*Note: This is the Part 2 of a three-part series on the cost-effectiveness of HIV/AIDS interventions
Evidence Showing that Male Circumcision (MC) Prevents HIV Seroconversion
Between 2005 and 2007, three randomized controlled trials were conducted to ascertain the effectiveness of male circumcision as a preventative measure against HIV infection for males. All three trials, in Kenya, Uganda, and South Africa, were halted early due to the highly significant preventative effect showed by preliminary results. It is now generally accepted among medical professionals and policymakers that MC has a preventative effect of 55-60%. As Klausner et al. point out, results of these RCTs are supported in real world settings, like West Africa, where HIV/AIDS has existed for nearly eight decades, yet has never peaked above 5-6% prevalence.
Studies have also indicated that the benefits of MC go beyond just preventing HIV infection. The trial in Uganda found that members of the treatment group reported fewer cases of genital ulcers. As Sawires et al. write:
Male circumcision is also associated with reduced risk of urinary tract infections, genital ulcer diseases, penile cancer, and a possible reduction in transmission of human papillomavirus (HPV) exists.
Challenges to the Cost-Effectiveness of MC as HIV Prevention
Despite the medical proof that MC is an effective prevention tool against HIV, scale-up of MC campaigns have been slow and face several key challenges.
First, roll-out of MC requires investment in health care infrastructure on a large scale. According to Whiteside, while many sub-Saharan countries have traditional MC ceremonies, these are more risky and might not provide the same protective effect if an inadequate amount of the foreskin is removed. Equipping medical facilities throughout Southern and Eastern Africa, where MC is less common and where it will have the greatest impact, would require training staff and providing medical instruments, anesthesia, and post-surgical treatments. Still, the cost of scaling up medical capacity in SSA should be shared across all health improvement efforts, not just HIV/AIDS. Facilities that provide MC could also provide other reproductive health and minor surgical procedures. Given the highly preventative effect of MC, the cost of scaling up medical facilities could be well-worth the benefits.
Second, some scholars have noted that the acceptability of MC varies across sub-Saharan Africa. Cultural and religious beliefs could prevent massive scale-up of MC in certain communities. As Dionne and Poulin found in Malawi, acceptability of MC varies according to ethno-regional lines. However, results from Kenya have been quite different, showing that regardless of region or ethnicity – the demand for MC is high. In addition, acceptability might range depending on which age group is targeted with MC interventions. Ideally, MC funding would target men at all ages. Whiteside argues that infant MC is less costly and less risky, but the benefits will be delayed for 25 years or more.
Thus, adult MC is critical to help curb the spread of the disease immediately. However, adult MC is costly, risky, and not as readily accepted as infant MC. One study showed that median acceptability among men and women for adult MC was 65% and 69% respectively. The same study found that median acceptability for infant MC was 81% among males and females. Therefore, to be cost-effective, policymakers must work extra hard to meet demand with adequate supply in areas where MC is culturally acceptable. This supply must also be tailored to the appropriate age group for the community.
Lastly, there are gender concerns regarding a big push for MC. The benefits of MC for female partners are still unclear. While studies have shown that MC can help prevent cervical cancer (via HPV) for females who have circumcised male partners, the reduction of transmission from circumcised HIV-positive males to their female partners is still uncertain. But in the long-term, MC will reduce the prevalence of HIV among both males and females because the pool of potential male partners who are HIV positive will decrease over time. As Kalusner et al. write:
While the main, directly protective effect of MC is for men, in places where many men are circumcised large numbers of women will also end up benefiting as they will be less likely to have sex with an infected male.
Sawires et al. cited concerns that a big push for MC will undermine efforts to end female genital mutilation (or female circumcision). They argue that communities that practice FGM will use MC as an argument for female circumcision – which actually has the reverse effect for women, causing infection and other medical problems which can ease HIV transmission.
Is MC as Good as an HIV Vaccine?
As with every medical intervention, MC scale-up certainly faces a host of technical and social challenges. Despite these challenges, the 60% preventative effect of MC cannot be ignored. This intervention is the first of its kind to show promise in long-term prevention with a single dose (or in this case snip) of treatment. According to Klausner et al., this makes MC just as effective, if not more so, as an HIV vaccine. In their 2008 editorial, Klausner et al. argue several main points:
Moreover, MC is a one-time, relatively simple procedure that is readily acceptable throughout most of sub-Saharan Africa, and would ultimately be highly cost-effective, especially in high HIV prevalence areas.
Modeling suggests that widespread circumcision in the rest of sub-Saharan Africa could avert up to 2 million new HIV cases and 300,000 deaths over the next 10 years, and 3.7 million infections and 2.7 million deaths in the following 10 years, many of these among women. This would not only save millions of lives, but would also abate the need for large future expenditures of AIDS medications; hence, studies have demonstrated that MC would be highly cost-effective intervention in the longer term.
Unlike a possible future AIDS vaccine or many other prevention interventions, MC has also been shown to eliminate or significantly reduce the risk of acquiring or spreading a number of other diseases and medical problems…
On the other side, the Copenhagen Consensus Center (RETHINK HIV Project) has argued that MC is not as cost-effective as an HIV vaccine. According to director Bjorn Lomborg, MC campaigns require massive mobilization funds to get men into clinics for treatment and MC could induce an increase in risky activity.
I’m more inclined to side with Klausner et al.’s argument. He makes good points regarding the effectiveness of MC in preventing other diseases and the simplicity of the procedure. Lomborg’s point on the cost of scale-up and mobilization are a bit unfounded. MC campaigns only require treatment of half the population, while an HIV vaccine would need to be available and affordable to everyone in the population. In addition, his points on increased risky activity have limited statistical basis. While the trial in South Africa saw some increased sexual activity, trials in Kenya and Uganda reported no change in sexual behavior within the treatment group. All three reports advocate for a multi-faceted approach to MC campaigns that incorporates education and treatment to avoid an uptake in risky behavior resulting from circumcision.
It’s also worth noting that Lomborg has faced serious criticism in the past for distorting data, selectively using statistics, and committing plagiarism to support his claims/ sell copies of his book The Skeptical Environmentalist.
The Bottom Line
Why aren’t policymakers investing more in MC? Why is there such a big push for an HIV vaccine? While I agree that an HIV vaccine would be cost-effective in preventing the spread of the disease, efforts to develop this vaccine should not undermine existing, proven interventions.
As food for thought, I’ll leave you with Klausner et al.’s explanation for limited MC support:
If this were an actual vaccine, packaged with a pharmaceutical company logo and shiny labeling, few people would be deliberating, constantly emphasizing a multitude of caveats and using bureaucratic speak to stress the need for prevention ‘packages’ and comprehension inclusive strategies in which the new vaccine would be ‘only one element among many other approaches.’ There would instead be massive mobilization, press releases and corporate titans using their public relations organs to announce the bravado of their achievements. Unfortunately in these times of profit-drive healthcare, no single entity stands to earn large sums of money from MC.