0844 Should male circumcision be incorporated into anti-HIV/AIDS policies?

At the time of writing this summary the media are reporting that the Health Dept is considering including male circumcision in its HIV/AIDS policies while a current edition of the South African Medical Journal carries a research paper and two commentaries on the inappropriateness of the procedure as a strategy to reduce HIV transmission. The debate has raged for some time but seemed to settle somewhat when a Cochrane review in 2003 found no conclusive evidence for an effect. However there were no randomized controlled studies (RCTs) available for inclusion in that review and the pendulum swung the opposite way when three RCTs from Africa (South Africa, Uganda, Kenya) showed a 50-60% reduction in HIV conversion rates among adolescent and young adult males who were randomized into control or intervention groups and followed up for 21-24 months. The international community celebrated the results and changes to prevention policies were recommended. The article in the South African Medical Journal is a 2002 population survey that sought history of circumcision (neonatal vs later) and HIV/AIDS conversion rates vs controls. In this study there were no differences between control and study groups, irrespective of whether the procedure was carried out early or late. Contradicting these results are observations showing a poor correlation between circumcision rates in South Africa’s nine provinces and the HIV transmission rates in those provinces, and also that there is considerable heterogeneity for the effect of circumcision across African countries. In other words there is a suggestion that the RCTs may not be generalisable to other regions. The commentaries in the South African Medical Journal argue strongly that circumcision is not justified in this situation and that it might lead to greater transmission rates because males develop a false sense of security, almost regarding the procedure as an immunization and ignoring condoms as a means of prevention. Combining these various opinions it seems that there may be promotion of late male circumcision in South Africa, but particularly since the procedure is illegal before 16 years of age (except when done as a religious ritual) it is unlikely that new policies will include routine neonatal circumcision.

Read more:
SAMJ 2008; 98: 762-4 and 781-2 and 789-94
Afr J AIDS Res 2008; 7: 1-8