Medical male circumcision now forms part of government's policy to reduce new HIV infections. "By 2011, medical male circumcision must be practiced all over South Africa", Health Minister Dr Aaron Motsoaledi announced recently when he detailed new protocols for TB and AIDS treatment which came into effect on April 1.
Making medical male circumcision part of HIV prevention measures has been a contested field for a few years. It's one of the issues that bedeviled the reign of former Health Minister, Dr Manto Tshabalala-Msimang. On the other hand, circumcision is a traditional rite of passage into manhood that has been practiced in South Africa and on the continent for many years. Convincing traditional leaders of the benefits of medical male circumcision was not easy. After much consultation, policy now exists.
"The evidence is clear that this is an intervention that is useful, that is scientific, that is evidence-based, that is an addition to the prevention package. The approach that has been taken is that there is no debate about the impact of male circumcision.
The issues were around working with the sensitivities of traditional practices vs whether or not this was an infringement of what other cultures do in terms of circumcision.
But now with the main issue around cultural sensitivities having been resolved, it's now something that has been totally embraced and accepted as a key component of our prevention strategy in South Africa", said head of the South African National AIDS Council, Dr Nono Simelela.
Medical male circumcision services were to start being offered on April 1, as part of the Health Department's new TB and HIV and AIDS treatment package. The Department has forecast that it will circumcise about 2.5 million South African men in the next year.
"We want to undertake massive male circumcision. We believe that by 2011, male circumcision will be practiced all over", said Health Minister, Dr Aaron Motsoaledi.
Three provinces have been targeted to introduce the service. KwaZulu-Natal is taking the lead in implementing the policy. Ironically, circumcision used to be a traditional practice among Zulu men about 200 years ago. Late last year, King Goodwill Zwelithini called upon Zulu men to go back to circumcision to protect themselves against HIV infection. Some district hospitals in KwaZulu-Natal are already offering the service.
"King Zwelithini announced publically that the tradition which the Zulu nation has been practicing for more than 200 years is going to come to an end - in terms of not practicing circumcision traditionally. They are going to do it medically.
By 2015, the Premier of KZN and the MEC and the King have pledged that they will have conducted 2.5 million male circumcisions. The Northern Cape have said they are ready, they want to do it. Mpumalanga have been quiet and I want to pledge for them. They must do it", the Health Minister said.
Policy towards medical male circumcision for HIV prevention followed a number of scientific studies that showed that it can reduce HIV infection in men by between 50% - 60%.
"Scientists observed for a long time that parts of the world where most men are circumcised tended to have lower HIV rates, in both Africa and in Asia. That doesn't prove anything because there might be other factors which explain the difference in HIV prevalence. So, they decided to do randomised control trials, which are the gold standard of research, to find out if it was actually circumcision that prevented HIV.
They did three studies - one in South Africa, one in Uganda and one in Kenya - and the results came out about two years ago and the results were remarkable. The three studies had almost identical results. The three studies showed that being circumcised provided about a 60% protection against the acquisition of HIV for men", said Scott Billy, technical advisor for the Society for Family Health (SFH).
However, it's important to note that circumcised men must continue using condoms as the addition of the latex sheath offers maximum protection. All sexually active men who can give consent to a medical procedure are encouraged to get circumcised for HIV prevention. The policy is yet to decide on infant circumcision. Provincial health departments will release details of their plans to roll out the service in the foreseeable future.
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The promoters of circumcision would love you to believe that the case is closed, but it certainly is not.
In the three trials (neither double-blinded nor placebo-controlled, which would have been the REAL gold standard) 5,400 men were circumcised and a similar number left alone. After less than two years, 64 of the circumcised men had HIV, while 137 of the control group did. The difference, 73 men, is the entire basis of the claim that circumcision is protective. Meanwhile 327 circumcised men dropped out, their HIV status unknown.
All three studies were cut short, so who knows what they'd have found if they were allowed to run their course? And now a study (Bassler et al., JAMA. 2010;303(12):1180-1187) has shown that stopping a trial early makes it more likely to seem to show a benefit, even if there is none. This is especially so where events are few (less than 500). The total number of events (men becoming HIV+) in the three trials was 201.
In at least six countries, a higher proportion of the CIRCUMCISED men have HIV than the uncircumcised (Cameroon, Ghana, Lesotho, Malawi, Rwanda, Tanzania, parts of Uganda, and in one survey, Swaziland - according to the National Health and Demographic Surveys, http://www.measuredhs.com/countries/). That certainly needs to be explained before proceeding with mass circumcision campaigns.
The three RCTs were held in countries where more of the intact men have HIV: just circumcising without understanding what is really going on may do no good at all. It may even do harm if it makes men careless, or increases the rate of transmission to women, as one study in Uganda seemed about to show before it too was cut short. (Wawer et al. Lancet, 374:9685, 229-37)
I would like to make two points:
Firstly, the research that showed a 60% reduction in infections is not universally accepted. A search of the internet will provide you with the errors made in the experiment and the cultural bias of the people involved.
Secondly, even if you accept the research, the effect is only on female-to-male infection. The trial, by the same people that tested male-to-female infection, showed that circumcision actually increased infections not decrease.
Given the fact that the western country with the highest HIV infection rate is also the only western country that regularly circumcises, its totally illogical to argue that circumcision is an effective tool to fight HIV/AIDS.