Recent evidence that the risk of female-to-male HIV transmission is reduced among men who have been circumcised has led to suggestions that circumcision programs could become a key component of anti-HIV efforts in Sub-Saharan Africa. However, findings from a pair of recent studies highlight some of the obstacles that large-scale circumcision programs would need to overcome. According to a prospective study conducted in Kenya, 35% of young men circumcised by traditional providers and 18% of those circumcised by medical providers experience complications after the procedure, suggesting that extensive training and resources will be needed if circumcision services are to be substantially expanded in developing nations.¹ The second study found that circumcising all HIV-negative men in Sub-Saharan Africa would be far less cost-effective than distributing free condoms to men who need them.² For example, on average, preventing one HIV infection via circumcision would cost an estimated $5,845—more than 100 times the cost of preventing a single infection with condoms.

Complication Rates in Kenya

Several studies have shown that circumcision reduces the risk of HIV acquisition by up to 60%, possibly by eliminating the foreskin cells that HIV targets and by promoting formation of a barrier of epithelial cells. As a result, the World Health Organization and the Joint United Nations Programme on HIV/ AIDS (UNAIDS) recommended in 2007 that access to circumcision services be increased in countries where circumcision rates are low and HIV prevalence high. Because data on rates of complications from circumcision in developing countries are lacking, researchers examined the safety and costs of the procedure in Kenya, where circumcision is almost universally practiced.

Using a two-stage cluster sampling approach, the researchers identified 1,103 males aged 5–21 in the Bungoma district of Kenya's Western Province who expected to undergo circumcision during the July–August 2004 "circumcision season." The 1,007 youth who were subsequently circumcised were interviewed 30–89 days after the procedure about their demographic characteristics; their satisfaction with the circumcision; whether it had been performed by a medical practitioner or a traditional one; and the complications they experienced, if any.

To gather additional information on methods, complications and treatments, the researchers observed the first 12 circumcisions performed by medical practitioners and the first 12 performed by traditional providers, and they examined these 24 participants three, eight, 30 and 90 days after their procedures. An additional 298 participants were examined 45–89 days after their circumcisions. Also, 21 traditional and 20 medical practitioners were interviewed to determine their level of training, their experience with circumcision and related complications, and the cost of their services. Finally, the researchers assessed the instruments and supplies of the traditional practitioners, and inventoried supplies at 15 private clinics, three hospitals and one health center. The researchers used logistic regression to examine associations among demographic characteristics, provider type and complications, adjusting for age, residence (rural vs. urban) and number of days since the procedure.

Slightly more than half (56%) of the young men interviewed had had circumcisions performed by medical practitioners; these participants were younger and more likely to live in urban areas than were participants who had obtained circumcisions from traditional providers. Complication rates were higher for procedures performed by traditional pro-viders than for those done by medical practitioners (35% vs. 18%; odds ratio, 2.5). Bleeding was the most commonly reported complication, followed by infection and excessive pain. Infection rates did not differ by provider type, but participants circumcised by traditional providers were less likely than those receiving circumcisions from medical providers to seek postoperative care at a health facility (odds ratio, 0.7). Among the 24 observed cases, only one participant circumcised by medical practitioners and two circumcised by traditional providers were entirely free of complications.

Examinations of the 298 additional respondents revealed that 45–89 days after their circumcisions, those circumcised by traditional practitioners were less likely than those circumcised by medical providers to have fully healed (79% vs. 90%; odds ratio, 0.4). In particular, young men circumcised by traditional providers were more likely than those circumcised by medical practitioners to have excessive foreskin remaining (12% vs. 2%; odds ratio, 5.3) and significant residual swelling (14% vs. 5%; odds ratio, 3.2); other common complications included lacerations and keloid scarring, each of which was observed in 17% of respondents whose circumcisions had been performed by traditional providers and 10% of those whose procedures had been done by medical practitioners.

Interviews with circumcision providers revealed that medical practitioners had more years of training than traditional practitioners (15.4 vs. 6.8), but had performed fewer circumcisions during the previous two years. Half of the practitioners in each group felt that they could benefit from further training; several traditional providers expressed a desire for information on penile anatomy and for training on how to stop bleeding. However, only one practitioner (a nurse in a government health facility) admitted to feeling inadequately trained to perform circumcisions. Although traditional practitioners charged less than medical practitioners (100–500 vs. 350–2,000 Kenyan shillings), the cost of a traditional procedure can surpass that of a medical one, as the celebration that often accompanies the traditional rite can cost thousands of shillings.

Among circumcisions performed by medical providers, complications occurred in 23% of those performed in private facilities and 11% of those done in public ones. Both types of facilities were frequently missing equipment necessary for safe circumcision; for example, working autoclaves (used for sterilizing medical supplies) were found in only 21% of private and 50% of public facilities. About half of both private and public facilities did not have the appropriate sutures; in fact, four of the 12 observed medical circumcisions were performed without stitching.

The rate of complications found in this study is higher than previously reported in Sub-Saharan Africa, note the researchers, who call the 35% complication rate following circumcisions performed by traditional providers "shocking." Given that this level of complications occurred in Kenya, where male circumcision is routinely practiced, the researchers suggest that extensive training for practitioners and greater resources for supplies and proper equipment will be required if circumcision services are to be ramped up as a means of HIV prevention in Sub-Saharan Africa. Even so, the investigators recommend that circumcision "not be considered a stand-alone medical procedure for HIV prevention, but rather be incorporated into a full complement of HIV prevention and reproductive health services, including, but not limited to, counseling about safe sex, diagnosis and treatment of sexually transmitted infections, HIV testing, and referral to HIV treatment and care."

Cost-Effectiveness: Circumcision Versus Condoms

Another potential obstacle to large-scale circumcision efforts is cost. Although at least one prior study concluded that circumcision may be a cost-effective strategy for fighting HIV, that analysis used data from a region of South Africa where the prevalence of HIV is extraordinarily high (26%). To assess the economic feasibility of circumcision for all of Sub-Saharan Africa, researchers made two adjustments to the approach used in the South African study. First, in calculating the costs of circumcision, they took complications into account, as these events can substantially increase the true cost of the procedure. Second, they estimated the costs not only for circumcision but for an alternative and possibly cheaper strategy: distributing free condoms.

The researchers assumed that the basic cost of a circumcision would be about US$55, as in the South African study. However, guided by results from a literature review, they estimated that 20% of circumcision recipients would have complications, such as excessive loss of foreskin; about a quarter of these complications, representing 5% of all patients, would require inpatient treatment costing an average of $334. Taking these and other "hidden" costs into account increased the average cost of a circumcision by 31%, to $73.

Thus, circumcising the estimated 70 million men in Sub-Saharan Africa who are HIV-negative and have not already been circumcised would cost $5.1 billion—roughly 27 times UNAIDS' 2006 budgeted core contributions for fighting HIV. Moreover, the annual cost of circumcising all HIV-negative males who reach age 15 each year would exceed $700 million. Training and educating the providers required to meet this extra demand for circumcision, and providing the additional clinic capacity that would be needed (some clinics in South Africa, for example, already have such lengthy waiting lists that clients must wait 6–8 months for a circumcision), would further add to the costs.

As an alternative, the researchers calculated the costs of providing free condoms for men unable to purchase their own. Producing and distributing such condoms would cost about three cents each; on average, every eligible man would require about 84 condoms per year. Providing these condoms to the 46% of Sub-Saharan African men whose income falls below the poverty line would thus cost about $224 million per year. Put another way, for the cost of a circumcision, a man could receive a 29-year supply of condoms, which would protect both him and his partner.

The researchers also calculated the number of circumcisions and condoms needed to prevent one case of HIV transmission. Using data from several studies, they estimated that 80 circumcisions would be required to prevent one infection. The same outcome would require 1,568 condoms, assuming consistent use with 87% effectiveness. The cost of preventing one infection, therefore, would be $5,845 for circumcision—about 124 times the cost of preventing an infection with condoms ($47).

Given these findings, the authors conclude that the high cost of circumcision makes it a "questionable" strategy for preventing HIV transmission. Providing free condoms "is estimated to be significantly less costly" and "more effective" than circumcision, and it has the advantage of protecting both men and women. Thus, they recommend that "before circumcision programs are created and funds are raised, their costs should be compared to other AIDS prevention programs so that a rational decision-making process, to spare as many lives as possible, is employed."

—L. Melhado and P. Doskoch

REFERENCES

1. Bailey RC, Egesah O and Rosenberg S, Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya, Bulletin of the World Health Organization, 2008, 86(9):669–677.

2. McAllister RG et al., The cost to circumcise Africa, International Journal of Men's Health, 2008, 7(3):307–316.