Male circumcision

Muula AS, Prozesky HW, Mataya RH, Ikechebelu JI. Prevalence of complications of male circumcision in Anglophone Africa: a systematic review. BMC Urol 2007;7:4.

egypt.jpgThere is growing evidence that male circumcision (MC) prevents heterosexual acquisition of HIV by males in sub-Saharan Africa, the region of the world heavily affected by the HIV pandemic. While there is growing support for wide-spread availability and accessibility of MC in Africa, there is limited discussion about the prevalence of physical complications of male circumcision on the continent. A systematic literature search and review of articles in indexed journals and conference abstracts was conducted to collect and analyze prevalence of complications of MC in Anglophone sub-Saharan Africa. Information extracted included: indications for MC, complications reported, age of patients and category of circumcisers. There were 8 articles and 2 abstracts that were suitable for the analysis. The studies were not strictly comparable as some reported on a wide range of complications while others reported just a limited list of possible complications. Prevalence of reported complications of MC ranged from 0% to 50.1%. Excluding the study with 50.1%, which was on a series of haemophilia patients, the next highest prevalence of complications was 24.1%. Most of the complications were minor. There was no firm evidence to suggest that MCs performed by physician surgeons were associated with lower prevalence of complications when compared with non-physician health professionals. Muula and colleagues conclude that the available data are inadequate to obtain a reasonable assessment of the prevalence of complications of MC in sub-Saharan Africa. Some of the available studies however report potentially significant prevalence of complications, though of minor clinical significance. This should be considered as public health policy makers consider whether to scale-up MC as an HIV preventative measure. Decision for the scale-up will depend on a careful cost-benefit assessment of which physical complications are certainly an important aspect. There is need for standardized reporting of complications of male circumcision.

Editors’ note: As part of the UN work plan on male circumcision, work is proceeding on the development of monitoring and evaluation tools to be used on a continuous basis for quality assurance and improved surgical outcomes for medical circumcision. It is important to note that this particular study reviews complication rates for medical circumcision performed by physicians or other health care providers; these rates are considerably lower than those for traditional circumcision.

Nagelkerke NJD, Moses S, de Vlas SJ, Bailey RC. Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa. BMC Infectious Diseases 2007;7:16.

Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear. Two mathematical models were examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya. In both models, male circumcision programs resulted in large and sustained declines in HIV prevalence over time among both men and women. Men benefited somewhat more than women, but prevalence among women was also reduced substantially. With 80% male circumcision uptake, the reductions in prevalence ranged from 45% to 67% in the two countries, and with 50% uptake, from 25% to 41%. It would take over a decade for the intervention to reach its full effect. Nagelkerke and colleagues conclude that large-scale uptake of male circumcision services in African countries with high HIV prevalence, and where male circumcision is not now routinely practised, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.

Editors’ note: Modelling the population level impact of a new HIV prevention technology, in this case male circumcision, on HIV prevalence helps better understand the coverage (in this case 50% and 80%) needed to produce important declines in HIV prevalence. Such a model assumes that no significant risk compensation or enhancement occurs and that male circumcision truly is part of combination prevention. Social change campaigns to create new masculine social norms need to convey protection and prevention as ‘real man’ attributes, e.g. I’m circumcised and I use condoms every time’, ‘I’m circumcised and I’m staying with my partner’, I’m circumcised and I’m waiting to start sex’.

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