Male circumcision to prevent heterosexual HIV transmission gets (another) green light, but traditional circumcision in Africa has 'shocking' number of complications

AIDS:

2 January 2010 - Volume 24 - Issue 1 - p N1-N2

doi: 10.1097/QAD.0b013e32832faec0

Notes and Quotes

Male circumcision to prevent heterosexual HIV transmission gets (another) green light, but traditional circumcision in Africa has 'shocking' number of complications

Crabb, Charlene

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In 2005 and 2007, a trio of clinical trials in Africa found that circumcising young men in modern medical settings reduces the risk of acquiring HIV from female partners by approximately 60%. In April, a second meta-analysis of the three studies, this time conducted by the Cochrane Collaboration, concluded that no further clinical trials are needed to make the point about the efficacy of circumcision to prevent HIV infection. The findings echo those of a meta-analysis reported in this journal last year by Helen Weiss and collaborators.

But as governments in Africa initiate circumcision programmes in communities that do not normally practice it, a serious concern is whether the procedure can be provided safely to large numbers of adult men in developing countries. A recent study emphasizes that worry. Researchers report 'shocking' and 'unacceptable' rates of a Pandora's box of complications, some life-threatening, resulting from circumcisions performed as part of traditional coming-of-age rites in Kenya. (Bull World Health Organ 2008, 86:669-677.)

'Our study demonstrates that as we roll out circumcision and try to make it widely available in health facilities, it's going to have to be done carefully, and it's going to require some resources,' says Robert Bailey of University of Illinois, Chicago, who led the current study, as well as one of the seminal 2007 clinical trials on circumcision and HIV infection. 'It's alarming that (traditional circumcision) has been going on for so long with such high rates of adverse events.'

The prospective study followed 1007 young men, aged 5-21 years, circumcised during the July-August 2004 circumcision season in the Bungoma district, Kenya. The men hailed from the Bukusu ethnic group, who consider circumcision obligatory and have practiced it for centuries. The participants had either a 'traditional' circumcision performed in a village or within a household compound, or a 'medical' circumcision performed by someone the participant considered to be a clinician in a hospital, health centre, dispensary or private office.

To document complications, the researchers interviewed the men 30-89 days after circumcision. Twenty-four men were directly observed during circumcision and after 3, 8, 30 and 90 days. The criteria for adverse events were the same as used in the earlier clinical trial.

However, after interviewing approximately two-thirds of participants and directly following the 24 cases, the researchers found 'very high rates' of complications. They decided to directly examine and interview the remaining 298 men, ranging from 45 to 89 days after circumcision.

Overall, 35.2% men circumcised traditionally suffered some form of postoperation complication. Among the men circumcised medically the adverse event rate was significantly lower, 17.7%. However, both rates are well above that of 1.7% observed in the Bailey-led clinical trial in Kisumu, Kenya, as well as those of infant circumcision rates in developed countries.

The types of adverse events ranged from infection, excessive bleeding and pain to permanent after effects such as excessive scarring, erectile dysfunction and mutilation of the tip of the penis, or glans. The rates might have been even higher, the authors note, if they had not intervened to redress wounds (20 cases) and give antibiotics (2 cases). One patient likely would have died if he had not been taken to hospital.

The problems stem from poor training and a lack of proper equipment and medical supplies. Inventories conducted by the researchers of three hospitals, one health centre, and 14 private clinics revealed, for example, that only half of the public health centres had working autoclaves compared with just one-fifth of the private facilities. Approximately, half of both private and public facilities had no sutures. The surgical kits of the 20 traditional circumcisers interviewed consisted of a knife made by the boy's family, a pinch of clay to help grasp the foreskin, herbs to staunch bleeding, and leaves or, perhaps, gauze and bandages, to wrap the penis.

The findings will likely further fuel discussions on how best to roll out circumcision as part of HIV prevention programmes. But Bailey hopes it will also stimulate action in areas where circumcision is already part of the cultural landscape. 'I'm afraid that 10 years from now, when we've put resources into circumcision in traditionally noncircumcising societies, we're going to look back and say, wait a minute, what were we doing in traditionally circumcising societies in which young boys were getting mutilated, and we ignored it.'

© 2010 Lippincott Williams & Wilkins, Inc.