298.
4 Halperin D, Bailey R. Male circumcision and HIV infection: 10 years
and counting. Lancet 1999;354:1813–15.
5 Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male
circumcision for HIV prevention in a South African setting. PLoS
Medicine Vol 3, No 12, e517. doi:10.1371/ journal. pmed. 0030517.
6 Blandy F. Circumcision fever sweeps Swaziland. Johannesburg: Mail
and Guardian online, 2007,
articlePage.aspx?articleid = 297770&area = /breaking_news/
breaking_news__africa/ (accessed 19 Apr 2007).
7 BBC. Ugandan men getting circumcised. London: British Broadcasting
Company (BBC), 2007,
(accessed 19
Apr 2007).
8 Sandiford P, Gorter A, Salvetto M. Use of voucher schemes for
output-based aid in the health sector in Nicaragua: three case
studies. Invited presentation at the World Bank workshop on
Output-Based Aid (OBA), Frankfurt, Germany, 24–26 Jan, 2002.
9 Janisch C, Potts M. Smart aid. Lancet 2005;366:1343–4.