Confusion over circumcision

resources.
The confusion has been triggered by an article by Boyle & Hill (2011) which was published in the Australian Journal of Law and Medicine and was then reported locally by a number of newspapers. Boyle and Hill are anti-circumcision campaigners and Hill is vice president of an advocacy organisation called “Doctors Opposing Circumcision”.
Boyle & Hill (2011) attempt to undermine findings from the three landmark randomised controlled trials (RCTs) that demonstrated both individually and collectively that male circumcision reduces an individual man’s risk of acquiring HIV by 60 percent.
Long term follow up of trial participants in South Africa and Uganda shows that new HIV infections are reduced by over 70 percent among the men who were circumcised during the trials and that the benefits are sustained over more than five years.
Mathematical modelling suggests that if 80 percent of men in the 13 VMMC priority countries in Eastern and Southern Africa (Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe) are circumcised by 2015, four million new adult HIV infections will be averted with a net saving of over US$16 billion in anti-retroviral treatment costs.
From a scientific perspective, the reasoning in the Boyle and Hill paper is seriously flawed and ignores a wealth of credible and rigorous scientific research.
Not only do the three randomised trials already mentioned conclusively demonstrate the benefits of circumcision, but data from numerous observational studies dating back over the last 20 years clearly show that countries with the highest HIV prevalence were those with small proportions of circumcised men.
While it is true that in a few African countries HIV prevalence among circumcised men is higher than among uncircumcised men, this is the exception and not the rule. In West Africa where male circumcision is nearly universal, HIV has been circulating for years and no country has an HIV prevalence greater than six percent. It is worth noting that in the few countries where circumcision is associated with higher HIV prevalence, this is likely to be a false association.
In some African communities partial circumcision is conducted as part of cultural rites, however, only full circumcision (complete removal of the foreskin) is protective against HIV. In surveys done to assess the prevalence of circumcision, many rely on self-report rather than medical examination.
These findings should be interpreted with caution. A study conducted by Lilienfield & Graham as far back as 1958 demonstrated poor reliability of self-reported MC, in that study 34 percent of uncircumcised men reported being circumcised.
Boyle & Hill (2011) maintain that circumcision diverts resources from other known preventive measures such as condoms (which are 80 percent protective).
However, circumcision is being promoted in conjunction with condom promotion not instead of it. When WHO/UNAIDS recommended that VMMC be implemented in countries with high HIV but low MC prevalence, they made 10 other recommendations, which have policy and programmatic implications for rolling-out VMMC.
These include the recommendation that male circumcision should never replace other known HIV prevention methods, and should always be considered as part of a comprehensive HIV prevention package which includes among other measures, promoting abstinence from penetrative sex, encouraging reduction in number of sexual partners and providing HIV testing and counselling services.

l Webster Mavhu is a social scientist and consultant based in Zimbabwe. The views expressed in this article do not represent views of any organisation.