The Great Debate

Circumcision is Africa’s best weapon against AIDS

By Ezekiel Emanuel
December 1, 2011

By Ezekiel Emanuel
The opinions expressed are his own.

They are sitting on pews.  One side of the pews is open to the air and the other side is a non-descript, white closed door.  Sitting close to the door is a boy dressed in black sports warm-ups.  He has a somewhat anxious look on his face.  As I begin to ask him a question, a woman walks toward the pews wearing a bright yellow T-shirt with blue lettering that says: “Want to get smart?  Get circumcised.”

I am at the epicenter of the HIV/AIDS epidemic: southern Africa.  To be specific this is Gaborone, the capital of Botswana.  The HIV/AIDS prevalence is about 25% among young women.

The boy in the track warm-ups tells me he is 17 years old and in high school.  At his school, people had presented on male circumcision. His parents approved. Today, a school holiday, he came to wait for his turn to go behind the door. There is only thing he is scared of: the pain.

The door opens, his tall friend comes out not looking any worse or in pain from the procedure.  Indeed, he looks as if the only thing that happened was a discussion. As he opens the door, he jokes about his friend being next to get cut.

Several other boys from the same high school class are waiting and give a similar story.  While this location is not overflowing, all the seats in the pews are filled with men waiting to go through the door. And if what these high schoolers say is true, all their friends are, if not excited, still planning to come to the center in the next few weeks. Centers like this will take boys as young as 10 years old. Interestingly, there seems not to be a push to circumcise babies yet.

In Botswana, circumcisions are performed by physicians with nursing assistance. When they have three tables going at once, a physician can perform up to 30 circumcisions a day because they do the anesthetizing, the procedure, and the first few “anchor” sutures, leaving the nurses to finish the suturing and apply the dressing. The estimate is that Botswana needs to circumcise about 500,000 men, almost a quarter of the population.  While this might sound like a huge number, one doctor working 5 days a week for 50 weeks a year can do 7,500 circumcisions.

The story is much the same in South Africa. The health minister of Kwa Zulu Natal province talks about circumcision:  “They are lining up.  Every time we have a camp for circumcision, we have openings for 50 and 100 show up to get it done.”  According to the minister, endorsement from the Zulu king has had an enormous impact in getting the population to accept circumcision.

Unfortunately, ramping up to implement circumcision has been slow. Secretary of State Hillary Clinton recently announced that 1 million circumcisions have been performed over the last 4 years, three-quarters funded by the U.S. government.  This is just 4% of the number of circumcisions needed in sub-Saharan Africa. This seems disappointing. It has been four years since randomized controlled trials definitively showed that circumcision can reduce HIV transmission by 60%. And at $75 or so per procedure, circumcision is one of the great bargains in the fight against HIV/AIDS.   As many cynics have observed, if there were an HIV/AIDS vaccine as effective as circumcision, we would have been celebrating wildly and intensely pushing its production and distribution. Why has circumcision been treated differently?  Why has it taken so long to ramp up circumcision?

Myriad reasons are given.  The most common is cultural acceptance.  While Muslim men in northern Africa are circumcised, the argument goes, men in southern Africa aren’t.  That’s true, but not practicing circumcision in southern Africa is not the same thing as circumcision not being culturally acceptable.  The pews in Botswana and the reports by the Kwa Zulu Natal health minister suggest demand is not the problem.

The problem now seems to be a lack of supply of trained circumcision personnel and sites, and a lack of will to push forward with the same fervor seen for rolling out anti-retroviral drugs.  For years, success of the United States government HIV/AIDS global program has been measured by two numbers: the size of the President’s emergency AIDS relief budget and the number of people on ARVs in developing countries. And funding for prevention has been half that devoted to care and anti-retroviral treatment. The number of men circumcised has to be given the same level of prominence and attention as the number of anti-retroviral drugs.  We need to demand faster action on circumcision.

Circumcision is a fast, one-time and cheap procedure that is tremendously effective in the fight to prevent HIV/AIDS. What have we been waiting for? We cannot and should not wait 4 more years or we will squander a tremendous opportunity to turn the fight against AIDS around.

PHOTO: A Zimbabwean woman walks past a billboard promoting male circumcision to combat Aids in the capital, Harare, February 9, 2011. REUTERS/Philimon Bulawayo

18 comments so far | RSS Comments RSS

In the developed world, the U.S. has the highest rate of circumcision AND the highest incidence of HIV.

Posted by PapaDisco | Report as abusive

NO NO NO. Condoms are the best weapon against AIDS for Africans as well as for everyone else.

“There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”
http://www.measuredhs.com/pubs/pdf/CR22/ CR22.pdf

The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.
http://www.info.gov.za/issues/hiv/survey _2009.htm

From the committee of the South African Medical Association Human Rights, Law & Ethics Committee :
“the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission.”

The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw:
http://www.thelancet.com/journals/lancet  /article/PIIS0140-6736(09)60998-3/abstr act

ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

Posted by ml66uk | Report as abusive

How can circumcision be “the best” weapon against AIDS when it OBVIOUSLY does NOTHING to protect women – who are at the greater risk – against being infected by HIV+ men?

A study in Uganda – Wawer et al., Lancet 374:9685, 229-37 – started to find that circumcising men INcreases the risk to women, but they cut that one short for no good reason before it could be confirmed.

We also know that empowering women to look after their own safety is important, and circumcision DISempowers them, because circumcised men will think they are immune.

We can not even be certain that circumcising men offers them any protection. The claim still rests on the very tiny and shaky basis of 73 circumcised men who did not get infected in less than two years, after a total of 5,400 men were circumcised in three randomised trials (and 64 of them did get it). 137 non-circumcised men were infected, and that difference is the whole “proof”. Contacts were not traced so we don’t even know which, if any of them were infected by women or even by sex. 703 men dropped out, 327 of them circumcised, their HIV status unknown. No attempt was made to compensate for the dramatic effect the performance and results of a painful and marking operation might have on behaviour in the experimental group, but not the control group. So there are many reasons other than circumcision the infection of the 73 may have been delayed (not prevented).

In 10 of 18 countries for which USAID has figures (http://www.measuredhs.com/pubs/pdf/CR22  /CR22.pdf), more of the circumcised men have HIV than the non-circumcised. In Malaysia, 60% of the population is Muslim (the only circumcised people in that country) but 72% of HIV cases are Muslim. Shouldn’t that at least be explained before blundering on with mass circumcision programmes?

It is clear that soon we will hear “success stories” about circumcision that won’t mention the intensive counselling, provision of condoms and general consciousness-raising that will go with the operation. Like the nail in the Nail Soup folktale, circumcision will get all the credit.

Posted by Hugh7 | Report as abusive

Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. They have various flaws. Authorities that cite the studies have other agendas. Circumcision causes physical, sexual, and psychological harm. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Please see http://www.circumcision.org/hiv.htm for more information.

Posted by RGoldmanPhD | Report as abusive

Perleeze, look who’s posting this, his name is Ezekiel Emanuel. Take a wild guess at whether he’s been circumcised.

This means he can either look for excuses as to why this is a good thing, or he has to look between his legs and realize than a creepy old man held him down and cut on his genitals because a talking shrub supposedly told an ancestor to 4,000 years ago.

If he realized that it was probably done to Jews by Egyptians to mark them as slaves, it’d probably ruin his day.

Posted by WillowWisp | Report as abusive

@ ml66uk I agree that the best solution for Africa remains in promoting the ABC strategy as the damage that will be done by the misconception that circumcision is a surefire way to prevent HIV infection. This is as asinine as the Jacob Zuma prevention myth – have unprotected sex as long as you shower afterwards! What a load of crunk and this new initiative is just another example of the developed nations using Africa as their lab. There is no correlation between circumcision and HIV prevention

Posted by Revenimus | Report as abusive

Noooooo. Protection and education is the best fight against HIV. That alone is near 100 percent effective against spreading the disease to someone. What circumcision does is that it gives men a false sense of security. The fight is getting people to use condoms, not giving them reasons not to.

Posted by savvysearch | Report as abusive

Wrong, wrong wrong.
The people who write articles like this and are pushing circumcision have a heavy pro-circumcision cultural bias. (It does not take Sherlock Holmes to figure out which culture this author came from and his psychological motivations for writing such an article.)
The real purpose of these pro-circumcision campaigns is to create a generation that thinks the circumcised penis is “normal” and “cleaner” and “healthier” — the same nonsense that was promulgated in North America by the pro-circ nuts coming up with a new batch of “health benefits” of foreskin amputation every decade or so.
That spiel is not selling in North America so much any more, so they need to find new markets for their vile wares. The illiterate, superstitious Africans and their venal governments are the perfect patsies for the pro-circumcision cabal.
It turns out that one of the best protections against sexually transmitted disease, including HIV, is for both partners to wash their genitals with soap and clean water after an encounter. But the majority of Africans do not have access to clean water!
Africa’s best weapon against a plethora of diseases is to provide clean, reliable water to its population. Really want to do something to help Africans? Implement programmes helping them to create clean water supplies and infrastructure for themselves.

Posted by LocutaDeBjorg | Report as abusive

Wawer/Gray 2009: Circumcising Ugandan men made them 50% MORE likely to infect their partners with deadly HIV.

Bailey 2010: Circumcised Kenyan men no less likely to have HIV after all.

Most of the US men who have died of AIDS were circumcised at birth. The US with its mostly-cut adult population has three times the HIV incidence that mostly-intact Europe has. In Africa, half the nations show a markedly higher HIV incidence in the circumcised population.

Circumcising to fight AIDS is irrational and dangerous.

Posted by TLCTugger | Report as abusive

not only does circumcision do nothing to help prevent the woman from getting HIV, it does little or nothing to protect the male. men in Denmark and France generally are not circumcised, yet they get 1/10th the number of infections that mostly circumcised American and Israeli men get.
no one advocates that a circumcised man have sex without a condom. it simply is not safe. if you have to use a condom anyway to be safe, why get circumcised? it removes about 50% of the skin, and 60% of the nerves, of the male genitalia.
condoms work. they protect both partners.

Posted by TFT | Report as abusive

Has anyone mentioned the factor of prostitution in spreading HIV? Discouraging men from sleeping around with women who might have the virus might be the most effective method of all.

Posted by pat167 | Report as abusive

So Hillary Clinton is promoting the broadspread genital mutilation of baby boys?

There are people on sex offender registries for merely looking at pictures. Why is Clinton not on a similar registry?

Posted by gwallan | Report as abusive

Circumcision does not reduce HIV transmission. The studies that claimed it did have been soundly discredited. In large scale surveys and studies done on populations in areas where circumcision is common, circumcision has been found to INCREASE the rate of HIV acquisition by a factor of between about 1.1 (Swaziland) and 4 (Cameroon). Most countries that were tested fall somewhere between those values.

There is no population of circumcised men anywhere in the world that I’m aware of, in which the rate of HIV is lower than in the intact population. Far from preventing HIV, circumcision facilitates transmission of the virus.

Posted by Beery | Report as abusive

I’m appalled at the overwhelming amount of people who are anti-curcumcision, citing facts taken out of context, that do not even apply to this particular case. It’s obvious that most of you have only read the articles on the opposing views but not from a scientific journal. Most of the articles against circumcision focus almost completely on the human rights issue of newborns and then try to argue against it’s efficacy for prevention of HIV in adult African males. Then you present statistics about higher transmission rates from male to female and the rates being higher in the United States. First off, circumcision protects a male from contracting HIV from an already infected partner. So if male to female transmission rates are higher for circumcised males it is because the male already has HIV DUH! If you knew anything about the different strains of HIV you’d know that HIV 1 in the United states is much more virulent and much more infections then HIV 2 which resides in Africa. The chances of a male contracting HIV from Anal sex even while circumcised is far greater given that the exposure to blood from anal fissures is possible. Have we not even considered the fact that homosexual sex is probably prevalent but not spoken about. The fact of the matter is, HIV 2 has become such a huge problem in Africa that having Men circumcised will by no means exacerbate their situation and if by chance it could help them why the hell not? These are not infants being forced into circumcision, these are adults being asked if they’d like to try to something could possibly help protect them. I honestly have no strong opposing or supportive view myself, but what I do have is the knowledge about the science behind the procedure, the physiology of the foreskin, and the biology behind HIV 2. The fact of the matter is, is that these tribal people from Africa have for so long never used protection or maintained monogamous relationships, and to educate them and tell them that they should use condoms or stay with one person, would not make them any more inclined to do so even if they were circumcised or not. They are going to have unprotected sex with multiple partners anyways, because this is just human nature. Always has been and always will be. So if they can be circumcised under anesthesia and have even 10% protection then by all means do whatever it takes. That’s a hell alot better then what females get during female circumcision with no anesthesia and with no ability to have pleasurable sex.

Posted by serenite67 | Report as abusive

Female genital mutilation may be more disgusting than male genital mutilation, but that doesn’t make it something good.

The American Medical Association’s Policy on Circumcision says the following on the subject of HIV transmission:

“circumcision cannot be responsibly viewed as “protecting” against such infections.”

Posted by Thunker | Report as abusive

It is Serenite67 who is spouting a bunch of things without scientific back up. The first posters cited scientific publications to back up their words. Please back up your statements with some sort of proof, sir.

Posted by Wingnuts | Report as abusive

I am concerned. Although, I am aware of the studies showing a correlation between circumcised men and lower incidences of HIV infection, circumcision is NOT a real source of safety. Proof? How about all the men who ARE circumcised and are HIV positive? The ONLY way to prevent HIV infection is with SAFE SEX. This practice concerns me because it seems, people are being led to believe that if circumcised they have a free for all pass to have unprotected sex. I don’t understand why they are not advocating the use of condoms to do this. Also the added plus of a condom is pregnancy prevention. Something that I’m pretty sure is desired. I won’t go into the human rights aspect of the issue, because these men are old enough to understand, not like a baby. However, the concern is the MAGIC SOLUTION aspect of this, and the misleading information being spread. No, as Serenite67 said, they won’t suddenly start being monogamous or using condoms, but with enough information, the practice can take hold. Condoms were hardly used in the US in the 60′s and now their use is widespread. In addition, the article mentions a prevalence of 25% amongst the women. Who or what is protecting them? Only condoms can protect a woman!

Posted by Marileana | Report as abusive

As a development economist, I can personally attest that numbers and statistics are very powerful. Numbers that are based on data collected in a sound and scientific manner, when interpreted properly, can provide key insights into solutions for difficult problems. If the collection of that data is questionable, or when interpreted improperly, numbers can be dangerously misused by policy makers and individuals. I am nervous that the claim that circumcision is 60% effective against preventing HIV, because it a) may not be valid, and b) might mislead people considering circumcision. A quick Google search generates several scientific articles which call into question whether circumcision is effective, and some suggest that circumcision may actual INCREASE the transmission rate of HIV. I will leave it to others to hash out whether circumcision is effective or not, but one thing that I find missing from the discussion thus far is consideration of the likelihood of getting HIV even if circumcision IS effective.

To explore this, let’s play a fun game with numbers. The object of the game? To find out what the probability of contracting HIV is over time, having unprotected sex, with a circumcision. This is the “best case scenario” which assumes that circumcision is as effective as what is implied in this article. Let’s first gather some basic stats to start with:

– A number of websites have suggested that the chances of transmitting HIV with vaginal sex are about 1/1000 (i.e. probability of contracting is 0.001).

– According to this article, about 25% of adults in Botswana have HIV (i.e. the odds of having sex with an infected person is 1/4, or 0.25).

– For the sake of this game, let us assume that this article is correct, and that circumcision is 60% effective (0.6).

– Let us calculate these odds for someone who has sex once a week with different partners (i.e. 52 times per year) over a 10 year period (i.e. 520 times)

For those who are a bit rusty with their stats, the formula to calculate these odds is:

Prob(Contracting HIV) = 1 – Prob( Not Contracting HIV)^(# of times having sex)

For unprotected sex, with no circumcision, to odds of contracting HIV is:

Prob(Contracting HIV) = 1 – (1-(0.001*0.25*(1-0.6))^520)

= 1 – (1-(0.00025*(0.4))^520)
= 1 – 1-0.0001)^520)
= 1 – (0.949)
= 0.01 ; or just over 5%

This means that even if circumcision is as effective as this article suggests, the odds of contracting HIV after 10 years is 5%. The average age that males and females start having sex in Africa is around 15-16. This means that EVEN IF ALL MALES WERE CIRCUMSIZED SINCE BIRTH, 1 out of 20 persons who are sexually active from this age would contract HIV by the age of 25; 1 in 10 would contract it by the age of 35! 1 out of 10! That’s IF circumcision is as effective as this article suggests. In my opinion, that is a very big IF. If circumcision is not effective (as others have suggested) that number jumps up to over 1 in 5 people contracting HIV by the age of 35!

Now it would be irresponsible not to remind readers to take these numbers in context. These probabilities depend entirely on the numbers that get put in to the formula. The probabilities will change depending the actual effectiveness of circumcision, how often someone has sex, and who a person is having sex with. Remember that WITH or WITHOUT circumcision, it is always possible to contract HIV even if you only have sex once.

So, what’s the point of this? The purpose of this exercise is to get people to realize that there are still potentially VERY HIGH consequences to having unprotected sex. Even if circumcision is 60% effective, it doesn’t mean that getting a circumcision will prevent you from getting HIV. In the BEST CASE scenario, there is still a 10% chance that you will contract HIV by the age of 35. That does not seem promising to me.

I invite those considering circumcision to try entering in their own numbers into the formula for the number of times having sex, the effectiveness of circumcision, the percent of people that have HIV (recall that it might be higher than 0.25, especially among prostitutes). I think that even with circumcision, that risk of unprotected sex is just too great.

***NOTE: Once again, please remember that this is just a mental exercise to shed light on this issue. Please do not rely solely on this information when making choices for safer sex; read as much as you can before making a smart and informed decision ***


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