Future Medicine: Male Circumcision is not the HIV vaccine we have been waiting for!

The May issue of Future Medicine carries an editorial authored by Lawrence W. Green of UCSF's Department of Epidemiology & Biostatistics, Ryan G. McAllister of Georgetown University, Kent W. Peterson of Virginia-based Occupational Health Strategies, and John W. Travis of North Carolina-based Wellness Associates.

The abstract to the aptly entitled article Male circumcision is not the HIV 'vaccine' we have been waiting for!:

Over the past several months, some researchers and health organizations [101] have proclaimed circumcision to be a compelling and important new HIV tool. A recent commentary claims that circumcision is “at least as good as the HIV vaccine we have been waiting for, praying for and hoping to see in our lifetimes” [1]. Thousands of African men now line up to get circumcised in the mistaken belief that it will save them from HIV, as some developing nations – lacking even rudimentary medical care and clean drinking water – rush to implement mass circumcision programs with encouragement and millions of pledged dollars from the US government [2, 102, 103]. In addition, there are calls for implementing mass neonatal circumcision [104].

The push to institute mass circumcision in Africa, following the three randomized clinical trials (RCTs) conducted in Africa [3-5] , is based on an incomplete evaluation of real-world preventive effects over the long-term – effects that may be quite different outside the research setting and circumstances, with their access to resources, sanitary standards and intensive counseling. Moreover, proposals for mass circumcision lack a thorough and objective consideration of costs in relation to hoped-for benefits. No field-test has been performed to evaluate the effectiveness, complications, personnel requirements, costs and practicality of proposed approaches in real-life conditions. These are the classic distinctions between efficacy and effectiveness trials, and between internal validity and external validity [6].

Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction [7], without the surgical risks and complications of circumcision, and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering people’s behavioral patterns and exposing them and their partners to new or expanded risks [8] . Given these problems, circumcision of adults, and especially of children, by coercion or by false hope, raises human rights concerns.

You can read the article online here. You can download it here: Download mcnotavaccine.pdf.

This article states the case very well. Among the bullet points presented:

• All three of the studies were halted early
• The durations of the experiments were short
• No long-term follow-up has been or can be done
• A large number of participants were lost to follow-up
• Many infections appear to be from nonsexual sources

Other important confounding factors considered:

• Condom use and safe-sex practices were repeatedly reinforced
• Participants were provided 2 years of free medical care
• Participants were paid to participate
• Participants were solicited who wanted to be circumcised, and who may, therefore, not be representative of the general population
• The trials were conducted in atypically sanitary and well-resourced settings that are unlikely to be replicated in mass African circumcision campaigns   

The authors conclude:

Regardless of whether circumcision might offer some heterosexual males a partial degree of protection from HIV, numerous other issues need to be thoroughly considered before instituting mass circumcision campaigns.

In short, given the large number of unknowns, confounding factors and lack of long-term follow-up in the three RCTs, it is premature to recommend circumcision as an HIV-prevention strategy. Much more evidence must be gathered on real-world efficacy of male circumcision as a prevention tool before mass surgeries are implemented.

An objective scientific assessment must be conducted to determine if the three RCTs are applicable in real-world settings. And, to determine the true cost of a circumcision campaign, there must be a comprehensive resource analysis of the plan. These mass circumcision costs also must be compared with the opportunity costs of funding ABC campaigns.

As part of these assessments, the very real risks of circumcision surgery, including directly increasing HIV transmission to men as well as indirectly increasing transmission to women, surgical risks such as hemorrhage, other infections, meatal stenosis, need for repeat surgery and even death, must be considered.

Finally, the value and function of the foreskin as an integral part of the male sexual organ [31] and the ethical issues surrounding such surgery, including informed consent, the possibility of coercion and the dangerous implications of conveying erroneous messages of HIV immunity, must also be carefully considered in any analysis.

ABC programs offer nearly full protection from HIV infection, yet even if circumcision’s effectiveness matches the 50–60% effectiveness the RCTs reported, it only partially protects men, does not protect women at all, and leaves women more vulnerable to unsafe sex practices being forced upon them.

Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections.

The world community must cautiously review and carefully consider the long-term consequences of mass circumcision campaigns, from the risk of increasing deaths and infections to human rights violations. In the rush to save lives, many may instead be lost and human rights trampled in the stampede. Circumcision is not the panacea the world has been waiting for in the battle to stem the HIV crisis.

At long last, members of the academic and health policy community, a sector from which much of this is emanating, have stepped forward with a systematic analysis of the problems and issues associated with the widespread promotion of circumcision for the purposes of addressing the HIV epidemic. We need more like this one.

Comments

[Joe]

This is far and away the most rational article I've seen come out of the public health community since this whole mess started.

[SunkenShip]

Wonderful editorial. Thank God there are still a few people left in the public health field with intellect and common sense.