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Welcome to AIDSCirc.org, a website devoted to the collection of research, news and information on the subject of HIV/AIDS and circumcision.

This site was created to fill the void that existed when researchers, instructors, parents and advocates alike sought one location to access a large compilation of diverse literature on the HIV/AIDS and circumcision debate.

The majority of research and news presented here is housed on other sites, or can be found published in a variety of professional journals. AIDSCirc.org serves as a bouncing-off point for further investigation into the subject, and a window into current commentary from a wide variety of sources on the topic.


New H.I.V. Cases Falling in Some Poor Nations, but Treatment Still Lags

New infections with H.I.V. have dropped by half in the past decade in 25 poor and middle-income countries, many of them in Africa, the continent hardest hit by AIDS, the United Nations said Tuesday.
The greatest success has been in preventing mothers from infecting their babies, but focusing testing and treatment on high-risk groups like gay men, prostitutes and drug addicts has also paid dividends, said Michel Sidibé, the executive director of the agency U.N.AIDS.
“We are moving from despair to hope,” he said.
Despite the good news from those countries, the agency’s annual report showed that globally, progress is steady but slow. By the usual measure of whether the fight against AIDS is being won, it is still being lost: 2.5 million people became infected last year, while only 1.4 million received lifesaving treatment for the first time.
“There has been tremendous progress over the last decade, but we’re still not at the tipping point,” said Mitchell Warren, the executive director of AVAC, an advocacy group for AIDS prevention. “And the big issue, sadly, is money.”
Some regions, like Southern Africa and the Caribbean, are doing particularly well, while others, like Eastern Europe, Central Asia and the Middle East, are not. Globally, new infections are down 22 percent from 2001, when there were 3.2 million. Among newborns, they fell 40 percent, to 330,000 from 550,000.
The two most important financial forces in the fight, the multinational Global Fund for AIDS, Tuberculosis and Malaria and the domestic President’s Emergency Plan for AIDS Relief, were both created in the early 2000s and last year provided most of the $16.8 billion spent on the disease. But the need will soon be $24 billion a year, the groups said.
“Where is that money going to come from?” Mr. Warren asked.
The number of people living with H.I.V. rose to a new high of 34 million in 2011, while the number of deaths from AIDS was 1.7 million, down from a peak of 2.3 million in 2005. As more people get life-sustaining antiretroviral treatment, the number of people living with H.I.V. grows.
Globally, the number of people on antiretroviral drugs reached 8 million, up from 6.6 million in 2010. However, an additional 7 million are sick enough to need them. The situation is worse for children; 72 percent of those needing pediatric antiretrovirals do not get them.
New infections fell most drastically since 2001 in Southern Africa — by 71 percent in Botswana, 58 percent in Zambia and 41 percent in South Africa, which has the world’s biggest epidemic.
But countries with drops greater than 50 percent were as geographically diverse as Barbados, Cambodia, the Dominican Republic, Ethiopia, India and Papua New Guinea.
The most important factor, Mr. Sidibé said, was not nationwide billboard campaigns to get people to use condoms or abstain from sex. Nor was it male circumcision, a practice becoming more common in Africa.
Rather, it was focusing treatment on high-risk groups. While saving babies is always politically popular, saving gay men, drug addicts and prostitutes is not, so presidents and religious leaders often had to be persuaded to help them. Much of Mr. Sidibé’s nearly four years in his post has been spent doing just that.
Many leaders are now taking “a more targeted, pragmatic approach,” he said, and are “not blocking people from services because of their status.”
Fast-growing epidemics are often found in countries that criminalize behavior. For example, homosexuality is illegal in many Muslim countries in the Middle East and North Africa, so gay and bisexual men, who get many of the new infections, cannot admit being at risk. The epidemics in Eastern Europe and Central Asia are driven by heroin, and in those countries, methadone treatment is sometimes illegal.
Getting people on antiretroviral drugs makes them 96 percent less likely to infect others, studies have found, so treating growing numbers of people with AIDS has also helped prevent new infections.
Ethiopia’s recruitment of 35,000 community health workers, who teach young people how to protect themselves, has also aided in prevention.
Mr. Sidibé acknowledged that persuading rich countries to keep donating money was a struggle. The Global Fund is just now emerging from a year of turbulence with a new executive director, and the American program has come under budget pressures. Also, he noted, many countries like South Africa and China are relying less on donors and are paying their own costs. The number of people on treatment in China jumped 50 percent in a single year.
Mr. Warren’s organization said in a report on Tuesday that the arsenal of prevention methods had expanded greatly since the days when the choice was abstain from sex, be faithful or use condoms. Male circumcision, which cuts infection risk by about 60 percent, a daily prophylactic pill for the uninfected and vaginal microbicides for women are in use or on the horizon, and countries need to use the ones suited to their epidemics, the report concluded.

Believing Circumcision Prevents HIV, Malawi Men Go on 'Sex Spree'

By Danelle Frisbie
Read More

Adult man reads about the 'benefits' of circumcision while undergoing the surgery with local anesthesia.
Photo by Amnon Gutman.

According to news out of Malawi, men who undergo circumcision are buying into the myth that they are now protected from HIV. As a result, many of the local men in Mangochi have gone on 'sex sprees,' participating in sexual intercourse with multiple partners, without condoms, all the while claiming they are now immune to HIV. 

The Malawi Voice reports that Dickens Mahwayo of Given Secrets Consultants detests the misinformation being given to men across Malawi. This past weekend at the College of Medicine (COM) Research Conference, Mahwayo told colleagues that he has found most men believe circumcision to be a license to have unprotected sex with anyone they choose. "What is most saddening is that most circumcised men are now engaging in unprotected sex, claiming they are immune to HIV." 

Mahwayo's research demonstrates that the vast majority, 74% of men, state that they no longer use any form of protection after being circumcised. In addition, 58% of female sex workers do not require their male partners to use condoms if they have been circumcised. 

Compounding the problem already in epidemic proportions is that circumcised men now pay significantly less for services from sex workers. "Circumcised men are now charged peanuts for sex compared to [intact] men," stated Mahwayo. Believed to be 'less of a risk' and easier to deal with, men who have undergone circumcision are given a break on cost. This spurs more men to sign up for circumcision under the guise that it will equal more sex, without any risk. 

The rate of intercourse with multiple partners is increasing, as is the rate of intercourse without any form of protection. This false sense of 'HIV prevention' that current campaigns to cut in Africa pose are bringing about greater rates of the virus now spreading at an alarming rate due to these cultural myths and practices. 

~~~~
Source:  Saving Our Sons

More than Foreskin: Circumcision Status, History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in Puerto Rico

Published in: The Journal of Sexual Medicine Volume 9, Issue 11, pages 2933–2937, November 2012 

ABSTRACT


Introduction.  Circumcision among adult men has been widely promoted as a strategy to reduce human immunodeficiency virus (HIV) transmission risk. However, much of the available data derive from studies conducted in Africa, and there is as yet little research in the Caribbean region where sexual transmission is also a primary contributor to rapidly escalating HIV incidence.
Aim.  In an effort to fill the void of data from the Caribbean, the objective of this article is to compare history of sexually transmitted infections (STI) and HIV diagnosis in relation to circumcision status in a clinic-based sample of men in Puerto Rico.
Methods.  Data derive from an ongoing epidemiological study being conducted in a large STI/HIV prevention and treatment center in San Juan in which 660 men were randomly selected from the clinic's waiting room.
Main Outcome Measures.  We assessed the association between circumcision status and self-reported history of STI/HIV infection using logistic regressions to explore whether circumcision conferred protective benefit.
Results.  Almost a third (32.4%) of the men were circumcised (CM). Compared with uncircumcised (UC) men, CM have accumulated larger numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P = 0.048), have higher rates of previous diagnosis of warts (CM = 18.8% vs. UC = 12.2%; P = 0.024), and were more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results indicate that being CM predicted the likelihood of HIV infection (P value = 0.027).
Conclusions.  These analyses represent the first assessment of the association between circumcision and STI/HIV among men in the Caribbean. While preliminary, the data indicate that in and of itself, circumcision did not confer significant protective benefit against STI/HIV infection. Findings suggest the need to apply caution in the use of circumcision as an HIV prevention strategy, particularly in settings where more effective combinations of interventions have yet to be fully implemented. 
Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, and García H. More than foreskin: Circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med 2012;9:2933–2937.

What does circumcising men do to women’s HIV risk?



Advocates for mass male circumcision have paid insufficient attention to protect women. Here are two ways these programs increase women’s risks for HIV.

Not protecting women from high risk to get HIV from a newly circumcised, HIV-positive partner

Only one study has followed wives of newly circumcised HIV-positive men to see what happens to their wives. That study, in Uganda, 2003-07, circumcised some HIV-positive men and left others intact, and then followed and tested their wives from time to time to see who got HIV. Over several years, wives of men circumcised for the study were 1.49 times more likely to get HIV than wives whose husbands remained intact (see Table below). Wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV within 6 months after their husbands were circumcised.
Despite this risk, UNAIDS recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[i] Donors and governments follow this advice – circumcising men without requiring them to take an HIV first and, if found to be HIV-positive, to bring their wives for couple counseling before proceeding with the circumcision.

Allowing women (and men) to think sex without condoms with a partner who may be HIV-positive is safe

Such beliefs conflict with available evidence. According to three studies, even with healed wounds, circumcised men transmit HIV to women. Whether they do so faster or slower than intact men is unknown. Two out of 3 studies that followed discordant couples — with HIV-positive men and HIV-negative wives – report that intact men transmit faster than circumcised men. The third study reports the opposite: that circumcised men transmit faster than intact men — not only in the first 6 months after circumcision, but continuing for the next 18 months as well (when the study ended).
Faster or slower? The jury is out. But what is clear from these studies is that women who want to be safe — not just safer — need to continue to use condoms with men who may be HIV-positive, whether they are circumcised or intact.
Table: Rate of new HIV infections (incidence) in women with HIV-positive partners who are circumcised or intact
Countries, yearsNew infections (%/year) in women whose partners are:Relative risk for HIV in women with circ’d vs intact partners
circ’edintact
Uganda, 1994-98[ii]5.213.20.39
Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, Zambia, 2004-08[iii]2.043.470.61
Uganda, 2003-07[iv]14.18.71.49

[i] Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf (accessed 1 December 2011).
[ii] Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. AIDS 2000; 14: 2371-2381.
[iii] Baeten JM, Donnell D, Kapiga SH, et al. Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples. AIDS 2010; 24: 737-744.
[iv] Wawer MJ, Makumbi F, Kigozi G, et al. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomized controlled trial. Lancet 2009; 374: 229-237.

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HIV/AIDS and circumcision: lost in translation

Marie Fox, Michael Thomson

School of Law, Keele University,
Staffordshire, UK
Correspondence to
Marie Fox, School of Law, Keele
University, Staffordshire ST5
5BG, UK;
m.fox@law.keele.ac.uk
Received 30 June 2010
Accepted 13 August 2010


ABSTRACT
In April 2009 a Cochrane review was published
assessing the effectiveness of male circumcision in
preventing acquisition of HIV. It concluded that there
was strong evidence that male circumcision, performed
in a medical setting, reduces the acquisition of HIV by
men engaging in heterosexual sex. Yet, importantly, the
review noted that further research was required to
assess the feasibility, desirability and cost-effectiveness
of implementation within local contexts. This paper
endorses the need for such research and suggests that,
in its absence, it is premature to promote circumcision
as a reliable strategy for combating HIV. Since articles in
leading medical journals as well as the popular press
continue to do so, scientific researchers should think
carefully about how their conclusions may be translated
both to policy makers and to a more general audience.
The importance of addressing ethico-legal concerns that
such trials may raise is highlighted. The understandable
haste to find a solution to the HIV pandemic means that
the promise offered by preliminary and specific research
studies may be overstated. This may mean that ethical
concerns are marginalised. Such haste may also obscure
the need to be attentive to local cultural sensitivities,
which vary from one African region to another,in
formulating policy concerning circumcision.

http://bmj-jme.highwire.org/content/36/12/798.abstract

Rolling out male circumcision as a mass HIV/AIDS intervention seems neither justified nor practicable

Two articles1,2 published in this issue address male circumcision (MC).
Connolly et al.1 show in a national survey that MC, whether pre-pubertal or post-pubertal, has no protective effect on acquisition by males of HIV infection as measured by prevalence.
Sidler et al.2 state that neonatal MC continues to be promoted without adequate justification as a medicalised ritual, via an HIV prevention rationale. They caution that for MC to be a therapeutic as opposed to a non-therapeutic procedure, it is necessary to gather more corroborative and consistent evidence of its benefit, consider the potential harms (psychological, sexual, surgical and behavioural/disinhibition), examine the ethical implications, and examine effectiveness and efficiency (costs and benefits) at the population and societal levels. They point out that MC is not just a technical surgical intervention – it takes place in a social context that can radically alter the anticipated outcome. At the 2008 International AIDS Conference3 in Mexico cultural, political and educational issues raised by the intervention, such as decreased condom use and marginalisation of women, were hotly debated. Some cultural interpretations may view MC as a licence to have unprotected sex. A case in point is Swaziland, where men are flocking to be circumcised with the understanding that this means they no longer need to use other preventive methods (e.g. wear condoms or limit the number of sexual partners).4
The 2003 Cochrane review5 of observational studies of MC effectiveness concluded that there was insufficient evidence to support it as an anti-HIV intervention. Three randomised controlled trials (RCTs) from South Africa, Kenya and Uganda in 2006 - 2007 show a protective effect of MC. However, Garenne6 has subsequently shown from observational data that there is considerable heterogeneity of the effect of MC across 14 African countries. Despite the South African RCT showing a protective effect, he reports for the nine South African provinces that ‘there is no evidence that HIV transmission over the period 1994 - 2004 was slower in those provinces with higher levels of circumcision’. Interestingly, in both Kenya and Uganda, where two of the RCTs were done, a protective effect of MC was observed, but a harmful effect was observed in Cameroon, Lesotho and Malawi. The other eight countries showed no significant effect of MC.
These somewhat discordant findings are difficult to interpret. While RCTs are theoretically strong designs, it is conceivable that their findings are not generalisable beyond their settings. Furthermore, there have been no trials of neonatal MC. Study flaws such as inability to obtain double blinding, and loss to follow-up in RCTs, may effectively degrade their quality to that of observational studies. Meanwhile other disturbing findings referred to by Sidler et al. are emerging, including the reported higher risk for women partners of circumcised HIV positive men, disinhibition, urological complications, relatively small effect sizes of MC at the population level, and relative cost-inefficiency of MC.
Not all objections to MC as an HIV intervention have to do with evidence of effectiveness or cost. Sidler et al. raise ethical objections. Owing to the current climate of desperation with regard to the HIV epidemic, evidence in favour of MC frequently seems overstated. This reduces the scope for informed consent and autonomy for adult men considering the procedure. Further problems arise in the case of neonates whose parents may be considering the procedure. Whereas informed consent is at least possible for adult men, it is clearly not possible for neonates. Parents can only guess what the child’s wishes would be if he were presented with the information they have at their disposal. If it could be shown that circumcision was necessary in the neonatal period, parental consent on behalf of the neonate would be justified. But since no valid surgical indications for circumcision exist in this period, and the future benefit to the child in respect of HIV avoidance is not relevant before sexual debut, the duty of parents may well be to err on the side of caution, and defer the procedure until the child can make an autonomous decision. In the absence of compelling indications, a procedure such as circumcision could also be seen as a violation of the child’s right to bodily integrity. Furthermore, the ethical principle of non-maleficence cannot be upheld as there are clear harms attached to this practice, to which Sidler et al. refer in their article. Lastly, at a societal level MC may be unjust insofar as it could compete for resources with more effective and less costly interventions7 and disadvantage women.
Despite a strong pro-circumcision lobby driven by enthusiasts who have been promoting MC as an (HIV) intervention for many years, and impatience expressed by protagonists about the long delay after the 2006 - 2007 RCT results and the UNAIDS/WHO policy recommendations8 of March 2007, few mass campaigns have been launched in African countries.
Given the epidemiological uncertainties and the economic, cultural, ethical and logistical barriers, it seems neither justified nor practicable to roll out MC as a mass anti-HIV/AIDS intervention.
A Myers
Humanities student, University of Cape Town
J Myers
School of Public Health and Family Medicine
University of Cape Town

Corresponding author: J Myers (jmyers@iafrica.com)
References
  1. Connolly C, Simbayi LC, Shanmugam R, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results from a national survey in 2002. S Afr Med J 2008; 98: 789-794.
  2. Sidler D, Smith J, Rode H. Neonatal circumcision does not reduce HIV infection rates. S Afr Med J 2008; 98: 764-766.
  3. Male Circumcision: To Cut or Not to Cut (dedicated session, 7 August). AIDS 2008 – Mexico City 3-8 August 2008 – XVII International AIDS Conference. http://www.aids2008.org/Pag/ PSession.aspx?s=41 (last accessed 8 August 2008).
  4. Swaziland: Circumcision gives men an excuse not to use condoms. http://www.irinnews. org/Report.aspx?ReportId=79557 (last accessed 7 August 2008).
  5. Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003362. DOI: 10.1002/14651858.CD003362.
  6. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research 2008; 7(1): 1-8.
  7. New study shows condoms 95 times more cost-effective than circumcision in HIV battle. http://www.prweb.com/releases/2008/08/prweb1151894.htm (last accessed 7 August 2008).
  8. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, 6 - 8 March 2007. Conclusions and Recommendations. http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf (accessed 25 August 2008).
http://www.cirp.org/library/disease/HIV/myers2008/

Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002

Catherine Connolly, Leickness C Simbayi, Rebecca Shanmugam, Ayanda Nqeketo


Objective. To investigate the nature of male circumcision and
its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3 025 men aged 15 years
and older who participated in the first national populationbased
survey on HIV/AIDS in 2002. Chi-square tests and
Wilcoxon rank sum tests were used to identify factors
associated with circumcision and HIV status, followed by a
logistic regression model.
Results. One-third of the men (35.3%) were circumcised. The
factors strongly associated with circumcision were age >50,
black living in rural areas and speaking SePedi (71.2%) or
IsiXhosa (64.3%). The median age was significantly older
for blacks (18 years) compared with other racial groups (3.5
years), p <0.001. Among blacks, circumcisions were mainly
conducted outside hospital settings. In 40.5% of subjects,
circumcision took place after sexual debut; two-thirds of
the men circumcised after their 17th birthday were already
sexually active. HIV and circumcision were not associated
(12.3% HIV positive in the circumcised group v. 12% HIV
positive in the uncircumcised group). HIV was, however,
significantly lower in men circumcised before 12 years of
age (6.8%) than in those circumcised after 12 years of age
(13.5%, p=0.02). When restricted to sexually active men, the
difference that remained did not reach statistical significance
(8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for
possible confounding.
Conclusion. Circumcision had no protective effect in the
prevention of HIV transmission. This is a concern, and has
implications for the possible adoption of the mass male
circumcision strategy both as a public health policy and an
HIV prevention strategy.
S Afr Med J 2008; 98: 789-794

http://www.ncbi.nlm.nih.gov/pubmed/19115756

The Cost to Circumcise Africa

RYAN G. MCALLISTERa JOHN W. TRAVISb
DAN BOLLINGERc CLAIRE RUTISERc VEERARAGHAVAN SUNDARc
a Georgetown University bWellness Associates c Independent Researchers


Male circumcision employed as a prophylactic surgical intervention for HIV transmission
reduction has been publicized in the media following recent results from
observational trials conducted in Africa. Yet in all of the discussions concerning
circumcision as a public health initiative, including a cost analysis performed on
circumcision as a prophylactic for reducing HIV transmission in Africa, none estimates
the endeavor’s scope or cost. Given the scale of the economics involved
in and the number of competing strategies available for addressing the HIV epidemic,
funding and cost effectiveness are vital concerns in the field. This raises the
question of which treatments and methodologies to fund, or not. In this study, we
use circumcision costs, census, and demographic data available from government
agencies and other published sources to estimate the cost to circumcise all HIVnegative
African adult males, including costs of complications. We compare that
cost to another androcentric penile alteration: using condoms (including their purchase
and distribution costs). Our findings suggest that behavior change programs
are more efficient and cost effective than surgical procedures. Providing free condoms
is estimated to be significantly less costly, more effective in comparison to
circumcising, and at least 95 times more cost effective at stopping the spread of
HIV in sub-Saharan Africa. In addition, condom usage provides protection for
women as well as men. This is significant in an area where almost 61% of adults
living with AIDS are women.

Read full text here.

Circumcision: A case of all or nothing?


By Mia Malan


More than half of South African men are now ­circumcised and most of them have been circumcised fully; in other words, the entire foreskin of their penises has been removed, not just part of it. That is according to the third "National HIV Communication Survey", the results of which were released at the International Aids Conference in Washington DC in the United States this week.
Research has shown that men who are fully circumcised are 60% less likely to acquire HIV from their female partners than uncircumcised men. Over time, this preventive benefit increases. A South African study has shown that circumcision reduces men's risk of getting infected with HIV by up to 76% after three years.
About 10000 respondents between the ages of 16 and 55 across all nine provinces were interviewed for the survey between February and May this year. Men were asked whether they had been circumcised and shown ­pictures of full, partial and uncircumcised penises. They then had to identify which picture resembled their penis best.
The study, which was jointly conducted by Johns Hopkins Health and Education South Africa, loveLife and Soul City, revealed that, of the men in the country who had been circumcised, 48.1% had been circumcised medically and 50.1% traditionally. Of those who had been traditionally circumcised, nine out of 10 said they had their entire foreskin removed.
The findings that male circumcision reduces men's risk of getting infected with HIV are based on findings in which study participants' entire foreskin was taken off. A concern with traditional circumcision practice is that none or only part of the foreskin is often removed. The effect of partial foreskin removal on HIV acquisition is unknown.
Communication survey
A study by the Desmond Tutu HIV Centre at the University of Cape Town, which was published in last month's South African Medical Journal, produced notably different results to those of the communication survey. Of about 200 mostly Xhosa men from Nyanga outside Cape Town who were enrolled in the study, 74% reported that they had been traditionally circumcised. Upon medical examination, it emerged that 27%, a percentage almost three times higher than that reported by the communication survey, had some or all of their foreskin remaining. Fourteen per cent (27) of the study participants were HIV infected, of whom most (21) reported that they had been traditionally circumcised.
According to research co-author Professor Linda-Gail Bekker, the difference in results could be attributed to the Cape Town study being focused on a much smaller sample and only on Xhosa men, whereas the communication survey was a national study involving men from several ethnic groups that might have different circumcision practices to those of Xhosa men.
Another difference was that the men in Bekker's study were medically examined – a doctor checked whether every participant's self-reported circumcision was indeed a full circumcision. In the communication survey, no medical assessments were done and the results were based on the men's own perception of the state of their penises.
The national HIV communication survey revealed that there was a huge increase in knowledge about the HIV-reduction benefits of medical male circumcision, with 47% of men and women now knowing that medical male circumcision reduced the risk of HIV infection, compared with 8% in 2009.
According to the survey, about one million men intend to get circumcised within the next year and 80.5% of them would prefer to be medically circumcised. However, although 66% of men in the South African Medical Journal study were aware of the preventive benefit of medical circumcision, most were unwilling to undergo it, stating religion, culture, notions of manhood and social disapproval as reasons.
Simplifying the procedure
According to health department deputy director general Dr Yogan Pillay, 529520 medical circumcisions have been conducted in South Africa.
"Once we have World Health Organisation-approved medical male circumcision devices, which we expect late this year or early next year, we intend to train traditional circumcisers to use them so that we are able to better ensure that men who are circumcised traditionally have their entire foreskin removed," he said.   
Medical circumcision devices make it possible to do bloodless circumcisions and simplify the procedure hugely. Studies have shown that one such device, the PrePex, can be  administered safely by junior nurses without the supervision of doctors.
But such devices first need to be vetted by the WHO, entailing an extensive scientific review and trial process, before large donors will fund their use  
Health Minister Dr Aaron Motsoaledi, who attended the launch of the communication survey results, said his department would do whatever it took to ensure that all South African men in need of medical circumcision were given access to it.
According to mathematical modelling studies, 20% of new HIV infections in South Africa will be averted by 2025 if 4.3-million men between the ages of 15 and 49 are fully circumcised by 2015.
"We need to meet demand, but must also ensure that circumcised men know they should still use condoms because the procedure is not foolproof protection against HIV," Motsoaledi said.  
Mia Malan works for the ­Discovery Health Journalism Centre at ­Rhodes University

Africa's male circumcision crusade: Boon or boondoggle?


By Judy Mandelbaum
View Original


Just imagine that a simple, harmless, one-time medical procedure could provide you, your loved ones, and all your neighbors with lifetime protection from a deadly epidemic. You’d sign up for it right away, wouldn’t you?
This is precisely what the World Health Organization, the Bill & Melinda Gates Foundation, and countless other NGOs and government programs are offering the continent of Africa: A comprehensive adult male circumcision campaign aimed at stemming the devastating HIV/AIDS epidemicAccording to the WHO, “Medical male circumcision reduces the risk of female-to-male sexual transmission of HIV by approximately 60%.” Moreover,
Medical male circumcision offers excellent value for money in such settings. It saves costs by averting new HIV infections and reducing the number of people needing HIV treatment and care. A one-time intervention, medical male circumcision provides men life-long partial protection against HIV as well as other sexually transmitted infections.
Thanks to the WHO’s lobbying and financing efforts, countries across Africa are submitting thousands of their male citizens to the operation. Uganda, which has a 6.5% adult infection rate, launched a giant voluntary circumcision program in 2010. In June, 2012, ten Zimbabwean parliament members announced that they would undergo circumcision to set an example to the population as a whole. More than a million Zimbabweans are living with HIV/AIDS.
This is indeed marvelous news. The way Bill Gates and the WHO describe it, circumcision sounds like the greatest invention since penicillin. And yet the story does raise a question: Is it true? Does circumcision really reduce the transmission of HIV/AIDS, making it serve as a sort of invisible condom?
Stand proud 
In fact, the pro-circumcision consensus the WHO implies in its statements is largely imaginary. Medical experts the world over doubt the wisdom of the campaign, and some studies suggest it is actually counterproductive. In May of 2011, the Panos Eastern Africa NGO determinedthat misconceptions about the procedure – specifically the widespread notion that circumcision alone, without taking additional precautions, significantly protects people from HIV/AIDS – was actually encouraging the disease to spread in Uganda. In December of 2011, an article in the Australian Journal of Law and Medicinecited grave flaws in three studies supposedly proving the benefits of male circumcision in reducing the spread of HIV/AIDS in Africa: “The trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission.”
Furthermore, the authors discovered that
In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain. 
There is also a concern that the procedure itself can spread the disease among participants and their sex partners if it is not performed under completely sterile conditions and combined with qualified followup care.
So is the Great African Male Circumcision Crusade a boon or a boondoggle? In order to cast some light on what appears to an extremely murky and emotional issue, I contacted Dr. Ronald Goldman of the Circumcision Resource Center in Boston to get some hard answers:
Dr. Goldman, a number of sub-Saharan African nations have begun a crash adult circumcision program aimed at drastically reducing the incidence of HIV/AIDS among their populations. Their leaders, encouraged by foreign governments and NGOs, have apparently convinced themselves that a circumcised penis is practically immune to the virus. What effect do you think the mass circumcision of African men will actually have on suppressing the illness?
Many professionals have questioned the reliability and validity of studies claiming that circumcision reduces HIV transmission. African national population surveys in eight countries found a higher rate of HIV infection among circumcised men compared to men who were not circumcised. There are at least 17 observational studies that have not found any benefit from male circumcision in reducing HIV transmission. Therefore, I do not expect a reduction in HIV transmission. It's even possible that the incidence of HIV transmission will increase because the mistaken belief of protection from circumcision will result in more risk-taking sexual behavior.
In the United States particularly, circumcision has long been regarded as a sort of “magic bullet” against disease and a host of other evils. Why do so many health professionals believe the procedure is so beneficial to society as a whole?
Actually, only a relatively few health professionals believe that circumcision has significant health benefits. Most doctors take a neutral approach to circumcision, following the recommendations of the American Academy of Pediatrics. The AAP is considered to be the highest authority on the subject, but their recommendations also have problems. For example, their current policy is not balanced and uses about ten times more space on the "potential benefits" than on the harm. In addition, there are many questions of harm that have not been studied. Because circumcision is common in the United States, there is a strong psychological motivation to believe it is harmless or beneficial.
 Stand proud.
Since circumcision is a religious duty among Jews and Muslims, do you see any religious ramifications to this policy? For example, could non-Muslims see it as a covert conversion campaign, or could the practitioners believe they are performing “God’s will”?
I don't think so. What is covert about the campaign is that circumcision is being promoted by circumcision advocates that have personal, religious, political, and financial conflicts of interest. They intended to find a benefit for circumcision, and they found it. As I have written elsewhere, there is a strong pro-circumcision bias among those who are circumcised, have circumcised sons, belong to circumcised groups, or have performed circumcisions.
What potential drawbacks or side effects do you anticipate from this wholesale circumcision campaign?
Many of the psychological, sexual, and social effects that I discuss in my book, Circumcision: The Hidden Trauma, could become more common as circumcision becomes more common. We expect that though men may choose circumcision now for themselves (based on misinformation about protection from HIV), the campaign is moving toward forcing circumcision on infants who will then have no choice. This is the source of the trauma. Imagine being forcefully held down and having the most sensitive parts of your genitals cut off. Trauma is remembered by the body and has long-term effects. Feelings, attitudes, and behaviors are affected. For example, some men are angry that they are circumcised. Other men are angry and don't know why. That repressed anger has many effects on their lives and the lives of others.
Condoms have proven to be vastly cheaper and far more effective than circumcision when it comes to reducing the spread of HIV/AIDS, and they also reliably prevent other sexually transmitted diseases as well as unwanted pregnancies. Why aren’t the UN and the Western nations showering Africa with condoms instead of removing men’s foreskins in what looks like an unprecedented social engineering experiment?
There is a lot of psychological motivation behind the advocacy of circumcision. Circumcision is traumatic. Psychologists know that there is a compulsion to repeat trauma on others. Some American circumcised men have placed themselves in administrative and research positions where they can act out this compulsion and influence many others to be circumcised. They are simply using the cultural beliefs and values (e.g, medical studies and authorities that claim that circumcision has benefits, etc.) to accomplish their goal.
 South Africa
From South Africa
As most people probably know by now, so-called female circumcision (a.k.a. female genital mutilation or FGM) is a much more radical procedure than the male version, frequently including the excision of the labia and even the clitoris. Do you see a possibility that government and NGO support for male circumcision could potentially water down campaigns targeting FGM?
I do not think so. I point out that the cutting of male and female genitals are qualitatively the same thing. The harm and violation start with the first cut.
If male circumcision is as harmful as you claim, does this mean that all male Jews and Muslims, not to mention tens of millions of Americans, are essentially “damaged goods” when compared to their non-circumcised contemporaries?
What circumcised cultures do not want to know is that a natural body part, in this case a penis, functions better than a surgically reduced one. We do not need studies to know this. It's just common sense. For example, if we cut off the thumb, the functions of the hand would be adversely affected. It's the same for the penis. Most American circumcised men (and doctors) do not know what they are missing. Based on recent reports, circumcision removes up to one-half of the erogenous tissue on the penile shaft, equivalent to approximately twelve square inches on an adult. Medical studies have shown that the foreskin protects the head of the penis, enhances sexual pleasure, and facilitates intercourse. Cutting off the foreskin removes several kinds of specialized nerves and results in thickening and progressive desensitization of the outer layer of the tip of the penis, particularly in older men.
The current African circumcision drive is being generously financed by the UN and WHO, foreign and national governments, and a variety of NGOs. It is big business for those involved and money, as they say, is the root of all evil. Would it be cynical to speak of a “circumcision-industrial complex” at work in Africa?
Certainly money is an important factor. An African official said, "Profiteering has trumped prevention." A WHO researcher said that billions of dollars have been wasted. The focus on circumcision reduces support for more effective measures.
 Swaziland
From Swaziland
Has anyone, aside from yourself and a handful of other circumcision skeptics, openly challenged the policy and called for resistance?
There are very reputable researchers who have been published in foreign medical journals because the peer reviewers for circumcision articles submitted to American medical journals are circumcision advocates. They will not approve of an article that is critical of circumcision. The review process is as deeply flawed as the studies that advocate circumcision.
There are other serious problems that prevent a fair and open debate. Circumcision advocates have access to much money, and American media, reflecting the pro-circumcision bias of the culture, routinely ignore stories critical of circumcision and focus on reports of circumcision "benefits." Journalist regularly violate their professional principles and obligations to report different views on this controversy.
 Botswana circumcision
From Botswana
Finally, circumcision advocates are afraid to debate circumcision critics. This shows up at professional conferences where critics are not provided equal opportunity to participate. The upcoming international AIDS conference will include a one-sided commercial for circumcision. The lack of debate is also apparent in the media. For example, two circumcision advocates refused to debate me on two radio talk shows.
If the circumcision program is indeed misguided, what alternative advice would you give to African governments seeking a viable solution to the HIV/AIDS crisis?
Most HIV infection in Africa are transmitted by contaminated injections and surgical procedures. The advice is simple: sterilize any instrument that will be used on a person's body. Condoms are better than 99% effective, less invasive, and the cost of one circumcision in Africa can pay for 3000 condoms. Unlike circumcision, condoms also have the advantage of also protecting women, and there are no surgical risks and complications. Even the pro-circumcision studies recommend using condoms in addition to circumcisions. With a condom, circumcision adds no significant additional protection value even if the advocates' protective claims for circumcision without condoms are true.
Ronald Goldman, Ph.D. is a psychological researcher, educator, and Executive Director of the Circumcision Resource Center in Boston, a nonprofit educational organization. Dr. Goldman is internationally known for his work on circumcision and is the author ofCircumcision: The Hidden Trauma and Questioning Circumcision: A Jewish Perspective. He gives lectures on the psychosocial aspects of circumcision, counsels parents and circumcised men, and has participated in over two hundred interviews with broadcast and print 
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