Male circumcision and HIV prevention

R esearchers have been exploring the possibility of a correlation between male circumcision and lowered risk of HIV infection almost since the beginning of the HIV/AIDS epidemic. Results from a randomised controlled trial in South Africa in 2005 indicate that male circumcision protects men against the acquisition of HIV through heterosexual intercourse, confirming the findings from 20 years of observational studies. Circumcised men in the South African trial were 60% (95% CI 32% to 76%) less likely to acquire HIV than their uncircumcised counterparts. A mathematical modelling study, based on the South African trial, estimates that the practice of male circumcision could avert two million new HIV infections and 300 000 HIV-related deaths over the next 10 years in sub-Saharan Africa. More recently, two randomised controlled trials in Kisumu, Kenya and Rakai, Uganda showed, respectively, 53% and 48% reductions in HIV acquisition among circumcised men than uncircumcised men in the trial. These results strongly suggest that male circumcision could play an important role in the struggle against the continued rise in new HIV infections. However, as observers noted at the 2006 XVI International AIDS Conference in Toronto, Canada, excitement about the potential epidemiological impact has overshadowed the debate over the difficult translation of research on male circumcision, into policy and practice. Similar calls for caution have been raised before and elsewhere. 8 The topic of male circumcision carries an enormous amount of ethical baggage. Male infants, worldwide, are circumcised for various medical, social and/or religious reasons. Circumcision is a cultural act and a surgical procedure; medical reasons are not the only reasons to circumcise that people have found and continue to find as compelling. Benatar and Benatar have argued that—when performed in adequate clinical settings— neonatal circumcision does not threaten the health and safety of a child to an extent that justifies society over-riding a parent’s right to decide what is in their child’s best interest on the basis of their own social or religious values. Others strongly object by arguing (in part) that in the absence of a defined and substantial benefit, the medical principle of ‘‘do no harm’’ should prevail. 11 The ethics of male circumcision cannot be considered apart from its historical context. In the past, medical communities in industrialised countries have recommended male circumcision to prevent or treat several health conditions. Some recommendations—such as the use of circumcision to treat mental illness, tuberculosis, excessive masturbation and schistosomiasis—turned out to be clearly mistaken. Although there is evidence of associations between male circumcision and lowered risk of penile cancer, acquisition of syphilis, urinary tract infections and penile human papillomavirus infection, these benefits for men are of questionable relevance: the absolute risk of penile cancer is negligible (1 in 100 000 in the US), and there are generally more cost-effective and lowerrisk ways of treating these infections than circumcision. Although recent studies indicate that male circumcision may reduce the risk of cervical cancer and chlamydia infection in their female partners, the fact remains that for many decades, in Western countries (particularly in the US), neonatal circumcision has been routinely performed in hospitals largely for sociocultural and religious reasons, as the medical and public health justifications for the intervention were weak. The new findings on male circumcision and HIV alter the terms of the debate over the ethics of male circumcision. The results of the trials in South Africa, Kenya and Uganda, all suggest that male circumcision could offer important clinical and public health benefits for individuals and populations in the high-HIV prevalence settings with heterosexually driven epidemics. Disagreements persist about the justification of promoting male circumcision as a part of the HIV prevention policy, on the basis of current scientific evidence. These disagreements hinge on whether a similarly high degree of protective effect can be replicated, over the long term, outside the context of a carefully controlled clinical trial. Some argue that health policies always involve risk, and HIV/AIDS is an urgent public health emergency, warranting and even demanding bold measures. However, the long term and/or absolute reduction in HIV transmission risk via male circumcision remains uncertain and partly depends on population prevalence. There is room for discussion about the justification of implementing male circumcision for HIV prevention before its overall health impact has been fully quantified. In this article, we will not focus on the scientific issues surrounding the current research on male circumcision. We will work from the perspective that the current evidence from studies in three sub-Saharan countries indicates that male circumcision is (at least) promising as an HIV-prevention strategy—that is, in public health terms, male circumcision is as promising as an HIV vaccine or preexposure prophylactic drug that showed a similar short-term protective effect in a series of randomised controlled trials. Using the age of circumcision as a vantage point, this article develops a new framework to understand the complex array of ethical and practical challenges faced by this controversial way of preventing HIV in high prevalence, lowincome countries, particularly in subSaharan Africa.