Article published in Future Medicine, Vol. 2, No. 3, pp. 193-199 , May 2008. DOI 10.2217/17469600.2.3.193 The authors examine the three randomized clinical trials (RCTs) conducted in Africa and find them wanting. A recent commentary claims that circumcision is "at least as good as the HIV vaccine we have been waiting for, praying for and hoping to see in our lifetimes." The article provides an analysis that refutes that statement.
The push to institute mass circumcision in Africa, following the three randomized clinical trials (RCTs) conducted in Africa, is based on an incomplete evaluation of real-world preventive effects over the long-term effects that may be quite different outside the research setting and circumstances, with their access to resources, sanitary standards and intensive counseling. Moreover, proposals for mass circumcision lack a thorough and objective consideration of costs in relation to hoped-for benefits. No field-test has been performed to evaluate the effectiveness, complications, personnel requirements, costs and practicality of proposed approaches in real-life conditions. These are the classic distinctions between efficacy and effectiveness trials, and between internal validity and external validity.
Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction, without the surgical risks and complications of circumcision, and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering peoples behavioral patterns and exposing them and their partners to new or expanded risks. Given these problems, circumcision of adults, and especially of children, by coercion or by false hope, raises human rights concerns.
This 2008 article is just as relevant today as it was two years ago. There are reports that men in Africa believe that their circumcision insulates them from HIV infection. With this belief, they are not attempting to practice safe sex.
The article also raises the point that the trials did not consider the long term effects of male circumcision. Even now, with African nations instituting mass circumcision policies, no one is considering further studies to see if the mass circumcision is actually reducing the HIV rates. Instead, men are being sold on the idea that having a circumcised penis is better than having an intact penis. It would be prudent for those countries to at least track the efficacy of circumcision to determine if the program is working as advertised.
In short, given the large number of unknowns, confounding factors and lack of long-term follow-up in the three RCTs, it is premature to recommend circumcision as an HIV-prevention strategy. Much more evidence must be gathered on real-world efficacy of male circumcision as a prevention tool before mass surgeries are implemented.
An objective scientific assessment must be conducted to determine if the three RCTs are applicable in real-world settings. And, to determine the true cost of a circumcision campaign, there must be a comprehensive resource analysis of the plan. These mass circumcision costs also must be compared with the opportunity costs of funding ABC campaigns.
As part of these assessments, the very real risks of circumcision surgery, including directly increasing HIV transmission to men as well as indirectly increasing transmission to women, surgical risks such as hemorrhage, other infections, meatal stenosis, need for repeat surgery and even death, must be considered.
Finally, the value and function of the foreskin as an integral part of the male sexual organ [31] and the ethical issues surrounding such surgery, including informed consent, the possibility of coercion and the dangerous implications of conveying erroneous messages of HIV immunity, must also be carefully considered in any analysis.
ABC programs offer nearly full protection from HIV infection, yet even if circumcision’s effectiveness matches the 50–60% effectiveness the RCTs reported, it only partially protects men, does not protect women at all, and leaves women more vulnerable to unsafe sex practices being forced upon them.