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How the circumcision solution in Africa will increase HIV infections Robert S. Van Howe, Michelle R. Storms

Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA

Correspondence: Dr. Robert S. Van Howe, Department of [...]]]> http://www.publichealthinafrica.org/index.php/jphia/article/viewArticle/jphia.2011.e4/html_9

Home > Vol 2, No 1 (2011) > Van Howe

How the circumcision solution in Africa will increase HIV infections

Robert S. Van Howe, Michelle R. Storms

Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA

Correspondence: Dr. Robert S. Van Howe, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, 413 E. Ohio Street, Marquette, MI 49855, USA.
Tel. +1.906.2287454 – Fax: +1.906.4852726. E-mail: rsvanhowe@att.net, vanhowe@msu.edu

Key words: circumcision, HIV infection, risk compensation.

Conflict of interest: the authors report no conflicts of interest.

Received for publication: 25 October 2010.
Accepted for publication: 9 December 2010.

This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0).

©Copyright R.S. Van Howe and M.R. Storms, 2011
Licensee PAGEPress, Italy
Journal of Public Health in Africa 2011; 2:e4
doi:10.4081/jphia.2011.e4

Abstract

The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.

Introduction

At the XVIII International AIDS conference held in Vienna, there was a strong push to gather funding to circumcise 38 million men in sub-Saharan Africa within the next five years. The belief is that male circumcision provides the best hope of decreasing the spread of HIV infection there. We believe these efforts are misguided.
Although the World Health Organization (WHO) and UNAIDS have supported circumcision as an HIV preventive in regions with high rates of heterosexually transmitted HIV, the circumcision solution has several fundamental flaws that have been glossed over by its proponents within these organizations. These proponents, who have been touting the “benefits” of circumcision for decades, have developed plans to circumcise Africa on behalf of WHO and UNAIDS.1 If their goal is to prevent the spread of HIV in Africa, circumcision will only serve to divert resources away from effective measures.
In this paper, we will expose the lack of scientific evidence, biological plausibility, and epidemiological evidence that provides the foundation for the circumcision solution. We will demonstrate how circumcision will likely increase the number of heterosexually transmitted HIV infections. Finally, we will discuss how poorly circumcision compares with other interventions.

Lack of scientific evidence

The results of three randomized clinical trials (RCTs) are often presented as proof beyond a reasonable doubt that male circumcision prevents HIV infection.2 After all, RCTs are the gold standard of medical experimentation. However, such accolades only apply to well-designed, well-executed trials. The three RCTs were neither.
The trials were nearly identical in their methodology and in the number of men in each arm of the trial who became infected. The trials shared the same biases, which led to nearly identical results. All had expectation bias (both researcher and participant), selection bias, lead-time bias, attrition bias, duration bias, and early termination that favored the treatment effect the investigators were hoping for.3 All three studies were overpowered such that the biases alone could have provided a statistically significant difference.
The common hypothesis for these trials was that male circumcision would decrease the rate of heterosexually transmitted HIV infections. A basic assumption adopted by the investigators was that all HIV infections resulted from heterosexual transmission, so no effort was made to determine the source of the infections discovered during the trial. There is strong evidence that this assumption was not valid.

In the South African trial, men who reported at least one episode of unprotected sex accounted for 2498 person-years and 46 HIV infections during the trial. Among the remaining men, who accounted for 2076 person-years, 23 become infected although they either had no sexual contact or always used a condom. These men, who had infection rate of 1.11/100 person-years (95%CI=0.74-1.67), presumably became infected through non-sexual means. The men at sexual risk of infection had an infection rate of 1.84/100 person-years (95%CI=1.38-2.46). It would be expected that all men in the trial shared the same baseline risk of non-sexual transmission and any additional risk could be attributed to sexual transmission. The infections attributed to sexual contact would be the difference between the total rate and the non-sexually transmitted rate (0.73/100 person-years). Consequently, only 18 (0.0073 infections per person-year * 2498 person-years) of the 69 infections in the South African trial can be attributed to sexual transmission.4
Similarly, in the Ugandan trial, men who consistently used condoms had the same rate of infection as those who never used condoms (Consistent condom use: 1.03/100 person-years; No condom use 0.91/100 person-years; RR=1.13, 95%CI=0.54-2.38, P=0.74). Men who reported no sexual partners for the duration of the trial accounted for 1252.1 patient-years and 6 infections (0.48/100 persons-years, 95%CI=0.22-1.07). If this rate is subtracted from the rate in sexually active men, at most 35 of the 67 infections in the Ugandan trial can be attributed to sexual transmission.5
Finally, in the first three months of the Kenyan trial, five men became HIV-positive who reported no sexual activity in the period before the seroconversion (0.73/100 person-years, 95%CI=0.30-1.76). If this rate is subtracted from the overall rate of infection in the trial, at most 36 of the 69 infections in the Ugandan trial can be attributed to sexual transmission.6 Conservatively for the three trials, 89 of the 205 infections (43.1%) were sexually transmitted. Without knowing which infections were sexually transmitted, it is impossible to test the hypothesis of whether circumcision reduces the rate of sexually transmitted HIV. Basing policy on studies that were unable to answer their own research question is unwarranted.
Lack of biologic plausibility

How does cutting off the foreskin prevent the transmission of HIV? This question remains unanswered. Proponents of the circumcision solution have speculated that the interior mucosa of the prepuce is thinner and more prone to tearing, but mucosa of the inner and outer prepuce have been shown to be of the same thickness.7 Proponents also speculate that HIV is more likely to be transmitted through the foreskin because it has a high concentration of Langerhans cells, which they believe are the entry point for HIV. Research has shown that Langerhans cells are quite efficient in repelling HIV and explains why the transmission rate of HIV is one per 1000 unprotected coital acts.8 The inner foreskin secretes langerin, which kills viruses.9 Langerhans cells also protect against other sexually transmitted infections (STIs), which may explain why circumcised men are at greater risk for getting an STI (unpublished data). In general, mucosal immunity provides a stronger barrier to infection than the skin. Finally, to support their plausibility argument, circumcision proponents have identified the sub-preputial space as a harbor for sexually transmitted viruses. Meta-analyses assessing the susceptibility to genital infections with herpes simplex virus and human papilloma virus have not shown an association with circumcision status.10,11,12 Unfortunately, these speculations have been repeated so often in the medical literature that many physicians and public health officials consider them factual. There is, however, no direct scientific evidence to support the hypothesis that the foreskin is a predisposing factor for infection.
Lack of consistent epidemiological evidence

If the RCTs are to be believed and circumcision provides 50% to 60% protection from sexually transmitted HIV infection, then the impact of circumcision should be readily apparent in the general population. This is not the case. In Africa, there are several countries where circumcised men are more likely to be HIV infected than intact men, including Malawi, Rwanda, Cameroon, Ghana, Zimbabwe, Lesotho, Swaziland, and Tanzania.13,14,15 Even in South Africa, where one RCT was undertaken, 12.3% of circumcised men were HIV-positive, while 12.0% of intact men were HIV-positive.16 If the national survey data that are available from 19 countries are combined in a meta-analysis (Table 1) the random-effects model summary effect for the risk of a genitally intact man having HIV is an odds ratio of 1.10 (95%CI=0.83-1.46), indicating that on a general population level, circumcision has no association with risk of HIV infection. Among developed nations, the United States has the highest rate of circumcision and the highest rate of heterosexually transmitted HIV.17 Within the United States, blacks have the highest rate of circumcision18,19,20,21 and the highest rate of heterosexually transmitted HIV.22 Among English-speaking developed nations there is a significant positive association between neonatal circumcision rates and HIV prevalence (data currently under submission, Scot Anderson). On a population level, circumcision has not been found to be an effective measure and may be associated with an increase in HIV risk.

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Table 1. Meta-analysis of population survey results from 19 countries15,16 comparing HIV prevalence based on circumcision status using fixed-effects and random-effects models on exact odds ratios and confidence intervals.11

Risk compensation

Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or increases.23,24 When modeling HIV infections in San Francisco, Blower and McLean found that if an HIV-vaccine offered 50% protection, but reduced condom usage, or increased other risky behaviors, it would likely result in higher HIV infection rates.21
Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom,25 and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed.26 If circumcision results in lower condom use, the number of HIV infections will increase.
African men, on average, have coitus once a week,27 and use condoms in 48% of their sexual encounters with women.5 Assume that 20% of sexually active women are HIV-positive, partners were contacted randomly, condoms are 98% effective when used, the baseline circumcision rate is 5%, and circumcision reduced the transmission rate of HIV infection by 50%. Since the transmission rate of HIV from females to males is one per 1000 unprotected coital acts, the HIV infection rate in men in this scenario would be 0.537 per 100 person-years (which is far below the rate reported in the three RCTs). If the circumcision rate increases from 5% up to 75%, the infection rate would decrease to 0.344 per 100 person-years. If in the baseline scenario with a 5% circumcision rate condom use increased from 48% up to 67.9% of sexual encounters, the infection rate would be 0.344 per 100 person-years. Consequently, the impact of a fifteen-fold increase in the rate of circumcision could be accomplished by a relative 41% increase in the use of condoms.
The leap of faith

Interventions and medications that demonstrate efficacy in a research setting are often failures in a clinical setting. Circumcision will provide another example of this. The results from the RCTs are of questionable value, and it is unknown how they will translate to the real world. Numbers gathered from general populations are outside the 95% confidence intervals generated by the RCTs.
Research results often fail to translate to other settings because the research population differs considerably from the targeted population. For example, to save money in a trial of a new antihypertensive medication, participants with the highest blood pressure will be recruited for the trial, because it is easier to show effectiveness in those with more severe disease. The new medication may do well with the participants, but when the medication is released for general use, it may not be beneficial for those with mild hypertension, let alone those who are normotensive.
The men attracted by a free circumcision to enroll in the RCTs are not representative of the general population. The RCT participants were required to want to be circumcised. A faithful monogamous man with a faithful spouse would have little motivation to seek a free circumcision. This selection bias may have resulted in enrollment of men more likely to engage in high-risk behaviors. The free circumcision and financial inducements may have added to the selection bias.
If the selection bias resulted in more men at high risk of infection being in the trial, then the results would apply only to men who engage in high-risk behaviors. This would be consistent with the observational studies finding that the association between circumcision status and HIV infection was present primarily in studies of high-risk men.
Instead of targeting sexually active men at high risk of HIV infection, the circumcision solution proposes circumcising all males (of all ages), which would be equivalent to recommending the above antihypertensive medication to everyone regardless of their blood pressure. In addition to the national survey data (Table 1), observational studies of general populations have for the most part failed to show an association between circumcision status and HIV infection.28,29,30 There is no scientific reason to believe that the RCT results would necessarily apply to the general population. It is quite likely that applying research results from a high risk population to the general population will lead to failure. Using the scenario above, if it is assumed that circumcision has only a 10% protective in the general population then increasing the circumcision rate from 5% up to 75% would decrease the infection rate from 0.548 to 0.509 per 100 person-years. Increasing condom use from 48% up to 51.8% would result in the same gains. So a fifteen-fold increase in the circumcision rate would have the same impact as a 3.8% absolute increase in the use in condoms.
Attractive, less invasive, less expensive, more effective alternatives

Before Africans address sexually transmitted HIV, a concerted effort to eliminate the iatrogenic spread of the virus is needed. As the numbers from the RCTs indicate, most infections can be attributed to non-sexual transmission. While this indictment of the medical system is unsettling, ignoring iatrogenic sources of infection will only allow the African epidemic to flourish.31
When it comes to sexually transmitted HIV infections, proponents of circumcision have consistently failed to compare the effectiveness and cost of circumcision to currently available alternatives, which include condoms, aggressive surveillance and treatment of STIs, and antiretroviral therapy (ART).
ART is a secondary preventive measure. When those infected with HIV are treated with ART, the viral counts can decrease to where the patient is no longer contagious. HIV-infected patients on ART with no currently active STI no longer need to use condoms to protect their partners.32 A recent model predicted that a “test and treat” model in a sub-Saharan setting could reduce the number of new HIV infections by 55-73.2%,33 making this approach attractive in Africa, San Francisco, and Washington, DC.34 This intervention directs prevention at those most likely to benefit: those exposed to the virus. With the circumcision solution, the vast majority of men who are circumcised will not benefit from the procedure (Figure 1). Secondary prevention is a more efficient use of resources and many HIV experts consider primary prevention extremely wasteful and ineffective.8 The “test and treat” approach is effective regardless of whether the infection was sexually or iatrogenically transmitted. Such an approach would not be limited to ART, as the use of other medications proven to decrease viral counts, such as decitabine and gemcitabine, may also become available.35
Aggressive surveillance and treatment of STIs has been shown to reduce the number of HIV infections by 40%36 at a cost of $217.62 per HIV-1 infection averted.37 This is more cost-effective than models for circumcision, which extrapolate the data collected from the 21 to 24 months of the RCTs to over 20 years, have predicted. These models, which incorporated major assumptions of questionable validity, presented circumcision as favorably as possible. In addition to being more cost-effective, aggressive surveillance and treatment of STIs have the advantage of treating and preventing the spread of STIs and avoiding the damage caused by removing the most sensitive portion of penis.38 Part of the success of STI treatment research may be due to a reduction of iatrogenically transmitted HIV, as the STIs were treated in research facilities.
In studies of discordant couples, condoms have been shown to be more than 99% effective in preventing infection.39 Condoms, in a public health setting, cost 2.5¢ each.40 A safe circumcision performed under sterile conditions in Africa using local anesthetic costs approximately $75,41 so for the cost of an adult circumcision, 3000 condoms, at 2.5¢ per condom, can be purchased. The nearly complete protection provided by condoms is a bargain compared with circumcision. In the first hypothetical scenario outlined above, the 0.193 infections per 100 person-years decrease in HIV infection rate brought by circumcision costs $52.50 per person. The cost per person of the additional condoms (at 2.5¢ each) for one year to achieve the same impact on the infection rate would total 25.87¢. To have the same effect for one year, circumcision costs 202.9 times more than condoms. Proponents for circumcision would argue that circumcision is a one-time expenditure, while condoms would be an ongoing expense. Using the scenario above with 3% discounting and assuming an average of weekly sexual contact over 45 years, the lifetime difference in the cost of condoms would be $6.13 per person. With 5% discounting the lifetime difference in cost would be $4.83. If circumcision is only 10% effective, with a 3% discount, the lifetime difference in cost of condoms would be $1.25.
One complaint has been that the 2.5¢ condoms are not attractive, which may explain why they are underused. Based on this analysis, if a man is having sex weekly for 45 years, an upgrade to condoms that cost ten times as much would be cost neutral (assuming a discount rate of 3%). Of course, if sexual contact was less frequent or a man was in a mutual monogamous relationship, further condom upgrades could be justified.
This is, however, a false comparison because, unlike circumcision, condoms can provide nearly complete protection.
Circumcision proponents believe that circumcision is the only proven effective preventive tool for HIV infection and have argued that condoms are ineffective.42,43 Condoms would be expected to be ineffective in regions where the majority of infections are from non-sexual transmission. Abstinence, be faithful, and condoms (ABC) should remain the focus of primary prevention for sexually transmitted HIV, but more resources need to be focused on the non-sexually transmitted infections, which is a much more efficient means of transmission.31
How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection). The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection.
Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended. The second tier would be primary prevention that focuses on the ABCs.
Resources are not unlimited. With the push for circumcision, public health workers in Africa are finding that resources that previously paid for condoms are now being redirected to circumcision. With every circumcision performed, 3000 condoms will not be available. For every circumcision performed, a health care provider is prevented from caring for someone in need of medical care. With trained medical providers busy performing circumcisions, patients will be forced to seek medical care provided in settings where sterility of equipment is less likely and HIV is more likely to be spread iatrogenically. For every circumcision performed, there are fewer resources that can be put into ART and other chemotherapies. Male circumcision is an unnecessary distraction that depletes the limited resources available to address the HIV epidemic. It also fails to address the underlying causes for the epidemic in Africa.

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Figure 1. Cumulative HIV infections over time using the combined data from three randomized clinical trials with early circumcision represented with the solid line and delayed circumcision (control group) in the dashed line. Nearly all of the men in the trial remained infection free.

References

1.World Health Organization, UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability. 2007. Available at: http://www.malecircumcision.org/media/documents/MC_Global_Trends_Determinants.pdf
2. World Health Organization, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. 2007. Available at: http://www. unaids.org/en/media/unaids/contentassets/dataimport/pub/report/2007/mc_recommendations_en.pdf
3. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999; 354:1813-5.
4. 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.
5. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-66.
6. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.
7. Dinh MH, McRaven MD, Kelley Z, et al. Keratinization of the adult male foreskin and implications for male circumcision. AIDS 2010;24:899-906.
8. Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. 2007. Radcliffe Publ., Abingdon, OX,UK
9. de Witte L, Nabatov A, Pion M, , et al. Langerin as a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med 2007;13:367-71.
10. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006;82:101-10.
11. Van Howe RS. Human papillomavirus and circumcision: A meta-analysis. J Infect 2007;54:490-6.
12. Van Howe RS, Storms MR. Circumcision to prevent HPV infection. Lancet Oncol 2009;10:746-7.
13. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008;7:1-8.
14. Demographic and Health Surveys. HIV Prevalence and Associated Factors (Chapter 15). In: Rwanda National Health and Demographic Survey for 2005. Available at: http://www.measuredhs.com/ pubs/pdf/FR183/15Chapter15.pdf
15. Mishra V, Medley A, Hong Ret al. Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. 2009. DHS Comparative Reports No. 22. Macro International Inc., Calverton, MD, USA.
16. Connolly C, Shanmugam R, Simbayi LC, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002. S Afr Med J 2008;98:789-94.
17. UNAIDS, World Health Organization. Global HIV/AIDS and STD Surveillance Project: Report on the global HIV/AIDS epidemic 1998. Available at: http://www. unaids.org/hivaidsinfo/statistics/june98/global_report/index.html.
18. O’Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995;88:411-5.
19. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007;34:479-84.
20. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007;2:e861.
21. Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: associated factors and length of hospital stay. J Fam Pract 1995;41:370-6.
22. US Centers for Disease Control and Prevention. Racial/ethnic disparities in diagnoses of HIV/AIDS – 33 states, 2001-2005. MMWR Morb Mort Wkly Rep 2007;56:189-93.
23. Blower SM, McLean AR. Prophylactic vaccines, risk behaviour change, and the probability of eradicating HIV in San Francisco. Science 1994;265:1451-4.
24. Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet 2000;355:400-3.
25. Bonner K. Male circumcision as an HIV control strategy: not a ‘natural condom’. Reprod Health Matters 2001;9:143-55.
26. Bridges JFP, Selck FW, Gray GE, et al. Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa. Health Policy Planning 2010; e-pub ahead of print.
27. Sawers L, Stillwaggon E. Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence. J Int AIDS Soc 2010; 13: 34.
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29. O’Farrell N, Egger M. Circumcision in men and the prevention of HIV infection: a “meta-analysis” revisited. Int J STD AIDS 2000;11: 137-42.
30. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16.
31. Gisselquist D. Points to consider: responses to HIV/AIDS in Africa, Asia and Caribbean. 2008. Adonis & Abbey Publ. Ltd, London, UK.
32. Vernazza P. La prévention du sida devient plus simpl, mais aussi plus complexe! Bull Med Suisses 2008;89:163-4.
33. Bendavid E, Brandeau ML, Wood R, Owens DK. Comparative effectiveness of HIV testing and treatment in highly endemic regions. Arch Int Med 2010;170:1357-54.
34. Charlebois ED, Havlir DV. “A Bird in the Hand…”: a commentary on the test and treat approach for HIV. Arch Int Med 2010;170:1354-6.
35. Clouser CL, Patterson SE, Mansky LM. Exploiting drug repositioning for discovery of a novel HIV combination therapy. J Virol 2010;84:9301-9.
36 Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995;346:530-6.
37. Gilson L, Mkanje R, Grosskurth H, et al. Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet 1997;350:1805-9.
38. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.
39. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med 1994;331:341-6.
40. Shelton JD, Johnston B. Condom gap in Africa: evidence from donor agencies and key informants. Br Med J 2001;323:139.
41. Krieger JN, Bailey RC, Opeya J, et al. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. BJU Int 2005;96:1109-13.
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“One man boasts that he got circumcised because it is “nice to have sex without condoms” — drawing a furious reaction from the recruiters.”

Circumcision does not prevent [...]]]> More and more reports are coming through of African men who abandon condoms in favour of circumcision.
Exactly what anti-circumcision activists have been warning all along:

“One man boasts that he got circumcised because it is “nice to have sex without condoms” — drawing a furious reaction from the recruiters.”

Circumcision does not prevent HIV, sends out the wrong message for safe sex, and puts women and men at more risk as they adopt riskier behaviour.

Use a condom, not a knife to prevent HIV.

It should make us all worry about believing in something too strongly, because it can blind us to the truth….as Mr. Morris to clearly illustrates.

http://www.youtube.com/watch?v=gdGbXdEo93U

Dear Dr Tshabalala and Mr Maxon,

It has recently come to our attention that the KZN-Natal Health Department is planning to encourage the universal  circumcision of infant boys in an attempt to curb HIV infection rates.

We hope that you have had time [...]]]>

Circumcision of babies for proposed HIV prevention unethical and illegal

Dear Dr Tshabalala and Mr Maxon,

It has recently come to our attention that the KZN-Natal Health Department is planning to encourage the universal  circumcision of infant boys in an attempt to curb HIV infection rates.

We hope that you have had time to review such ideas over the Christmas break and have decided not to continue with such a drastic plan, which would violate several aspects of current law, most notably the Children’s Act number 38 of 2005, as well as the National Health Act.

Children’s Act

According to the Children’s Act, children can only be circumcised for ‘medical reasons’ related to current pathology of the foreskin, not for prophylactic reasons. In other words, circumcision of a foreskin is now illegal unless the child has a current medical pathology that can only be remedied by the amputation of the foreskin. It is Important to realize that it is extremely rare for a newborn male infant to have a pathological condition of this nature. If a child happens to have a mild condition such as phimosis or a urinary tract infection, less drastic remedies must always be used in a genuine effort to resolve the problem without resorting to circumcision.  In other words, infant male circumcision is only legal if it can be proved that such a serious measure is genuinely  in the best interests of the child, a standard that can only be met in extraordinary circumstances,  and only after several more conservative treatments have been attempted and failed.

These legal stipulations exist for what should be obvious reasons. Circumcision is a serious surgery that is inevitably traumatic for the infant, and is irreversible. Circumcision that is deemed “successful” always results in a significant loss of sexual sensation and capability. A healthy foreskin is important for normal sexual functioning when the child becomes an adult. If the guidelines imbedded in current law are not followed, once the child becomes an adult he will have a strong basis for accusing the KZN-Natal Health Department of having violated his basic human right to a complete body.

The standard for a legitimate prophylactic reason to circumcise a baby boy would be much higher than can be met by any existing medical danger, including the possibility of eventually contracting HIV. No credible scientific basis to justify the removal of healthy tissues in male children for HIV prevention has been found, and circumcision performed on that basis violates a child’s right to bodily integrity and medical ethics. Since the infant is being circumcised to ‘possibly’ prevent HIV, there is no immediate medical need, making circumcision illegal, unnecessary, and unethical.

Medical circumcisions require a valid ICD-10 code to indicate the medical reason for the circumcision and thus define whatever  pathology the doctor believes justifies the circumcision. The written consent of  both parents is also required. This documentation will become a permanent record of the basis upon which the circumcision was performed, available for scrutiny at any later time in which the legitimacy of the reasons for the circumcision are questioned by the child, his parents, or others.

Religious circumcision

Doctors cannot act as agents of a social custom in the Health Department, and thus cannot perform a circumcision on a child unless it is medically indicated; that is, unless an actual current medical disease exists and is deemed to be so serious that circumcision is necessary. Circumcision for religious reasons are not for the Health Department doctors to carry out, since they carry no immediate health benefit and are a social custom. These should be performed by a Jewish or Muslim doctor privately, and according to the regulations of the Children’s Act, including the completion of the appropriate consent forms (see attached).

Legal action

The KZ-Natal Health Department will be opening the door for  legal challenges should they go ahead.

The medical records of any children that are circumcised in your departments are required to be kept until the age of majority of the child. We will be supporting these children to take appropriate legal action against the KZN-Natal Health Department and individuals promoting the proposed agenda of routine neonatal male circumcision despite these warnings. Parents of children will also be encouraged to take legal action whenever they become aware of legal stipulations in current law that were willfully overlooked.

No scientific basis for circumcision of babies for HIV prevention exists.

While we are aware of the well-known randomized control trials (RCT’s) used to justify the circumcision of consentingadults in order to provide some protection against HIV, we would like to remind you that there are currently no RCT studies in existence showing that circumcision of infants reduces their chances of acquiring HIV later in life. Any suggestion that such evidence exists is inferred and not based on medical fact. Willfully proceeding with plans for routine circumcision of infant boys with no valid medical reason, therefore provides legal and medical justification to sue. Since the KZN Department plans to proceed at least 12-14 years before the child becomes sexually active, by which time a vaccine may be present, and since ways exist to educate young people about how to protect themselves against HIV, it is unreasonable and inhumane to assume that a radical genital modification doomed to fail in its intended purpose and doomed to bring great unhappiness on a massive scale is necessary to achieve these aims.

Circumcised men still acquire HIV at an alarming rate, and circumcision is no permanent safe-guard against HIV infection.

Only a condom is proven to reduce HIV acquisition over repeated exposures. Any circumcised man having regular unprotected sex over time will ultimately carry the same risk of HIV exposure and increase the risk of his partner, especially if he falls prey to the belief that he is protected from HIV. Already, throughout Africa, men are beginning to believe that they do not need to wear a condom because they are circumcised.

We would be happy to engage your department in face-to-face discussions and to provide you with any information you may require to assist you in adjusting your present position.

This letter will be uploaded to our website in the interest of public knowledge. Please also find supporting articles attached.

Sincerely,

Shelton Kaye

Co-director

NOCIRC-SA

www.nocirc-sa.co.za

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Circumcision can be seen as a form of mutilation and a form of abuse when done to a child or baby against it’s will and the systematic routine practise of this disgusts me. In hospitals all over America right now, babies are strapped into a plastic mould called a ‘circumstraint’ with two [...]]]>

[Source]

Circumcision can be seen as a form of mutilation and a form of abuse when done to a child or baby against it’s will and the systematic routine practise of this disgusts me. In hospitals all over America right now, babies are strapped into a plastic mould called a ‘circumstraint’ with two arm restraints and two leg restraints and a clamp fitted onto the end of each baby boy’s penis which is fixed so tightly it crushes the tissue, damaging the penis, just so there is less blood when they make the incision and cut off the foreskin. It’s a pretty horrific and barbaric practice.

“There is reason why they call it ‘cut’ – because you loose something.”

It is not a normal act to lob off a piece of skin and flesh from a baby. When you think about it, anyone caught doing this in any other circumstance would be imprisoned. Under the guise of religion and tradition however, it slips under the radar. What would happen if, let’s take Scientologist’s as an example (as they are considered a relatively new religion) announced to the world that all their babies were to have their ear lobes removed at birth as standard practise? There would be outrage from most if not all communities of the world. And why? – because it’s a very weird, unnecessary thing to do and morally wrong to permanently change a baby physically, cause it pain and scar it, emotionally and physically. However, because people have been practising circumcision for many years, it’s deemed as being perfectly ok to do – even though it’s no different to removing an earlobe, nipple or eyelid. There is absolutely no good reason to cut off a boy’s foreskin, unless in adult life it is causing complications and the reason is medical. Even circumcision for women is deemed ‘wrong’ by the western society, but for men it’s supposed to be okay?

How does this affect you if you are religious? Well, it states nowhere in the Koran anything at all about circumcision. Nor do you have to be circumcised if you are a Jewish – it is simply a ‘gesture’ of dedication, but not necessary. The main culprit of circumcision is actually Americans.

The reason why American’s first started the procedure in 1870′s was because they thought it ‘cured’ ‘diseases’ such as ‘masturbation’ and ‘madness’. It was done to children as soon as they were born as a sort of ‘vaccination’ against these ‘diseases’. In the 1890′s there was also an attempt to make it law for all “Negro boys to be circumcised so as to reduce their sex drive and protect white women from rape.” Dr John Harvey Kellogg’s, of Corn Flake fame, was a huge supporter of this, and actually wrote in a book in 1877 that he thought the procedure should be done to babies with no anaesthetic so that the baby would have an emotional pain memory to learn not to masturbate;

“The operation should be performed without administering an anaesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment.

“In a way, he was right to assume that circumcision will affect the sexual habits of the individual. In recent scientific demonstrations, it is shown how a cut penis often does not perform correctly or naturally during sex and can be problematic for both men and women. There is not enough skin to accommodate an erection – therefore there is no ‘give’ necessary for more pleasurable sex from the perspective of the person being penetrated. Essentially you are being poked hard and awkwardly which can cause pain and discomfort. The edge of the head of the penis, called the ‘coronal ridge hook’ is not protected by bunched up foreskin on cut penis and so it not only scrapes the lining of the vagina/**** when being withdrawn but it also looses the vacuum to hold in the natural lubrication. The vagina was designed with the foreskin to create this vacuum to hold in the man’s ejaculation – it helps procreate. No vacuum means less sperm are trapped and getting pregnant, if that is your aim, can be more difficult. Not to mention it is very difficult to masturbate without having to use lubrication – another opportunity for someone to sell you something you don’t need and making the natural spontaneity of sex and masturbation into something synthetic and artificial.

The very common and weak excuse about cleanliness and that cut men are cleaner or healthier is misguided. All of our body gets dirty and builds up dirt – earwax, mucus, nails, hair – we wash them all and survive, do we not? Nobody tells us to cut fingers off at birth just in case they get dirty, do they? There is absolutely no evidence to say it is healthier to have a cut penis, apart from the view that is if you have no foreskin you therefore automatically eliminate any remote chances of it being infected in the foreskin simply because you do not have one to be infected, but to the same example, if you remove children’s teeth then the chances of them having tooth decay is zero simply because they have no teeth to become decayed – that doesn’t mean that a child’s teeth will become decayed if they are not removed, obviously. Or even breast tissue – working on the same principles of that argument, we should remove the breast tissue of every newborn baby girl just in case they develop breast cancer in the future – ridiculous and flawed.

The actual practise of circumcision can also be very dangerous and it is a very major procedure to be undertaking on a newborn child and has been fatal in some cases. Doctors have quoted it is a barbaric act, unnecessary and the British Medical Association claim it is a completely unethical practise and that the reason why it is still going on and not being challenged is because it is a multi-billion dollar industry. Up until now, Americans have had to pay for healthcare and therefore pay to get a child circumcised – if Americans suddenly realised it was wrong to cut up a child’s natural penis there would be a huge impact on the health industry and fat cats would loose a hell of a lot of money – billions in fact. So basically, to save them loosing money – you or your child looses a necessary and natural part of your body. Mutilating and hurting new-born babies to make a buck – ahh, the American dream.

Finishing here a beautiful quote from ‘Elizabeth Blackwell’, who in as early as in 1894 clearly pointed out how absurd and arrogant it is to think that God and/or nature could make a mistake in the making of not only ‘man’ but all male mammals on the earth;

“Circumcision is based upon the erroneous principle that boys, i.e. one half of the human race, are so badly fashioned by Creative Power that they must be reformed by the surgeon; consequently that every male child must be mutilated by removing the natural covering with which nature has protected one of the most sensitive portions of the human body. The erroneous nature of such a practice is shown by the fact that although this custom (which originated amongst licentious nations in hot climates) has been carried out for many hundreds of generations (by Moslems and Jews), yet nature continues to protect her children by reproducing the valuable protection in man and all the higher animals, regardless of impotent surgical interference.”

STORIES BY MUSA SIMELANE

http://www.times.co.sz/index.php?news=20909

MBABANE – Even though male circumcision is considered to have a protective effect for HIV infection, circumcised men have a slightly higher HIV infection than those who are not.

The Times SUNDAY can today reveal that government has known this for close to [...]]]> More circumcised men are HIV positive

STORIES BY MUSA SIMELANE

http://www.times.co.sz/index.php?news=20909

MBABANE – Even though male circumcision is considered to have a protective effect for HIV infection, circumcised men have a slightly higher HIV infection than those who are not.

The Times SUNDAY can today reveal that government has known this for close to three years.

It is contained in the Swaziland Demographic and Health Survey (SDHS) of 2007 which still prevails.

This report summarises findings of the 2006 survey carried out by the Swaziland Central Statistical Office (SCO).

The report places the infection rate for circumcised males at 22 per cent while for those uncircumcised stands at 20 per cent.

HIV stands for Human Immuno Deficiency Virus. It is the virus that can cause the acquired immuno deficiency syndrome (AIDS).

The report states that the protective aspect of male circumcision is based in part because of the physiological differences that increase the susceptibility to HIV infection among uncircumcised men. However, the relationship between HIV prevalence and circumcision is not in the expected direction.

“It is worth noting that the relationship between male circumcision and HIV infection may be confounded by the fact that the circumcision may not involve the full removal of the foreskin, which provides partial protection,” stated the report.

But additional analysis is needed to determine if this lack of a relationship between male circumcision and HIV infection is a result of confounding factors or represents the true situation.

In 2007 government introduced a policy on male circumcision, which has a goal of halting the spread of HIV infection to achieve an HIV-free generation.

Cited in the report is that to meet this objective, male circumcision services, as part of the national comprehensive HIV prevention package, would have to be availed to men of all ages.

To maximise the health benefit for HIV prevention, the primary targets of the services are men who are HIV-negative, in the age bracket of 15-24 and also newborn babies.

Additional information collected by the SDHS in the 2006 to 2007 period revealed that eight per cent of men age 15-49 were circumcised.

“Older men are markedly more likely than younger men to have been circumcised, which the rate peaking at 20 per cent among men aged 35 -39 years. Urban men (13 per cent) are more than twice as likely to be circumcised compared with rural men (six per cent),” said the report.

Also discovered is that the rate of circumcision among men is slightly higher in the Hhohho and Manzini regions compared with the rate in Shiselweni and Lubombo.

Meanwhile, the belief that circumcision can provide a considerable measure of protection against HIV infection has been questioned by academicians and medical professionals of repute.

Last week Occupational Health Specialist Dr Cleopas Sibanda questioned the rationale of circumcision to justify it being adopted as part of the national HIV and AIDS prevention strategy.

“What exactly happened in Uganda as far as HIV and AIDS and population demographics are concerned to correctly attribute the observed previous decline in their national HIV and AIDS statistics to wholesale male circumcision?” Sibanda was quoted as having asked.

But he noted that circumcision for the wrong reasons can be very dangerous, in fact it has increased episodes of diminished consistent use of condoms and increased incidences of HIV and AIDS affected populations.

Three primary sites where circumcision is performed

* PSI’s Litsemba Letfu Clinic in Matsapha

* Family Life Association (FLAS) Mbabane

*Manzini Nazarene Hospital

An international conference has delivered a clear message to US medical bodies not to recommend any infant genital cutting that is not strictly necessary, organizers say. The 11th International Symposium on Genital Integrity ended at the University of California at Berkeley this evening.

“We learned how circumcision does much [...]]]> July 31st, 2010 by ICGI

An international conference has delivered a clear message to US medical bodies not to recommend any infant genital cutting that is not strictly necessary, organizers say. The 11th International Symposium on Genital Integrity ended at the University of California at Berkeley this evening.

“We learned how circumcision does much more harm and less good than most people imagine,” co-organizer Marilyn Milos said, “and how circumcision instruments have particular risks—as we were reminded last week when a boy was awarded $10 million for a tragic botch.”

The American Academy of Pediatrics and the Centers for Disease Control are both considering revising their currently neutral advice about neonatal circumcision in the United States, following claims from trials in Africa that it reduced the rate of HIV transmission from women to men by 1.8%. Over three trials, the rates were 2.49% of non-circumcised men and 1.18% for circumcised men.

“We heard how the African trials are irrelevant to the US, where HIV is mainly transmitted by sharing IV drug needles and sex between men,” Milos said.

“The AAP should have learned from its recent experience with female cutting, that even a token nick is not acceptable, and male circumcision and intersex reassignment are much more extensive than a token nick,” Milos said.

Speakers came to the symposium from Australia, Brazil, Canada, Egypt, England, Ireland, Italy, and New Zealand.

Tomorrow the National Organization of Circumcision Information Resource Centers (NOCIRC), one of the conference organisers, marks 25 years in existence.

For more information, contact Marilyn Milos, RN, (415) 488-9883, or Georganne Chapin, (914) 806-3573.

The US male infant circumcision rate is now 32%, according to the CDC. This is great news for Intactivists and even better news for the more than one million boys who are now remaining intact every year. This means that their efforts have been successful in continuing the steady [...]]]> August 14th, 2010 by ICGI

The US male infant circumcision rate is now 32%, according to the CDC. This is great news for Intactivists and even better news for the more than one million boys who are now remaining intact every year. This means that their efforts have been successful in continuing the steady decline of an unnecessary surgery upon defenseless infants.

The genital integrity community is astonished and happy that the US circumcision rate is now below one-third. Intactivists had been predicting that the 50/50 point wouldn’t occur until 2011 or 2012. This is a huge drop. And, social change can happen quickly. Circumcision has been in the news a lot lately, primarily from the efforts of Intact America.

Intactivists have responded variously to this news. Some are giddy and self-congratulatory, others question the “too good to be true” number, while others are ignoring it because it came from their opposition.

But most of the credit goes to parents who are learning more about circumcision before making the decision. What many are saying is that their decision wasn’t based on whether or not circumcision was beneficial or harmful, but that it is not their place to decide on elective surgery for their child. They figure that since it is his body, not theirs, that he can make the decision when he is older. By leaving him intact, they are leaving him with a choice, not living with an irreversible condition.

The statistic was released during a presentation at the AIDS 2010 conference in Vienna, Austria, late last month. Presenters were C. El Bcheraoui, K. Kretsinger, and R. Chen from the CDC, and J. Greenspan from SDI Health. The CDC hired SDI Health, one of the country’s largest health-care analysts, to do the research. They looked at 21% of hospital records for the last 4 years and found that the circumcision rate has continued to drop, from 56% in 2006, to 32.5% in 2009. SDI Health has worked with the CDC on previous studies. US circumcision rates peaked at about 85% in 1979.

Less than 1/10th of one percent of adult males opt for circumcision, indicating that circumcision has never been medically useful. But, with more boys remaining intact, they will later be at risk for circumcision from mis-diagnosis of penile conditions, and from doctors prescribing amputation to treat them instead of first trying less invasive treatments.

[Source]

CAPE TOWN — The southern African distributors of the Tara KLamp circumcision device have rejected a call for it to be put on hold until safety concerns have been addressed.

The call was made yesterday in a joint statement by the Treatment Action Campaign and the Southern African HIV [...]]]> 09 Jul 2010
Sapa

CAPE TOWN — The southern African distributors of the Tara KLamp circumcision device have rejected a call for it to be put on hold until safety concerns have been addressed.

The call was made yesterday in a joint statement by the Treatment Action Campaign and the Southern African HIV Clinicians’ Society.

Tony Lawrence, spokesperson for distributors Carpe Diem Enterprises, said, however, that the statement contains numerous allegations about the clamp which are “totally inaccurate, unjustified and unfounded”.

“We are determined to correct the views of all the parties concerned, as the experiences of our medical doctors across the country can attest to the efficacy and ease of use of the [clamp].”

He promised a full response later.

TAC and the doctors said they encourage voluntary male circumcision as a way of reducing the risk of heterosexual men contracting HIV and the human papilloma virus.

In a controlled trial of the Tara KLamp at Orange Farm in Gauteng, circumcised men using the clamp reported worse pain than men using the forceps-guided method of medical circumcision.

That trial was stopped early due to the unacceptably high rate of adverse events, and the researchers have “strongly” cautioned against using the clamp on young adults.

The clamp is attached to the foreskin, and after about a week the device, along with the foreskin, usually falls off. But in some cases the device does not fall off, forcing the patient to have it removed surgically.

“Currently, the balance of evidence shows that the [clamp] is unsafe for use on adolescents and adults,” TAC and the doctors said.

“The [clamp] must be withdrawn from sale and distribution for adolescent and adult circumcision throughout sub-Saharan Africa, until the device’s safety concerns are addressed.”