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On Evidence in support of Male Circumcision in HIV Prevention: What Next?

Posted by plosmedicine on 30 Mar 2009 at 23:47 GMT

Author: Adamson S. Muula
Position: Department of Community Health
Institution: University of Malawi College of Medicine, Malawi and Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, United States
Submitted Date: October 27, 2005
Published Date: October 27, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The study by Auvert et al (1) will certainly go into the history of HIV prevention as a landmark. The study is important because the results are the first blinded randomized study demonstrating that HIV can be prevented by male circumcision (MC). Although double-blinded studies are considered a panacea, the nature of the intervention, however, necessitated that double blinding was impracticable - i.e. it was impossible for the men to be circumcised without them knowing that they had been circumcised.

The study suggests that MC could join the interventions for HIV/AIDS already available - i.e. highly active anti-retroviral therapy (HAART), short-course anti-retroviral therapies and caesarean section in preventing mother to child transmission, post-exposure prophylaxis, condoms, abstinence, and treatment of sexually transmitted infections. Like many other health interventions, MC (if further demonstrated in randomized studies and adopted as policy in countries) will be indicated and suitable for some people, but not others, for a variety of reasons. It would therefore be unfortunate if we then start promoting MC at the expense of other intervention measures. The authors did not suggest that we should do so, but there is always the danger that some people will want to galvanize one intervention at the expense of others.

The other challenge is that medical practice is conservative - i.e. it is unlikely that any country will immediately include MC in its policy for the prevention of HIV. The reasons include: these studies may not be corroborated in forthcoming studies, the potential harms still need to be considered in order to assess the cost-benefit ratio. Even in South Africa where the study was carried out, it will be a while before MC is incorporated into the national HIV prevention policy. Interestingly, however, the institutional review board stopped the study prematurely, as is always deemed ethical, before the completion of the study, suggesting implicitly perhaps their endorsement that MC works and ought to be standard practice and no one needed to be further exposed to not being circumcised.

In the inclusion criteria, the authors indicate that "To wish to be circumcised" was one of the criteria. It is not clear to me what this "wishing" was - i.e. was it that these were people who found MC acceptable or they had wanted to be circumcised but for some reason had not had the opportunity to have the procedure? If the interpretation is the latter, it would be important later to identify the barriers to MC that may operate in countries in Southern Africa. Knowledge about these will inform the policy debates.

While the policy debates rage, the scientific community has an enormous responsibility - i.e. ensuring that well-conducted studies are carried out in other settings to either confirm or dispute the findings. Results from other settings will be awaited with eagerness.

Researchers in the HIV field face the dilemma of not subjecting their study subjects to undue harm through stigmatization and discrimination. In several Southern African countries, providing HIV test results to clients of health services and research subjects is at the discretion of the client. That there is no requirement for people who test positive to inform others who may benefit from the disclosure is, in my opinion, an important omission in the prevention of HIV in the region. It may be useful, to include at the time of obtaining informed consent that "should you test HIV positive, we will encourage you to inform your sexual partners about the test results."

While it has been demonstrated that MC can be effective, it is yet known why that might be the case. The authors have suggested that perhaps the keratinization that may ensue, rapid drying of the glans penis after sexual intercourse and prevention of STIs may be reasons. These are plausible explanations but will require separate studies that may elucidate the mechanism(s).

The authors suggest that if women were aware of the effectiveness of MC, this would in turn lead them to encourage males to be circumcised. While I agree that all stakeholders ought to be mobilized in promoting an effective HIV intervention, or any public health intervention, the "role" of women, sadly is minimal in decision-making in most parts of the southern African region. But that does not mean that attempts should not be made to involve them.

1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005). Randomised, controlled intervention trial of male circumcision for the reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2(11): e298

No competing interests declared.