Male Circumcision, HIV/AIDS and the "Real World"

This past week, PLoS Medicine put forth multi-piece expose (start with this lead/summary article) on medical male circumcision, its cost-effectiveness in combating HIV/AIDS and methods and challenges to scaling up this practice in Sub-Saharan Africa, where the epidemic is at its worst. The upshot of this series of papers was covered in a recent Scientific American piece (which quotes yours truly). To summarize, the argument is that medical male circumcision works (as demonstrated in three large randomized clinical trials, all conducted in Africa) and is cost-effective. Indeed, it may even be cost-saving, with high upfront costs that are easily recovered over a 10 year period. Challenges to scale-up include finding health care workers to carry out circumcisions (in a way that doesn't crowd-out provision of other important health care services), getting people to adopt the practice in a respectful, non-coercive yet effective way, especially in areas where there are strong traditional norms over circumcision, and dealing with any risk compensating behavior (if circumcised individuals think circumcision is protective, they may be more likely to engage in riskier sexual behaviors than they otherwise would - more on this in a later post).

Circumcision is one of those topics that seems to always bring with it a vociferous debate. Those opposed to the practice make their stance known quite vehemently. In my opinion, much of what is being spouted against medical male circumcision as a tool for HIV prevention is based on an incomplete understanding of the available evidence and already strong negative priors against the practice that are almost impossible to shift (for example, see this clip or refer to any of the comments to the aforementioned Scientific American article).

However, I think there is one oft-cited argument against medical male circumcision that is worth discussing further. In particular, opponents point to evidence from a 2009 UNAIDS study that uses recent survey data from 18 African countries and concludes that "there appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher." This is contrast to the large randomized clinical trials mentioned above which show that circumcision reduces HIV rates by greater than 50%. The fact that the clinical trial results are not borne out in the sample survey data, opponents argue, means that circumcision does not work in "real world settings."

In a recent study, Brendan Maughan-Brown, Nicoli Nattrass, Jeremy Seekings, Alan Whiteside and I offer a different explanation for this differential set of findings. It has to do with the fact that the UNAIDS study looks at population that were circumcised in a multitude of settings (clinics, traditional healers) whereas the clinical trials focus on medical circumcision only. In practice, there great deal of heterogeneity in traditionally circumcising populations: some people do not have all of their foreskin removed, and others are circumcised several years after their peers. In our study population of blacks living in the Cape Town metro area, when we don't account for this heterogeneity, we find only a weak negative effect of circumcision on HIV positivity. However, once we "unpack" circumcision, we find that the practice actually has a strong negative association with the probability of testing HIV positive, provided it is done earlier and that there is complete removal of the foreskin.

These results suggest that the UNAIDS results may simply be due to measurement error. In a traditional setting, a circumcision is not a circumcision is not a circumcision. Treating every circumcised person the same introduces measurement error, and statistically it is well known that this would deflate the estimates of the impacts of the practice towards zero. So, the differential results between the UNAIDS findings and the randomized clinical trial findings is not that circumcision doesn't work in the real world. Rather, it is that we really need to understand better the heterogeneity in male circumcision and what can be done to ensure better outcomes for everyone involved.