1. English audio file (mp3 format, 31.9 MB)

A.     Bailey (Kisumu, Kenya). Around 10% of the local men are circumcised and HIV incidence was increasing prior to the trial. Screened 6,686 screened. Around 8% were HIV infected at screening. Ultimately, 2781 were randomized\. About ¼ were HSV-2 antibody +. Slightly higher HSV prevalence the circumcision group. HIV incidence is around 3.5% annually. By 24 months 85% were still in f/u; there were data for 91% of the visits. Both groups decreased their risk taking behavior. Almost 96% complete. 27 adverse events, mild; 99% of the men reported satisfaction with the procedure. 10% of the men had sex within a week of the trial. Annualized incidence for both groups 1.8%, little lower than projected. Last DSMB  6/2006. Expect to stop next summer unless DSMB indicates otherwise

B.     Schaffer (Kericho, Kenya): Tea plantation cohort. 2,801 men, to prepare for intervention studies. 19.1% of the men were uncircumcized ¾ were circumcized by a traditional healers. Circumcized men had a 0.79 annualized HIV incidence, but it was 2.48 for uncircumcised men. Rural cohort, helps support the thesis that circumcision can decrease HIV incidence.

C.     Masaen (Yale): Modeling the impact of circumcision. Modest circumcisions could provide significant benefits over 5 years. If risk behaviors increase, the benefits of the programs may be more  limited-but will need to think about the level of behavioral disinhibition.

D.    Kahn (USA): He did a cost-benefit analysis of the implementation of male circumcision programs. Estimated that cost/circumcision was $55, added @13 for mild side effects and $334 for serious side effects. Adding in the costs of the AEs, one more dollar, so total cost $56. Savings per male circumcision was about $2,000 per person, when the saved costs of medical care, etc, were added in. Circumcision would save $181 per HIV-infection averted.

E.   Agot (Kenya): Working with USAD and University of Washington. Prior studies have shown that 40-85% of African men would consider circumcision for health. They studied men who decided to be circumcised in public health settings in Kenya. Men who were circumcised were not behaviorally very different than uncircumcised men, perhaps allaying concerns that post-circumcision men may increase their risky behavior.

Perhaps more aptly titled “time to cut”, this session had presentations on male circumcision programmes in different parts of Africa, all of which proclaimed a benefit in terms of reducing HIV transmission from women to men (assuming as so many do that none of the men participating were also actually having sex with other men, but that’s another issue entirely).

Randomised controlled trial in Kisumu Kenya

Trial under a hypothesis that male circumcision would reduce HIV incidence among men aged 18-24 by 50% in an area where male circumcision (MC) is not traditionally practiced.  1391 men entered the circumcision arm, with 1393 in a control arm (all participants tested negative for HIV at baseline).  Condom use was just over 20% at baseline, rising to around 38% at 24 months.  1.7% participants in circumcision arm reported adverse events “probably” related to the procedure.

Male circumcision among tea plantation residents in Kericho Kenya

Reported incidence figures after 2 years follow up of  2801 18-50 year olds (1081 women excluded, alongside men who tested positive for HIV (7% of total) and 5.2% lost to follow up. 1378 men circumcised from diverse backgrounds, where 73% had the procedure carried out by a traditional healer and remainder by health workers and others.  Nearly half the men were between 10 and 14 years of age at the time of MC.  Concludes “careful attention must be given to the risk benefit profile of circumcision as an HIV prevention measure alone”.

Potential benefits of expanded male circumcision programmes in Africa

On a pretext that current prevention is not enough, this study questioned whether circumcision might be an effective “vaccine” available now on the basis that other trials indicate a potential 61% decrease in female to male HIV transmission  after circumcision.  Study included a 20 year mathematical model  extrapolating data from a 5 year programme looking at outcomes including infections prevented and HIV prevalence, also examining changes in condom use in Soweto, South Africa.

Baseline probability of male negotiated condom use was 50% ; number of sexual partners per year 0-3 depending upon disease stage (HIV negative status was not prerequisite to participation).  Mathematical model suggested reducing HIV prevalence to 14% through circumcising 10% of men predicted to prevent 32,000 infections over 20 years; scaling up to 20% plus factoring in an assumed 30% increase in risk behaviour, potentially could prevent 18,000 infections and reduce prevalence to around 15%.

Conclusions are that circumcision is already having tangible impact on the epidemic.  Even modest expansion of MC can confer substantial health benefits and should be implemented immediately, sensitive to the impact of MC on subsequent risk behaviour.

Cost Effectiveness of male circumcision in sub-Saharan Africa

Goals were to assess cost effectiveness of MC for Gauteng Province South Africa, and use the analysis model to estimate cost effectiveness in sub-Saharan settings with different epidemiology or costs.

Base costs were US $55 per MC; 5% of participants had mild side effects costing average $13 to treat; 0.4% had serious side effects costing an average $334 to treat.   HIV prevalence was 25.6%, risk compensation of 25% was factored in and the lifetime cost of HIV treatment (20 years) was assumed at $8000.

Cost effectiveness was calculated at $181 per infection averted, net saving adjusted for averted medical costs was reported at -$2,411.   Even if cost rose 45 fold, MC would break-even per infection prevented.  Scale appeared to have less than 1% on impact although could lower costs.

Many in the audience were uncomfortable with the cost benefit analysis, while others questioned whether any public health modelling had taken place on the benefits of childhood circumcision and public health planning for this.  When pushed on the potential use of traditional practitioners instead of health workers, the presenter responded “I think it makes sense to look at who are the appropriate providers in different conditions”.

Male Circumcision in Siaya and Bondo districts, Kenya

Dr Kwango Agot began her presentation by saying “if it’s not helpful to women, it’s not helpful at all”, then went on to explain her prospective cohort study assessing behavioural disinhibition.  This was another 50/50 trial where men were offered circumcision while others were used as the control.  Clients were not randomised, circumcision was elective.  The short follow up period may mean the findings would not be sustainable (risk behaviour may increase over time, but during the follow up there were repeated visits and counselling perhaps supporting behaviour change).  Participants were not tested for HIV at the outset.

At one month (after the wounds healed), 48% of circumcised men were reporting less than 0.5 sex acts per week (how do you have less than a whole sex act was never asked), and 87% were less likely to report risky sex than the uncircumcised control (these proportions remained constant over 12 months).  Even though 47% had chosen circumcision to protect against HIV and STI’s, their behaviour afterwards did not differ from those who elected MC for other reasons.

Between 45 and 80% of men would apparently accept the notion of circumcision, but their reasoning for doing so was not always sound – under questioning it emerged that some men thought that MC would cure them of erectile dysfunction. 

The controversy of whether MC in communities where circumcision is not the norm was actually male genital mutilation on a horrific scale was endorsed by another African questioner who accused all the trials of being invented by white men in the west and imposed on Africa; “how do we roll out white and western research that tell us predominantly black men what to do with their penises ..  we can’t even get them to use condoms”.  No evidence was produced to show any benefit to women from MC.

None of the presenters seemed prepared for these attacks, yet in presenting their findings had alluded to study participants electing MC for a whole range of reasons that had little to do with desired outcomes.  Researchers were accused of confusing people, that condom use was no longer required (remember some of these men were HIV positive at the outset even if they weren’t tested).

Moving forward there are policy issues to address around the ethics of whether men are giving informed consent if they undergo MC in the mistaken belief it is a cure for other conditions; some men from cultures where it is not traditional practice view MC as genital mutilation on a parallel with that of female circumcision. Others questioned the symbolism of the act of circumcision as a deeply meaningful social and cultural act and accused the trial organisers of “deeply fetishising” the act.  Some African commentators questioned the ethics of imposing potential solutions devised outside Africa that effectively tell black African men what to do with their bodies.

Further evidence on the protective effect of male circumcision on the incidence of HIV among adult men was presented today, in concert with positive data it is cost-effective and does not increase sexual risk taking behaviour.  

Dr. Robert C. Bailey relayed the results of a study on the effect of male circumcision on HIV incidence among men aged 18 and 24 in the Kisumu district of western Kenya.  Currently at the midpoint of the 24-month study, the overall incidence of HIV is 1.8%, below the 2.5% predicted among uncircumcised controls.  Dr. Bailey believes that soon ‘we can add male circumcision to the very limited armament of HIV prevention methods’.  A cost effectiveness analysis based on data from a previous South African study calculated the cost of a male circumcision program per averted adult male HIV infection would be $181 (USD). 

To date, studies have not examined the impact on the incidence among women, an absence that prompted Dr. Kawango Agot to remark “If it is not helpful for women, it is not helpful at all”.  Dr. Agot’s study to assess changes in the sexual behaviour of men following elected circumcision refuted concerns that circumcision would result in an increase in risky sexual activity and decrease in condom use.  Although no studies have involved youth, panellists concurred that circumcision would likely provide the same protective effect to young males as to adults.

The panel drew criticism on the absence of an anthropological perspective, and male-circumcision as a method of HIV prevention was accused of de-contextualizing male circumcision from its traditional cultural context.  A front-line HIV/AIDS worker from Africa criticized the almost entire western composition of the panel and accused male circumcision studies of being out of touch with the male behaviour and attitudes fuelling the epidemic. How can we get men to be circumcised, she asked, if we can’t even get them to wear a condom?