To snip or not to snip?

Three times a week, the general surgery team at McCord’s hospital in South Africa would send a few junior doctors to perform circumcisions at a nearby clinic.  The first time I went to the clinic, I was surprised to see a bunch of young men instead of a bunch of crying babies. (The two are not mutually exclusive, of course).

You see, here in the US, circumcision is an almost routine procedure done on many if not most newborns. (Interestingly, this is not true in Australia where circumcision is not offered as a standard option… a separate discussion).  In South Africa, however, McCord’s Hospital collaborates with the Ministry of Health and USAID to offer free circumcisions to teens and young men.

I know what you are thinking.  FREE?? How could anyone turn that down?!

In all seriousness, free or not, most of us would never volunteer for a circumcision without good reason.  In South Africa, the good reason is very simple: HIV.  In the last 5 years several good studies have provided definitive evidence that circumcising men reduces the man’s risk of acquiring HIV.

A innovative circumcision device on display in Capetown

In a South African study, men were randomly assigned to either being circumcised or not.  After 14 months, the trial was terminated for ethical reasons because fewer than half as many circumcised men contracted the virus – in other words, the circumcision was so successful the the researchers couldn’t (in good conscience) withhold it from half the group.  In fact, researchers have found that male circumcision provides greater protection than microbicides and greater protection than treating someone with HIV medications prophylactically (prior to infection).  It is even more effective than any vaccine that has been tried to date.

As a result of these studies, circumcision has been heralded as a ‘surgical vaccine’ and clinics similar to the one I visited have increasingly gained favor.  In almost assembly-line fashion, men are examined pre-operatively, anesthetized, and circumcised – all in about 20 minutes.  Disposable sterile kits containing all the tools needed for the procedure help make the process even smoother.

A male circumcision kit similar to what we used (photo: missionpharma.com)

Despite its effectiveness, circumcision has not been taken up at the numbers we would expect. In South Africa, just over 100,000 men have been circumcised in such clinics.  One group of authors predict that if 80% of South African men were snipped, more than a million infections would be averted and the country could save $6.5 billion in healthcare costs (by 2025).  With a current circumcision rate of 42%, South Africa has a ways to go still: the country would need to circumcise more than 4 million men to reach this target.

The reasons behind the slow uptake are – well – multifold.  Certainly, the cultural interpretation of circumcision is important.  In Ethiopia, Orthodox Christian practices and Islam presumably explain part of the 93% circumcision rate. But low-uptake in South Africa isn’t just about men being attached (er…figuratively attached) to their foreskin.  Setting up surgical camps to circumcise men with foreskin requires resources such as surgical kits, people to do the procure, sterile operating fields, and people to follow-up with the patient.

Beyond the resource issue, however, I suspect healthcare providers might be a limiting factor.  Though official policy in many African countries favors circumcision, anecdotally, it seemed to me that many doctors are less than enthusiastic.  I myself wondered if these boys getting circumcised now thought they were ‘protected’ and would in turn ignore other safe-sex practices, thereby increasing the risk of infection.  The evidence, however, was against my suspicions.  Even accounting for increased sexual behavior amongst circumcised men, the South African trial reported a 61% rate of protection.

Still, I wondered, even if these boys are protected what about the women they are sleeping with? Would  there risk maybe be even higher? Again, however, logic and data were against me.   If fewer boys carry HIV, fewer women are likely to get infected due to the overall decrease in HIV prevalence.  One study estimated that male circumcision was associated with a 46% reduction in male-to-female transmission.  My own internal bias against circumcision (“not medically necessary” was the standard teaching) was overcome by sound evidence that it really works in lowering the rate of HIV infection.

While most policy makers have accepted that male circumcision is a tool in the fight against HIV, it doesn’t seem to have been warmly embraced.  As healthcare providers we can probably do a better job letting go of our own biases (be they historical or cultural) and follow the evidence to where it leads us.  A more robust and, for lack of better word, whole-hearted approach to circumcision is called for.  While it was heartening to see young-men lining up to lower their risk, we no-doubt need to think creatively about how to substantially increase the number of cases that are done.

Oh, while we are at it – and for the sake of the teenage boys of 2025 – let’s start circumcising babies too.

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2 comments

  1. coxysopinions

    Thanks for the great article Saurabh. It’s a contentious issue for sure, I go back and forth on my position on this as I come across numerous supportive and contrasting views or studies on the efficacy of circumcision as a preventative method for acquiring HIV.

    Whether circumcision alone is an effective preventative is still unclear in my view, but what is for sure is that it can be an important PART of the response (though it seems to me it’s almost a public health ‘fad’ at the moment within Africa). I think we still need to be very cautious. Circumcision will never be as an important as advocating for positive behaviour change in high-risk communities or improving access to condoms.

    As someone who works in community advocacy in Malawi I would like to see this pursued only in places with extraordinarily high rates of HIV (like Southern Africa), but would personally be cautious in other parts of Africa where HIV rates are already being improved upon through other interventions or measures.

    • Mark! Thanks for your comment. Took me a bit to figure out who was posting. You bring up some good points and I agree that this cannot be a sole strategy. I guess I go back and forth a bit too – I would just hate for the medical world to turn its back on evidence when it isn’t convenient. But you are right that the overall prevalence rate is extremely important in any risk benefit calculation. Maybe I’ll turn my attention to Gardasil in one of my future posts. Not a surgical vaccine, but something that could really reduce the surgical burden of disease for women (I.e prevent late stage cervical cancer). I think that there are some parallels between these two prevention strategies that are best utilized prior to the age of sexual activity.

      Next time you are stateside lets chat about this in person!

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