Voluntary Medical Male Circumcision
Male circumcision has now been shown in three randomized clinical trials to reduce the risk of HIV acquisition for men by 50-60% (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Male circumcision at birth as part of postnatal care could result, upon sexual initiation and during his lifetime, in a reduction in the risk of HIV acquisition. Voluntary medical male circumcision (VMMC) requires men to take action to prevent HIV acquisition and thus to protect their female partners. Counseling for both men and women concerning the addition of voluntary medical male circumcision to the HIV "prevention toolbox" is an important recent advance.
The Evidence for Rolling Out Voluntary Medical Male Circumcision is Strong
Male circumcision is a one-time procedure with lifelong protective benefits (Njeuhmeli et al., 2011) and thus potentially highly cost-effective (Galarraga et al., 2009; Njeuhmeli et al., 2011). Scaling up voluntary medical male circumcision is also cost saving, preventing future treatment costs (Hankins et al., 2011; Njeuhmeli et al., 2011) and it is imperative that scale-up is rapidly accelerated (WHO et al., 2011a; Wamai et al., 2011). Mathematical modeling found that voluntary medical male circumcision is cost saving for Botswana, Ethiopia, Lesotho, Malawi, Mozambique, Namibia, Kenya, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zimbabwe and Zambia. By December 2013, estimates show nearly 6 million men had been circumcised in these 14 VMMC priority countries (Sgaier et al., 2014 cited in Njeuhmeli et al., 2014). Most clients accessing VMMC services in these countries are adolescents aged 10 to 19 years (Njeuhmeli et al., 2014). In order to achieve maximum impact, an estimated 20.3 million circumcisions among men 15 to 49 should be performed by 2015 (Njeuhmeli et al., 2011). If this were accomplished, an estimated 3.4 million new HIV infections would be averted in the next 15 years (Njeuhmeli et al., 2011). The number of voluntary medical male circumcisions needed to avert one HIV infection ranges from a low of four in Zimbabwe to a high of 44 in Rwanda (Njeuhmeli et al., 2011). Among the infections averted are those among women, because as more men are circumcised, women are less likely to encounter sexual partners who are living with HIV (Njeuhmeli et al., 2011). "Early on, most HIV infections averted occur among men, but the proportion among women would steadily increase over time until almost half of all HIV infections averted in the year 2025 are those that would have occurred among women" (Hankins et al., 2011: 3-4). Modeling from Tanzania found that in the absence of male circumcision, the annual number of new HIV infections is expected to rise from 84,000 in 2010 to 86,000 in 2025. However, with voluntary medical male circumcision, a significant decline of 64,000 additional HIV infections is expected (Ally et al., 2012).
"... Despite compelling scientific evidence, most countries in sub-Saharan Africa have been slow in developing national policies on circumcision or programmatically providing access to voluntary medical male circumcision. This provides another missed opportunity for reducing HIV risk in young women and implementing a highly efficacious HIV prevention intervention" (Abdool Karim et al., 2010a: 126). In 2010, 350,000 men were circumcised in eight priority countries, an increase from 100,000 in 2009 (UNAIDS, 2011a). But to achieve population level prevention benefit in Eastern and Southern Africa, more than 20 million additional men need to be circumcised in Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, United Republic of Tanzania, Uganda, Zambia and Zimbabwe (UNAIDS, 2011b). Kenya has achieved more than 50% of their goal (Mwandi et al., 2011) and in Swaziland, 13.3% of the 80% target has been reached; but all the other countries have achieved less than 5% of the 80% target (Wamai et al., 2011). Kenya's greater achievement is likely due to demonstrated country ownership (Dickson et al., 2011) where officials reached out to tribal leaders and conducted voluntary medical male circumcision campaigns using tents rather than fixed facilities, similar to campaigns conducted to reduce the backed-up demand for female fistula surgery (Gay and Ramsey, 2009).
There are some barriers to achieving higher levels of voluntary medical male circumcision. The setting of targets may make men hesitant. Just as women welcome contraceptives to reduce their own unintended pregnancies, rather than for the purposes of meeting global demographic targets, men will most likely welcome male circumcision as an intervention to prevent HIV acquisition rather than for the purposes of achieving a target. Another potential barrier to scaling up of voluntary medical male circumcision is that in some countries, the age of consent to be operated on for male circumcision is age 18 (Strode et al., 2010). Between 4% and 22% of adolescent boys in 13 of the 14 VMMC priority countries reported engaging in sexual intercourse by the age of 15 years, and between 25% and 71% by age 18 (Njeuhmeli et al., 2014). Scientists are working to develop non-surgical methods for male circumcision (Barone et al., 2011 cited in Padian et al., 2011b). Voluntary medical male circumcision programs can, however, be a gateway to increase HIV testing and counseling for men: in 2010, more than 56% of those receiving male circumcision also received an HIV test (WHO et al., 2011b). "Offered as a comprehensive package, adolescent VMMC can potentially increase public health benefits and offers opportunities for addressing gender norms" (Njeuhmeli et al., 2014: S193). Further evaluated interventions and studies are awaited on this topic.
"To avoid stigmatizing HIV-1 infected men, WHO/UNAIDS guidelines recommend that circumcision be provided to healthy men who request the procedure, regardless of HIV-1 serostatus, including for those declining HIV-1 testing. Thus, HIV-1 infected men will undoubtedly undergo circumcision as roll-out programs are implemented" (Baeten et al., 2010: 738). A study in Uganda found that "circumcision of HIV-infected men did not reduce transmission of the virus to uninfected female partners. Furthermore, we cannot exclude the possibility of higher HIV transmission in couples who resumed intercourse before complete healing of the surgical wound... The findings suggest that strict adherence to sexual abstinence during wound healing and consistent condom use thereafter must be strongly promoted when men living with HIV receive circumcision" (Wawer et al., 2009: 235). In addition, this same study noted "an increase in HIV viral load in antiretroviral-nave men after surgery, which could result in higher infectivity" (Wawer et al., 2009: 235).). "Understanding the potential short- and long-term effects of circumcision on HIV-1 infected men on risk of HIV-1 transmission to their sexual partners is a public health priority" (Baeten et al., 2010: 738). While male circumcision may have reduced efficacy such as early return to sex and disinhibition, "... none of these considerations (are)... a basis for rejecting male circumcision as part of HIV prevention strategies" (Wamai et al., 2011: 6). Two mathematical models, using DHS data on the HIV epidemics in Zimbabwe and Kenya, estimated that an increase in the risk of HIV acquisition and transmission during wound healing for male circumcision is unlikely to have a major impact on circumcision interventions. Estimates suggest that male circumcision confers a 46% reduction in the rate of male-to-female HIV transmission (Hallett et al., 2011). If this reduction begins two years after circumcision, the impact on infections averted by the intervention overall increases by 40%, doubling the number of infections averted among women. Modeling suggests that high degrees of increased risky behavior among circumcised men would not lead to increases in incidence overall under the intervention. If only uninfected men are circumcised in the intervention, the eventual reduction in incidence is increased by 30% overall and 66% for women, compared with 44% and 95%respectively, if HIV-infected men are circumcised too. Although male circumcision is an intervention applied to men, it brings substantial benefits to women as well (Hallett et al., 2011).
Questions Remain About the Short-Term Impact of Male Circumcision on Women
"We need more information and workshops on medical male circumcision" South African women (Kehler, 2010: 15)How can male circumcision be effectively introduced so that it complements and does not detract from other HIV prevention strategies? Will male circumcision affect women's ability to negotiate condom use? Will male circumcision confer any protection during anal sex? (AVAC, 2007) Operations research will be useful to iteratively improve program delivery and impact, including rigorous monitoring and evaluation of expansion of male circumcision services "to ensure that there are no adverse consequences for female partners of men who become circumcised" (Weiss et al., 2010: S64). Surveys by women's groups on the ground in Kenya, Namibia, South Africa, Swaziland and Uganda have found cause for concern (AVAC et al., 2010). If a man refuses an HIV test, is circumcised and thinks he is protected, then "his partner is in a worse position than before" (Berer, 2008a: 172). "As sexual partners, women should not abandon negotiation of condom use with circumcised men, and this will be greatly facilitated if everyone understands that with circumcision alone, men are not fully protected and their partners are not directly protected from HIV infection" (Hankins, 2007: 65).
Yet male circumcision programs could be a platform to promote gender equity and all HIV risk reduction strategies as well as men and women's sexual and reproductive health with increased couple communication (Wamai et al., 2011). PEPFAR recommends that "where VMMC services are provided, they must be part of a comprehensive HIV prevention package along with provision of HTC, treatment for STIs, promotion of safer sex (including counseling of men and their sexual partners to prevent them developing a false sense of security) and provision of condoms (including how to use them correctly)" (PEPFAR, 2011b: 20). While not addressing counseling needs for men or for women, WHO has released considerations for implementing models for optimizing the volume and efficiency of male circumcision services (WHO, 2010h). These questions will need to be addressed as male circumcision is rolled out. It is clear that male circumcision is an important component for HIV prevention strategies, but the extent to which it protects women is, while promising for the long term, unclear about women's risk in the short term. The protective effects of male circumcision "will eventually percolate to women and uncircumcised men if sufficient circumcision levels are achieved" (Hallett et al., 2008a; White et al., 2008 cited in Katsidzira and Hakim, 2011: 1124).
Given evidence that male circumcision could potentially put women at an increased risk for HIV under certain circumstances in the short term, how best to roll out programming through gender-equitable approaches that do not increase short term HIV risks for women remains to be evaluated (Zachariah et al., 2011a). "The roll out of male circumcision presents [an ideal opportunity] to... provide interventions to transform harmful gender attitudes and behavior as part of programming of the roll out of male circumcision" (Greig et al., 2008: S37-8). "Outside the clinical trial setting, the effect that the decreased perceived risk of HIV infection will have for circumcised men's willingness (and women's ability to negotiate) condoms requires close monitoring" (Gruskin and Ferguson, 2008). Women will benefit in the long run from male circumcision, as fewer of their male sexual partners will be HIV-positive. Clear and consistent messages must emphasize that male circumcision is an additional prevention method for men, but that it does not replace measures such as delay in the onset of sexual relations, avoidance of penetrative sex, reduction in the number of sexual partners, and correct and consistent use of male or female condoms (Doyle et al., 2010b). Communicating partial protection remains challenging (Dickson et al., 2011).
Circumcision for male infants should be incorporated into WHO's Expanded Program on Immunization (Zachariah et al., 2011a). Targeting newborns is not cost saving because circumcision will occur many years before men experience their highest HIV infection risk. However, after 20 years, the intervention directed at neonates is as cost effective as targeting adults (Galarraga et al., 2009). Circumcised male neonates, as they become sexually active, will be less likely to acquire HIV and subsequently, less likely to transmit HIV to their female partners. Neonatal male circumcision has several advantages over the procedure performed in other age groups. Complication rates have been observed to be low and neonatal male circumcision can be performed as a clean procedure (rather than sterile) in a newborn nursery or a post-natal outpatient clinic (Wiswell Geschke 1989 cited in Plank et al., 2010). Neonatal male circumcision does not require an operating room, can be done with topical anesthetic and without sutures, and can be performed by midwives, in addition to physicians. Neonatal male circumcision can be performed at one-tenth of the cost of adult male circumcision (Manji 2000 cited in Plank et al., 2010). A tool to calculate costs and impact of male circumcision (Decision Makers' Program Planning Tool DMPPT), as well as additional information on male circumcision is available at: www.malecircumcision.org.