Public Health & Economic Benefits Overview of Circumcision

Motivation for Circumcisions

  • HIV Prevention
  • WHO has recognised that circumcision reduces HIV transmission from women to men by 60%
  • VMMC (Voluntary Medical Male Circumcision) has a substantial impact on HEALTH CARE COSTS
  • Male Circumcision provides life-long public benefits for men and women

Circumcision in Sub-Saharan Africa

Of 36 million HIV-positive people in the world, 24 million live in Sub-Saharan Africa (SSA), of which about 6 million are living in South Africa.

The WHO has set targets to circumcise 80% of 20 million men in Sub-Saharan Africa by 2016. By circumcising 16 million men in the prescribed period, in SSA for a cost of 2 Billion USD, a net saving of 25 Billion USD can be achieved by 2025.

Circumcision as HIV Prevention

Medical Male Circumcision constitutes a high impact and cost-effective intervention for HIV prevention besides other Public Health benefits.

Combined results of strong scientific evidence from landmark studies in Africa, 2007, showed that VMMC reduce the incidence of HIV infection by 60%. Circumcised men have a lower risk of acquiring HIV.

Uncircumcised men are at higher risk of contracting HIV, because the moist inner foreskin layer of the Penis and the Glans allow HIV-infected cells to pass through the epithelial layer and attach to the Langerhans cells (who live in the mucosa), and transport the virus to local nymph nodes, thus causing the HIV-Infection.

 

HIV Virus invading CD4 Cell

hiv lifecycle

On average, for every 4 males circumcised, one HIV infection can be prevented, not needing ARV's lifelong.

Cost savings through Circumcision

Reaching these targets of circumcision 16 million men in SSA, will impact the devastating effect of HIV on the nations in Southern Africa and can prevent up to 60% of new HIV infections that would require life-long ARV's (Anti Retro Viral Medication). ARV's are costly and have associated problems like compliance, distribution, side effects of medications, and patients needing counseling.

Circumcision in South Africa

In South Africa, around 1.4 million circumcisions have been performed since implementation of it's Prevention Program in 2009 / 2010, using mainly the conventional open surgical circumcision method. This is roughly only about 30% of it's 80% target for 2016.

The current target to impact the HIV Epidemic in South Africa is to circumcise 5 million males over the next 4 years.

Up-scaling Circumcision and adding value

Cost savings through Circumcision

Male circumcision is at present the most cost effective method in fighting HIV, and the cost savings through circumcision are enormous. The challenge for areas with high HIV prevalence (patients being HIV-positive)is to rapidly up-scale circumcisions.

Scale-up is far behind target in Sub-Saharan Africa and it has been constrained by the technical difficulties of performing open surgical circumcision, the only method approved by PEPFAR. Key issues countries are facing in up-scaling circumcision as part of a HIV Prevention Program, are the technical difficulties, recruiting for VMMC, limited financial and human resources, complications of Techniques and Devices used, and time to healing.

Circumcision using the surgical method is impractical for up-scaling Medical male circumcision, due to time needed to perform and Human Resource constraints. Using open surgical techniques (Forceps Guided, Dorsal Slit and Sleeve techniques), which all expose subcutaneous tissue, require suturing and take at least 20 to 45 min to perform.

Therefore, WHO is actively seeking additional circumcision methods that can facilitate widespread scale-up of VMMC. Given the drawbacks of the PEPFAR approved surgical circumcision for VMMC, the WHO is seeking an ideal method for up-scaling circumcisions.

Non-surgical in-situ circumcision devices (patient wearing circumcision device for several days) have proven benefits for up-scaling, but not without disadvantages.

The method using circumcision devices is in general quicker to perform, safe, easy to teach, and requires less Human Resources.

Public Health Benefits of Voluntary Medical Male Circumcision (VMMC)

Benefits and Risks of Circumcision

There are benefits for men and women. The long- term functional and cosmetic outcomes of circumcision in a modern setting are generally excellent, while the surgical risk of circumcision is extremely low.

Although infancy is the ideal time for a circumcision, many adult men and teens seek circumcision for medical, sexual, cultural, religious, or cosmetic reasons.

Benefits of circumcision for Men

CIRCUMCISION reduces the chances of getting infected with the HIV-Virus up to 60%: Male circumcision reduces female-to-male transmission of HIV when adequate amounts of mucosa are removed. World Health Organisation recommends complete removal of mucosa for effective HIV prevention through circumcision.

  • getting narrowing of the foreskin (Phimosis)
  • getting and transmitting STD's
  • getting bladder and kidney infections (UTI's)
  • getting inflammation and infection of the foreskin
  • getting cancer of the Penis and Prostate
  • passing on the HPV-Virus which increases the chances of getting cancer of the Cervix (womb) in women

Benefits of Circumcision for women if men are Circumcised

Male circumcision

  • Reduces the risk of Cervical cancer, caused by Human Papilloma-Virus (HPV)
  • Decreases risk of Bacterial Vaginosis and Chlamydia Trachomatis which can cause pelvic inflammatory disease
  • Protects women getting Genital viral infections (Herpes) HSV-2
  • Reduces the chance of getting infected with HIV and Syphillis
  • Reduces Ectopic pregnancy and infertility

Risks of Circumcision (rare)

All surgery involves some risks, but in western countries risks from circumcision in men and teens are low, and are lower still for infant circumcision.

Bleeding, swelling, infection, wound dehiscence. 
Complication rates/risks are related to the experience of the health provider. Risks are minimised if circumcision performed by trained circumcisers and in safe environment.

Around 2-3% of men circumcised by experienced practitioners will have minor complications such as bleeding or infection. Each is easily treated. The risk of serious injury is extremely rare.

Many uncircumcised males will develop a medical condition leading to suffering and, in some cases, even death. In contrast, circumcision can prevent most of these medical conditions.

 

CIRCUMCISION PROVIDES A LIFETIME OF MEDICAL BENEFITS. BENEFITS OUTWEIGH RISKS BY 100 TO 1

 

HIV Prevention

PREVENTION and HIV

ABC'S of HIV Prevention

  • Abstinence
  • Be faithful
  • Circumcision and condoms

Circumcision: up to 60% protection from contracting HIV during vaginal sex
Treating HIV-infected people with ARV's early: protects partners from infection with HIV by up to 90%

Being circumcised and using a condom provides almost 100% protection from being infected with the HIV virus if used properly

COMPREHENSIVE STRATEGY, in which social and structural determinants are addressed, remains the core element for long-term Prevention.

Approaches should aim to modify social conditions, addressing key drivers of HIV vulnerability, which affect the ability of individuals to protect themselves and others from HIV / AIDS.

Key Drivers of HIV Vulnerability

Poverty, gender inequity and Human Rights violations increase people's vulnerability contracting HIV. The challenges of social and structural interventions are daunting, as is assessing the impact. These are important considerations in Prevention Interventions.

HIV-Prevention through Circumcision - Scientific Proofs

Three Landmark Randomised Trials carried out in SA, Kenya, and Uganda were published in 2007. The trials were all terminated early based on interim analyses that showed a significantly lower rate of newly acquired HIV infection for the circumcised versus the uncircumcised men. These 3 studies later formed the basis of a Cochrane review, which confirmed the value of surgical circumcision with healing by primary intention as a method for preventing heterosexual HIV transmission.

The combined results showed that VMMC reduced incident HIV infection rates by 60%. 
As for the Emergency response to HIV / AIDS, the implementation of evidence based scientific studies, in up-scaling programs, is as challenging, but more readily achievable. ARV's have recently proven to be preventative (more than 90% Protection in transmitting the virus), but are costly. ARV's need to be taken lifelong.

 

History of Circumcision

Circumcision

Male circumcision (from Latin circumcidere, meaning "to cut around") is the removal of the foreskin (prepuce) of the human penis. It is a simple surgical procedure that removes the foreskin which is a sleeve of skin covering the tip of the penis.

Circumcision is one of the oldest known surgical procedures. In respect of males it has been widely practiced as a religious rite since ancient times. An initiatory rite of Judaism, male circumcision is also an obligation for Muslims. To them it signifies spiritual purification.

Circumcision is no longer confined to societies with religious motivations; it is now gaining in popularity on account of its health and social benefits. In the United States, Canada, sub-Saharan Africa and parts of Australasia & the Pacific Islands, non-religious circumcision is performed routinely on boys from infancy to adolescence. Worldwide, approximately one in three men are circumcised. This makes male circumcision the most commonly performed surgical procedure on the planet.

History of Circumcision

egypt circumcision smallAlthough its origins are unknown, the earliest reliable evidence of the practice comes from ancient Egypt in the form of pictures dating from 4300 years ago. Cave paintings approximately 15,000 years old appear to show circumcised penises, but not the act of circumcision itself. By the time of the Roman colonisation of Egypt in 30 BC, the practice had acquired a ritual significance; only circumcised priests could perform certain religious rites.

Circumcisions Globally

15 million circumcisions per year, each taking about 20 minutes, means that approximately 500 males are being circumcised right now.

 

Numbers of Circumcised Men Worldwide

Globally, the total number of circumcised men aged 15 years and older can be estimated to be between 661.5 million and 727.65 million or 30% – 33% of men.

ARV’s to Be Taken Early When HIV Positive

There is increasing pressure on the already overburdened Health Services, to commence HIV-positive patients earlier on ARV'S. ARV initiation, according to 2010 Treatment guidelines, is to commence ARV treatment at CD4 counts of 350 cells or lower. In June 2013, the WHO recommends raising the CD4 counts to 500 cells per microlitre of blood. This means, that treatment should start at a much earlier stage of infection.

Problems with ARV’s

ARV's, once started, need to be taken lifelong. Infra structucture needs to be established for Monitoring and Distribution.

If not taken regularly, therapy will fail, Resistence to Medication developed to Medication, and Pro-Viruses may become activated

ARV’s and Cost Savings

Curnently, if every HIV-positive person in Southern Africa (around 22million) would be on ARV's at the cost of $100 per year with the new daily ARV Regime of $9 per month, this would ad about $2 billion per year to the current cost of the 32-year AIDS epidemic in Southern Africa.

Integrating Private Sector into VMMC

Attempting to integrate VMMC into existing State and Public Health Circimcision programs only to achieve targets in Southern African countries is unobtainable. It is absolutely essential to also involve the Private Healthcare sector to reach targets.

WHO Framework for Clinical Evaluation for Circumcision Devices

According to the Framework for Clinical Evaluation of Devices for Adult Male Circumcision (WHO, 2011):

"WHO and other health authorities wish to identify one or more devices that

  • would make the VMMC safer, easier, and quicker
  • would have more rapid healing than current methods and/or might entail less risk of HIV transmission in the post-operative period
  • could be performed safely by health-care providers with a minimal level of training and
  • would be cost-effective compared to standard surgical methods for male circumcision scale up."