Ann Ist Super Sanità 2010 | Vol. 46, No.

4: 349-359 349
DOI: 10.4415/ANN_10_04_02

Male circumcision as strategy

Research and Methodologies

for HIV prevention and sexually transmitted
diseases. The potential role of traditional
birth attendants in neonatal male circumcision
Catia Dini
Direzione Generale per la Cooperazione allo Sviluppo, Ministero degli Affari Esteri, Rome, Italy

Summary. In developing countries, it would be advisable to give priority to human immunodeficiency

virus (HIV) prevention strategies, because of the high mortality caused by the rapid spread of the pan-
demic. Furthermore, HIV prevention could contribute to the mitigation of tuberculosis (TB) propaga-
tion, which is tightly correlated to acquired immune deficiency syndrome (AIDS). As demonstrated,
male circumcision (MC) confers protection against HIV and sexually transmitted diseases (STD). The
suggested strategy considers the neonatal MC advantageous, since it is safer, feasible, culturally more
acceptable and less costly than adult MC. This approach is based on the assumption that, if newborn
males are circumcised, within the next 15-20 years the sexually active population will be almost entirely
circumcised and, consequently, the HIV transmission will be reduced. The employment of retrained
traditional birth attendants is considered in order to implement the MC after the child birth and to
facilitate its acceptance in those contexts where it is not traditionally performed.
Key words: HIV, acquired immunodeficiency syndrome, sexually transmitted diseases, male circumcision, tuber-
culosis, traditional birth attendants.

Riassunto (La circoncisione maschile come strategia di prevenzione dell’HIV e delle malattie sessualmen-
te trasmissibili. Il ruolo potenziale delle ostetriche tradizionali nella circoncisione maschile neonatale).
Nei paesi in via di sviluppo, sarebbe opportuno dare priorità alle strategie di prevenzione del virus
dell’immonodeficienza umana (HIV), a causa dell’alta mortalità provocata dalla pandemia e della sua
rapida diffusione. La prevenzione dell’HIV potrebbe inoltre contribuire a mitigare l’aumento della TB
che è strettamente collegata all’HIV. è stato dimostrato che la circoncisione maschile (CM) protegge
dall’HIV e dalle malattie sessualmente trasmissibili (MTS). La strategia proposta considera i vantaggi
della CM neonatale, in quanto più attuabile, culturalmente accettabile e meno costosa della CM adul-
ta. La strategia si basa sul presupposto che se i bambini vengono circoncisi alla nascita, in 15-20 anni
la popolazione sessualmente attiva sarà quasi del tutto circoncisa e di conseguenza la trasmissione
dell’HIV ridotta. L’utilizzo di ostetriche tradizionali riqualificate viene preso in considerazione per
eseguire la CM subito dopo la nascita del bambino e facilitare la sua accettabilità nei contesti in cui
non è eseguita tradizionalmente.
Parole chiave: HIV, sindrome da immunodeficienza acquisita, malattie sessualmente trasmissibili, circoncisione
maschile, tubercolosi, ostetriche tradizionali.

INTRODUCTION discussion about the prevention methods of HIV, by

Human immunodeficiency virus (HIV) is a global identifying key actors for the implementation of the
health issue, being a threat to the health of the entire practice.
mankind, through population mobility and tubercu- Investing in MC as a part of a comprehensive HIV
losis (TB) co-infection associated with the HIV pan- prevention package is justified by the proliferation of
demic. the virus not only in Africa, Asia, and the Caribbean
The present paper is a review of the international de- area, but also in Eastern Europe, in Mexico and more
bate about an HIV prevention approach, the male cir- recently in Central America. MC could prevent millions
cumcision (MC). Epidemiological evidence, showing of HIV new infections especially in sub-Saharan Africa
a significant association between the lack of MC and and save on future treatment costs [1]. The practice is
the HIV infection, has raised the consideration of MC an opportunity to develop innovative programmes and
intervention as a strategy to reduce HIV prevalence in to re-engage with policymakers and planners about the
affected areas. This paper is willing to contribute to the implementation of a prevention strategy.

Address for correspondence: Catia Dini, Direzione Generale per la Cooperazione allo Sviluppo, Ministero degli Affari Esteri,
Piazzale della Farnesina 1, 00135 Rome, Italy. E-mail: catia.dini@esteri.it.
 350 Catia Dini

Given the enormous mortality and morbidity mental evidence of the efficacy of MC in protecting
Research and Methodologies

caused by HIV/AIDS, prevention efforts should be men against HIV infection, as it was conducted in
greatly prioritized in the response to the pandemic. a general population and was the first randomized
A global health task force could be created also in control trial testing the impact of MC. The dem-
Italy – and the Istituto Superiore di Sanità may lead onstration in this study of a causal association be-
it – offering guidelines, according to the internation- tween HIV infection and MC is consistent [13]. The
al research findings, for the implementation of MC study states that MC provides a degree of protection
by all cooperation relevant actors. against acquiring HIV, equivalent to what a vaccine
of high efficacy would have achieved. Consequently,
Male circumcision a practice thousands of years old the authors think that MC should be regarded as an
Performed especially among Jews and Muslims important public health intervention and point out
for reasons of religious duty, MC is also widespread the importance of the MC at a time when no vaccine
among the Coptic Christians and in some parts of or microbicides are currently available. Auvert et al.
Oceania. The World Health Organization (WHO) make a reference to a previous study which suggested
and the Joint United Nation Programme on HIV/ that the widespread use of antiretroviral will not sub-
AIDS (UNAIDS) estimate that 664 500 000 males stantially reduce the heterosexual spread of HIV in
aged 15 are circumcised (30% global prevalence), sub-Saharan Africa [14]. Moreover, counselling asso-
with almost 70% of these being Muslims [2] and that ciated with MC, by advising about safe habits, could
in the US 56% of male are circumcised [3]. determine an increase of correct sexual behaviours.
However, the population-based prevalence in the A further analysis suggests that “MC could avert
US is likely closer to 79%, as reported by the National nearly six million new infections and save three mil-
Health and Nutrition Examination Surveys [4]. A lion lives in sub-Saharan Africa over the next twenty
study indicates that the recognition of the potential years” [15].
benefits of the neonatal MC may have been responsi- In December 2006, two randomized trials carried
ble for the observed increase in the US rate between out in Rakai District, Uganda [16] and Kisumu,
1988 and 2000 of newborn circumcision by 6.8% [5]. Kenya [17], revealed at least a 51% and 53% reduction
in the risk of acquiring HIV infection, respectively.
These two trials results support the findings pub-
STUDIES, MEDICAL TRIALS AND lished in 2005 from the South Africa Orange Farm
RECOMMENDATIONS OF UNITED NATIONS Intervention Trial, sponsored by the French National
A number of observational studies point out that Agency for Research on AIDS. “The three trials
circumcised men have lower levels of sexually trans- found that circumcision decreases HIV acquisition by
mitted diseases (STD) such as HIV, penile carcinoma, 53% to 60%, herpes simplex virus type 2 acquisition
urinary tract infections, and ulcerative STD [6, 7]. by 28% to 34%, and human papilloma virus preva-
Similarly, a review of MC and ulcerative STD strong- lence by 32% to 35% in men. Among female partners
ly indicates that circumcised men are at lower risk of of circumcised men, bacterial vaginosis was reduced
chancroid and syphilis than uncircumcised men [8]. by 40%, and Trichomonas vaginalis infection by 48%.
The reason lies in the fact that “the inner surface of Genital ulcer disease was also reduced among males
the foreskin contains Langerhans’ cells with HIV re- and their female partners. The findings are supported
ceptors; these cells are likely to be the primary point by observational studies conducted in the US” [18].
of viral entry into the penis of an uncircumcised man” The analysis by Williams et al. provides evidence
[9]. By removing the mucosal surface of the penis fore- that, while the protective benefit to HIV-negative
skin, the MC reduces the susceptibility to the virus. men will be immediate, the full impact of MC on
A study published in 1999 pointed out that a dec- HIV-related illness and death will be apparent in ten
ade had passed since the publication of Cameron to twenty years.
and colleagues prospective study [10] that showed a In February 2006, a further medical study conduct-
greater than eight-fold increased risk of HIV-1 in- ed on more than 300 Ugandan couples, suggested
fection for uncircumcised men [11]. that MC also benefit women. The study estimated
that circumcised men infected with HIV were about
Trials and main medical studies 30% less likely to transmit it to their female partners.
A trial conducted in 2005 by the French National 299 women acquired HIV from an uncircumcised
Agency for Research on AIDS with the National male, compared to just 44 who acquired it from a
Institute for Communicable Disease of Johannesburg circumcised partner [19]. A review summarises the
in South Africa randomized 3274 uncircumcised evidence studies for a direct effect of MC on the risk
men, aged 18-24 [12]. of women becoming infected with HIV [20].
MC was offered to the intervention group immedi-
ately after randomization and to the control group at Recommendations of United Nations
the end of the follow-up. Results showed that in the Organizations about male circumcision
group of men that had been circumcised, the level of  In April 2006, The National Council in Zambia,
protection achieved against the infection was 60%. A with support from the UN Theme Group on HIV,
study assesses that the trial provides the first experi- launched the HIV Prevention Year 2006 [21]. The
 Male circumcision as strategy for HIV prevention 351

frame reports the experiences of countries where  IV AND TUBERCULOSIS

H

Research and Methodologies

United Nations Development Programme (UNDP) CO-EPIDEMIC: A SEVERE THREAT
operates on MC and suggests the urgent need of TO THE GLOBAL HEALTH
expanding MC services, in order to respond to the HIV prevention is also an important global health
increasing demand from people. Moreover, UNDP priority as the largely collision of HIV and TB epi-
provides programmes for traditional healers (TH) demics, exploded in sub-Saharan Africa, has created
[22]. a co-infection that is rapidly spreading.
 In 2007, UNAIDS Practical guidelines for inten- The HIV/TB co-epidemic represents a setback to
sifying HIV prevention. Towards universal access, global control of TB, which would otherwise be in
provided information about the MC and suggested large-scale decline. These twin epidemics present a new
the involvement of faith-based organizations (FBOs) health threat and raise the prospect of a global pan-
and traditional healers for HIV prevention and pro- demic of extensively-drug-resistant TB, which will be
motion of MC [23]. extremely difficult to treat.
In 2008, WHO led a consultation on MC in the
African Region [24]. It was observed that the introduc- Why the HIV infection is driving the TB epidemic
tion of MC services could provide opportunities for HIV is one of the strongest risk factors for develop-
capacity building in the health sector, such as training ing active TB, similarly TB sufferers are more vulner-
of personnel in minor surgical procedures and coun- able to HIV infection. In fact, the number of TB cases
selling. in Africa is expected to double over the next decade
In 2008, WHO published a “technical manual” on largely due to the HIV epidemic [29].
MC, in order to provide a practical guide on safe meth- There is evidence that the stage of HIV infection is
ods to perform MC, both on newborns and adults [25]. correlated with increased risk of TB infection. The
The manual points out that countries in sub-Saharan immune system uses CD4 cells to defend the body
Africa where MC is common ( > 80%) generally have against TB. A decline in CD4 cells, due to HIV, less-
an HIV prevalence well below those of countries where ens the immune systems ability to prevent the growth
MC is less common (< 20%). and spread of TB. A weakened immune system allows
The manual includes the following benefits of cir- for dissemination of bacteria to areas other than the
cumcision: lungs, which explains the increased chance of extra-
- reduced risk of urinary tract infections in child- pulmonary TB among HIV-positive individuals. TB
hood; increases HIV replication and viral load, worsening
- prevention of inflammation of the glans (balani- the course of related immunodeficiency.
tis) and the foreskin (posthitis), of the phimosis An example of the rapid rise of HIV co-infection
and paraphimosis; in TB patients can be found in South Africa’s gold
- reduction of the risk of some STD, especially ul- mines. According to a study in the Free State Province,
cerative diseases, such as chancroid and syphilis; the TB prevalence rose from 15% in 1993 to 45% of
- reduction of the risk of becoming infected with all HIV patients in 1996 [30]. A retrospective cohort
HIV; study of South African gold miners found that TB
- reduction of the risk of penile cancer; incidence doubled within the first year of HIV infec-
- reduction of the risk of cancer of the cervix in fe- tion, thus supporting the need for widespread HIV
male sex partners. testing as a preventive measure against TB [31].
In 2009, a toolkit was provided in order to hasten The risk of developing active TB in an HIV-nega-
the MC implementation in endemic countries, show- tive individual is 10% over the course of their life-
ing the feasibility of MC performed by well trained time. This risk increases 5-10 times to 7-8% per year
providers belonging to the public health system or in HIV-positive people [32]. Research also shows that
to the traditional healing services [26]. HIV infection during infancy increases the risk of de-
WHO is leading the UN agencies: UNAIDS, veloping TB [33]. TB manifestations are more severe
UNICEF and United Nations Population Fund in HIV-positive children and progression to death is
(UNFPA) to support countries to develop MC poli- more rapid than in HIV-negative children [34].
cies, within the context of a comprehensive HIV pre- A study, which followed adult patients attending
vention strategy. the University of Cape Town’s HIV clinics between
According to the above agencies, HIV prevalence in 1986 and 1996, shows that the incidence of TB in
the south and southeast Asian Countries where near- AIDS patients is 500 times that of the general pop-
ly all men are circumcised (Bangladesh, Indonesia, ulation and TB likely accounts for nearly 40% of
Pakistan, Philippines) remains particularly low, de- AIDS deaths in the African region [35].
spite patterns of risk factors for HIV and other STDs
similar to those found elsewhere in the region [27] HIV and multi-drug resistant TB
According to UNICEF, the education sector is a Co-infection with HIV/TB presents serious medi-
vital channel to inform young people and to pre- cal and scientific challenges, among them difficul-
vent the HIV. In Lesotho, Namibia and Zambia it ties in diagnosis, infection control, and managing
is making assessments of the effectiveness of this co-toxicities between drugs previously used to inde-
strategy [28]. pendently treat the two diseases.
 352 Catia Dini

TB patients with HIV have been shown to be b) in communities where male circumcision is not
Research and Methodologies

twice as likely to have MDR-TB as people who common, in addition to the above activities,
are not HIV-positive. There is also evidence that the assessment of MC acceptability, address-
in resource-limited settings where TB is a major ing any myths and misconceptions associated
cause of mortality among HIV patients, a multi- with MC, and presenting the evidence of the
drug resistant TB (MDR-TB) and an extensively protective effect of MC on HIV infection;
drug resistant TB epidemic (XDR-TB) are emerg- c) identification of a curriculum that provides infor-
ing [36]. mation and develops skills related to the benefits
of MC, personal hygiene, post-surgery wound
care, avoidance of high-risk behaviours and
CHRISTIAN AND CATHOLIC ASRH.
VIEW ON MALE CIRCUMCISION
The Catholic Medical Mission Board (CMMB)
has commissioned a study on FBOs and MC ACCEPTABILITY
practices in Kenya. CMMB convened the Eastern OF MALE CIRCUMCISION
and Southern Africa FBOs Male Circumcision One of the concerns around the potential of MC
Consultation Meeting in Kenya in 2007 [37]. The as an HIV prevention measure is that it may not be
motivating factor for the meeting is the increased acceptable in communities which do not tradition-
involvement of African FBOs in MC. ally circumcise.
Surveys and qualitative studies among young as
Catholic Medical Mission Board. Faith-based well as older men in six African countries have found
organizations and adolescent male circumcision that a considerable proportion expressed interest
The lessons learnt from country experiences iden- in MC, ranging from 45% in Harare, Zimbabwe,
tified three key areas to be developed, if FBOs to over 80% in a large survey in Botswana. In the
want to make a substantive contribution to provid- surveys, the men reported that their main interest
ing MC, both for HIV prevention and as an entry in MC was related to hygiene, infection control and,
point for adolescent sexual and reproductive health. for some, a belief that condom use is easier for men
Participants in the conference: who are circumcised [38].
- recognised that FBOs have a significant role to A recent comprehensive review addresses this issue
play in scaling up MC for HIV prevention among by summarising 13 studies assessing the acceptability
adolescents, as they are trusted and respected in of offering MC services among traditionally non-cir-
the communities and they already have infra- cumcising groups in east and southern Africa. The
structure, capacity and networks that could be median proportion of uncircumcised men willing to
used to provide MC services; become circumcised was 65% [39]. Similarly, 69% of
- agreed on priority actions to improve the cover- women favoured circumcision for their partners and
age and effectiveness of MC for adolescents: a 71% of men and 81% of women were willing to cir-
national MC policy framework; mobilization of cumcise their sons. According to the study, the influ-
communities to increase the acceptability of MC; ence of women on the decision to circumcise is likely
monitoring/evaluation of existing MC services; to be highly variable across cultures and across fami-
testing of different models of service delivery, lies within communities. However, in many settings,
both hospital and community-based, including women, as mothers and as partners, are likely to have
adaptation of existing programmes and techni- considerable influence, even if it is not explicit. The
cal guidance available from WHO and UN part- effort to promote MC will be more successful if it
ners; appeals to women as well as men.
- identified factors to consider when using adoles- The review underlines that the most salient barri-
cent MC as an entry point for adolescent sexual ers to the acceptability of MC were the concerns for
and reproductive health: safety, the cost of the procedure and the fear of pain.
a) in settings where MC is common (traditional), In areas where MC is uncommon, the clear prefer-
community mobilization and advocacy steps ence was for a medical practitioner to be the provid-
to expand their focus to HIV prevention and er, as this was perceived to be safer.
adolescent sexual and reproductive health Cost as a primary consideration was shown by the
(ASRH). Actions should include: stakehold- pilot intervention in Siaya, Kenya, where men came
er meetings and communication that target in large numbers when the charges of MC were low-
traditional circumcisers, church, traditional ered to US$ 1.45 [40].
leaders and health providers; the use of IEC The study identified that the main factors associat-
(information-education-communication) ma- ed with willingness to be circumcised were improved
terials; community meetings and entertain- hygiene and a reduced risk of STD. Penile hygiene
ment to support MC; resource mobilization was recognized as a major benefit of MC by both
to enhance the availability and accessibility of men and women. MC was widely perceived to protect
safe MC services, thus increasing the uptake against infections and to allow for easier identifica-
of adolescent MC; tion of sores and ulcers, permitting earlier treatment.
 Male circumcision as strategy for HIV prevention 353

Studies about the acceptability of male circumcision adults was higher than 5% were investigated.

Research and Methodologies

A number of studies assess the acceptability of MC. Recently, the evidence of the range of health ben-
A survey carried out in the Dominican Republic efits that MC provides and cost-effectiveness data in
[41] found that rolling out circumcision services is both Africa [47] and US [48, 49] offer further incen-
feasible. An education and information programme tive for implementation.
about the benefits of MC aimed at sexually active Moreover, benefits are greater than estimated as MC
young males and mothers is essential to increase the confers protection on women in addition to the circum-
acceptance of the procedure. The objective of the cised men and prevent infections among newborns, due
study was to assess the opinions and attitudes about to protective effect on adult women. Implementation
MC, the acceptability of the procedure, the circum- of MC can lower public health system costs because
cision status, sexual practices, and history of STD of the resulting averted HIV care costs.
among men 18 to 50 years of age in the Altagracia
Province. A survey was administered to 368 men in 5 Male circumcision implementation
municipalities across the province. The sample con- in southern African countries
sisted of 238 (65%) Dominican men and 130 (35%) Despite the positive evaluation of the MC prac-
Haitian immigrants. Almost all the men were uncir- tice, progress in achieving coverage of adult target
cumcised (95%) and about half (52%) were single. people is very slow [50, 51].
Overall, Haitian men were more likely to agree to a Potts et al. point out that waiting for further re-
circumcision than Dominicans. sults of randomised trials for MC interventions can
In western Kenya, among the Luo, a large, tradi- cost hundreds of lives, especially in poor countries
tionally non-circumcising ethnic group, both men with great need and potential to benefit. In their
and women desired availability of MC clinical serv- study of 2006, the authors underline the necessity
ices in the Province’s health facilities [42]. of beginning the MC implementation immediately,
In Malawi, acceptability was lower in the North as the demand for MC in Africa vastly exceeds the
where the practice was little known, higher among supply [52].
younger participants and in central and south- Countries all over Africa are at various stages of
ern districts where MC is practiced by a minority developing and implementing policies for mass MC,
Muslim group (Yao) [43]. but only in Kenya MC has been rolled out on a large
In Zimbabwe, despite the absence of specific edu- scale. In November 2008, the Ministry of Health
cational or promotional efforts, and before knowing (MoH) launched a voluntary MC plan, which aimed
the results of current clinical trials of circumcision’s to have 1 million men circumcised by 2013. By the
efficacy in preventing HIV, nearly half of the men end of 2009, 90 000 men had been circumcised, es-
(data were collected from a sample of 200 men aged pecially in Nyanza Province, where the HIV preva-
31 years) expressed willingness to undergo the pro- lence is the highest in the country. In the Province
cedure [44]. 650 providers have been trained [53] and the support
In India a study found MC to be highly acceptable of traditional leaders has been pivotal [54].
among a broad range of mothers in Mysore who ap- In a number of African countries, the lack of policies
peared to be greatly motivated to learn more about and planning, the training of an insufficient number of
MC. Although the majority of men in this popu- providers, the missed involvement of nurses and tradi-
lation are currently uncircumcised, 88% of partici- tional healers and the lack of financing have led to a
pants with uncircumcised children stated – after be- poor implementation. Few examples are given below.
ing informed of the risks and benefits of MC – that - Namibia: a study to understand attitudes, impact,
they would “definitely” or “probably” circumcise and resource implications of implementation has
a male child if the procedure was offered free of been done and a MC action plan, submitted to the
charge in a hospital setting [45]. Parliament in 2009, included shifting of surgical
tasks to nurses. The cost of the procedure (unit
cost for adults is US $88 and $ 72 for newborns)
PROSPECTS AND CHALLENGES was the main constraint to a large scale implemen-
FOR MALE CIRCUMCISION tation.
MC is among the most economically efficient HIV - Lesotho: MC services are limited, with about 4000
prevention strategies in sub-Saharan Africa. According men circumcised annually through government
to Auvert et al., medical adult male circumcision clinics and two NGOs. Even though advocacy has
(MAMC) may avert 2 to 8 million HIV infections over been done with traditional leaders and ways to in-
20 years in sub-Saharan Africa and costs less than volve traditional providers are being explored, a
treating those who would have been infected [46]. The formal scale-up has not yet started.
authors estimate the financial and human resources - Swaziland: despite a number of relevant interna-
required to roll out MAMC and the net savings due tional partnerships for MC implementation in the
to reduced infections. The model developed included adolescent and adult male population, the train-
costing, demography and HIV epidemiology. Fourteen ing of providers is taking time and the few trained
countries in sub-Saharan Africa, where the prevalence are not properly utilized as the number of males
of MC was lower than 80% and HIV prevalence among circumcised by each provider is very low.
 354 Catia Dini

Male circumcision formal training care of the wound himself, heal faster than if done
Research and Methodologies

Johns Hopkins Program for International Education post-pubertal, and has likely not begun sexual ac-
in Gynaecology and Obstetrics (Jhpiego) based in tivity [58].
US, is the organization leading the training program If local anaesthesia could be necessary for chil-
for MC providers in sub-Saharan Africa. In 2008, dren, demanding specific training of providers and
Jhpiego developed in Zambia a “training model” that supplies, MC can be performed without anaesthesia
integrated clinical and counselling services around and at the least physical risk on infants [59].
MC and tested the feasibility of providing MC, es- In low endemic countries, the strategy combining
pecially in private clinics. Jhpiego is also working in neonatal MC and pre-adolescent MC could allow
Swaziland where it is supporting the MoH to intro- total MC coverage for future generations, slowing
duce international doctors, in order to assist with down the advance of HIV infection.
delivery of MC and build capacity of local medical
staff to provide MC. Circumcision of boys and adolescents. In Swaziland,
best practices to provide adolescents relevant infor-
mation on MC are emerging through schools and
REASSESSING THE STRATEGY communities [60]. The strategy to combat the pan-
Current WHO and UNAIDS guidelines emphasise demic could start by the central role of the school
MC as a clinical practice within health delivery set- in the society. Besides the study curriculum, that can
tings. However, the strategy described above needs provide a comprehensive information about HIV pre-
lots of providers to be trained in order to target adult vention, circumcision of boys could be performed di-
males and lot of medical supervision. At the same rectly in schools by retrained TH or registered nurses,
time it requires health facilities and equipment. thus carrying out it before sexual maturity.
The need to ensure sufficient qualified personnel
available to do MAMC is critical. The implemen- Circumcision of newborn male children. Newborn
tation of MC in poor contexts and the consequent MC has existed for more than 6000 years.The results
accessibility for the majority of adult people is very of the clinical trials present the opportunity to re-
slow: already overwhelmed health systems run the examine national and professional policies on infant
risk of retarding the MC availability. The benefits circumcision.
may be confined only to those who have access to WHO and UNAIDS recommend that neonatal
the health facilities and can afford the MC cost. circumcision should be a component of prevention
In the meantime the planning of services for new- campaigns, since “neonatal circumcision is a less
borns and pre-adolescents is not scheduled, although complicated and risky procedure than circumcision
– especially for babies – the procedure is simpler and performed in young boys, adolescents or adults [and]
quicker. countries should consider how to promote neonatal
The scale-up of children MC requires the use of circumcision in a safe, culturally acceptable and sus-
local human resources available at community level tainable manner” [61].
such as local traditional practitioners [55, 56]. The In addition, a study by Schoen found out that
development of plans including community human postneonatal circumcision was 10 times as expensive
resources and FBOs should be prioritized. Research as neonatal circumcision ($ 1921 per infant vs $ 165
on the ethnic and cultural dynamics of scale-up per newborn) [62].
should be encouraged [57].
Rwanda: a cost-effectiveness study [63]. In
Age for male circumcision Rwanda, where adult HIV prevalence is 3%, MC is
The age at which males become circumcised will not a traditional practice. Before the introduction
have an effect on how rapidly MC interventions may of a country-wide MC program, in accordance with
impact the HIV epidemic in any given area. A pro- the Rwanda National AIDS Commission, research-
gramme for MC can be performed for all the neces- ers identified the most cost-effective way to increase
sary target groups: adults male who do not have HIV, MC rates. The scholars developed a simple cost-ef-
those already HIV positive, newly born children and fectiveness model and applied it to three hypotheti-
children before puberty. In hyper endemic countries cal groups of Rwandans: newborn, adolescent boys,
significant achievement in the reduction of HIV pan- and adult men. Analyses showed that MC is a cost-
demic can only be obtained if all males after puberty saving HIV prevention intervention, since both neo-
are circumcised. However, the implementation of natal and adult MC could save Rwandan resources
services for MAMC is taking too much time as sub- for each HIV infection averted.
stantial human and financial resources are needed. The findings suggest that infant MC for the pre-
There appeared to be two leading directions: vention of HIV infection later in life is highly cost-
- circumcise male babies, due to a simpler and low effective and likely to be cost-saving. The cost of
cost procedure, less fear, easier care and faster neonatal MC is US$ 15 while adolescent and adult
healing; MC are significantly more expensive (US$ 59). The
- circumcise children at ages 7-13 years, since the boy researchers estimated the cost of circumcision of in-
can understand the significance of the event, take fants employing the Mogen Clamp method.
 Male circumcision as strategy for HIV prevention 355

That technique was selected because it is a simple An investigation by Coffee et al. considers that in

Research and Methodologies

procedure that requires only one reusable piece, does South Africa the circular labour migration has pos-
not need suturing and causes less pain and compli- sibly disseminated the disease widely, as the high-
cations than other methods. The Mogen Clamp risk behaviour of migrants leads to increased HIV
method appears suitable for national roll-out, even exposure of their partners in rural communities
in remote areas. [66]. This aspect is more relevant when workers re-
Given the low cost and long term benefits, the study turn frequently to their villages. A further research
suggests that countries with moderate HIV epidemic by Coffee et al. in South African rural areas indi-
should offer routine infant MC, integrated into ex- cates that high HIV prevalence may be influenced
isting health services and concludes that providing by migration. The mobility causes social disrup-
universal access to MC, especially neonatal MC, will tion, increasing high-risk sexual behaviour, both
reduce the overall cost of fighting severe HIV epi- among migrant workers and women who remain in
demics, driven by heterosexual transmission. rural communities, as they may engage with differ-
The research mentioned above points out that African ent partners. Therefore, the frequent return of mi-
governments and development partners should stop grants may only exacerbate the risk of HIV propa-
managing the HIV response as an emergency issue gation [67].
only and release themselves from a 1-year or even a 5- It is worth taking into consideration a number
year planning perspective to focus on sustainable long of countries where the HIV prevalence is presently
term options for endemic countries. The study strongly low, but where risk factors exist, such as migrations
indicates that from a development viewpoint, as infant (seasonal and mid-term), risky behaviours, malnu-
MC is proven to be an effective means of HIV preven- trition, poverty, illiteracy, TB, malaria, limited ac-
tion, action cannot be deferred simply because gains cess to health services and lack of knowledge about
will be achieved in the future. HIV aetiology. Emerging HIV epidemics have long
latency periods, as the infection grows within con-
centrated risk groups and then extend to the general
PLANNING FOR NEONATAL population [68].
MALE CIRCUMCISION
Neonatal circumcision has been proven to be con- Acceptability of infant male circumcision
siderably safer and significantly less expensive than Few studies underline the growing interest for in-
adolescent or adult circumcisions. fant MC. A small number of inquiries about accept-
ability of newborn circumcision have been carried
Planning in regions more at risk of HIV infection out among mothers or expectant parents.
The exceptionally high prevalence of HIV in most A survey investigated the acceptability of infant
southern African countries has raised questions MC among mothers in south-eastern Botswana
about the factors that have contributed to the rapid [69]. Women were given an illustrated pamphlet, a
spread of HIV in that region and about the even- written description of MC techniques and a list of
tual prevalence the epidemic might reach in regions benefits and potential risks. The main benefits listed
showing the same pattern The presence of such risks were the reduction of the risk of urinary tract in-
have been analysed in a number of researches. fections in childhood and of acquiring STD later in
It is important to start the scheduling of the MC life, including HIV. Sixty women (97%) completed
procedure in those countries that present risk fac- the questionnaire. When asked if they would be in-
terested in having her newborn son circumcised free
tors that could lead to high prevalence of the HIV
of charge at that hospital by a trained doctor, 55
infection in the next future. (91.7%) women said yes (95% CI 81.6 - 97.2%), 1
was unsure and 4 said no. When asked who would
Migration primarily influences HIV spread be the primary decision maker as to circumcise their
A multi-centre study [64] analyses the socio-economic son, 38 (63%) women identified themselves, 13 (22%)
contexts that give rise to population mobility and their their partner, 6 (10%) their mother, 2 (3%) said their
relationship to vulnerability to STD/HIV. It points out own father and 1 (2%) said the child himself if he
that in Central-America and Mexico, migrant women was at least 16 years old. 51 women (85%) said their
and sex workers are particularly exposed to HIV, due to partner would definitely have to agree to the proce-
transactional sex or sex for survival, becoming means dure before their male infant could be circumcised. 6
for further contagion of male partners. (10%) said they could be the only decision maker. 3
Moreover, in areas of increasing migration, factors were unsure.Another example is Thailand. Although
such as separation from families and communities and the country has a predominately non-circumcision
hard working conditions contribute to an increased culture, neonatal MC was found to be acceptable
vulnerability of the migrant men to STD/HIV, as they to expectant parents if they were informed about
engage habitually in high risk sexual behaviors. the benefits and risks of the procedure. Expectant
A study by Lurie et al. provides evidence for the cru- parents were more willing to circumcise their newborn
cial role of migration in the spread of HIV in South sons if they were in a lower income group or if the pro-
Africa [65]. The research also emphasises the role of cedure was recommended by a physician or if it was free
migration in the early stages of the epidemic. of charge [70].
 356 Catia Dini

Facilitators of acceptability. MC was only rolled Therefore TBA can act as a link between public
Research and Methodologies

out to neonates, it would take at least a generation health policies and the community.
before a population-level effect occurs. For this rea- To rely on TBA is also a very cost-effective measure
son, it is important to start MC in settings with low since, when attending deliveries, they are awarded by
HIV prevalence, where – on the other hand – there families in kind or with small amount of money, on a
are risk factors that could rapidly increase the vul- volunteer basis. This fact makes the model sustainable
nerability to HIV. The acceptability of the practice by the community itself. Therefore, the strategy could
could be increased by governments, throughout ap- be easily replicated.
propriate campaigns and the use of local traditional Finally, TBA could deal with those social determi-
leaders. nants that elevate the HIV infection risk between ado-
lescent males.
Traditional health leaders and acceptability of the
procedure. As the health system needs to be strength- TBA training
ened in order to increase access to safe MC services, The public-health system and the international agen-
the inclusion of retrained TH and TBA – as mem- cies are working to increase the availability of trained
bers already active in the community in respect of TBA in communities with high rates of maternal mor-
whom rural people have full confidence – should be tality [74].
given priority. The retrained TH together with local The same approach could be used in providing TBA
communicators are able to convey the most appro- with all necessary knowledge and skills about HIV pre-
priate messages to raise awareness in communities vention. They can easily be trained in order to carry out
and overcome barriers to acceptance of MC in ar- MC on babies in the rural and suburban areas, at the
eas where it is not practiced. In countries where MC same time as they are retrained for a proper assistance
is already performed it is worth working in concert to pregnant women. Neonatal MC could be included
with the local traditional authorities. in a broader “reproductive health programme”. The
teaching should focus on safety and hygiene in both
The potential role of TBA in expanding neonatal practices: delivery and neonatal MC.
male circumcision services. One of the main chal- Therefore, during the refresher training, TBA should
lenges to HIV prevention is to provide vulnerable learn technical skills related to:
groups with evidence-based and cost-effective pre- a) the informational campaigns, in order to create
vention strategies. Decentralization of HIV preven- awareness of the population about the spread of
tion services is a crucial priority and could be eas- STD/HIV and to facilitate the acceptability of
ily implemented through locally available human neonatal MC;
resources, according to the strategy of the Primary b) the assistance before, during and after delivery,
Health Care [71], that “relies, at local and refer- performing the skills learned during the refresher
ral levels, on health workers, including physicians, training, supported by the proper equipment (fetal
nurses, midwives, auxiliaries and community work- stethoscope, gloves, etc.);
ers as applicable, as well as traditional practitioners c) the implementation of neonatal MC, supported by
as needed, suitably trained socially and technically the essential equipment;
to work as a health team and to respond to the ex- d) the education of mothers concerning the youth
pressed health needs of the community” [72]. sexual risky conduct, thus promoting conscious-
MC offers the opportunity to reengage with ethnic ness about safe behaviours in adolescents, there-
or indigenous groups, if MC is considered a part of fore offsetting cultural factors that encourage un-
larger “reproductive health programme” aiming at safe habits.
diminishing the rates of maternal mortality, through
refresher trainings for TBA (or midwives). In 2006, Health ministries involvement
UNFPA and WHO launched an intensive country Training should start without delay in nursing
support initiative, recognizing the pivotal role of and midwife schools in resource-poor settings. This
midwives in providing quality women-centred ma- should be a priority for governments, non govern-
ternity care [73]. mental organizations (NGOs) and multilateral or-
Although MC implementation could be critical ganisations. Regional centres of excellence should
in regions where it has no cultural value, the com- be established for training practitioners, monitoring
munity health resources can offer a significant link quality and assessing outcomes [75]. The study sug-
between modern and traditional health services. gests that country specific tool kits for health min-
TBA could be the human resources required to ex- istries should be developed, including manuals and
pand safe neonatal MC services, as they share the modules for the training of trainers.
language and the cultural background and play a Governments and development agencies should
relevant role in the community, attending mothers move towards a planning perspective for sustainable
an babies. Therefore informational campaigns may national programmes. In preparation for scale-up,
be more effective if targeted to the particular cul- widespread public information campaigns that de-
ture of indigenous populations, utilising the TBA, scribe benefits and place neonatal MC into the larg-
as they know local customs, traditions and values. er prevention context should be undertaken.
 Male circumcision as strategy for HIV prevention 357

CONCLUSION is appropriate in countries where HIV has low prev-

Research and Methodologies

Countries currently characterized by low preva- alence, but where the presence of risk factors could
lence of HIV should be carefully monitored if lead to an hyper-endemic situation in the next years.
risk factors, such as mobile population, are highly In order to increase the acceptability of this prac-
present. Such issues could cause, in 5-15 years, the tice, it would be crucial to involve TBA as perform-
same patterns of prevalence noticed in sub-Saharan ers of MC. They are in charge of attending women
Africa. In fact, migrant populations are particularly delivery and can be retrained in both maternal repro-
vulnerable to HIV, due to their risky sexual behavior. ductive health and in neonatal MC. Moreover, they
In Central-American countries and Mexico, migra- are recognized members of the communities and can
tions are widely present and could lead to the fast play a key role as educational resources, explaining
spreading of HIV pandemic in the region. the benefits of the procedure to the population, thus
As it is stated in many studies, MC could be con- facilitating the acceptance of the practice.
sidered an effective method of preventing HIV in
heterosexual intercourses. Significant achievements The ideas expressed in this paper do not necessarily reflect any
in the reduction of the pandemic could be obtained official view of the Italian Ministry of Foreign Affairs.
if the majority of males were circumcised.
The implementation of programmes that perform Conflict of interest statement
MC in adults and children (before or after puberty), is There are no potential conflicts of interest or any financial or per-
sonal relationships with other people or organizations that could
taking too long, because important human and finan- inappropriately bias conduct and findings of this study.
cial resources are needed. However, MC can be imple-
mented in newborn children with minimum risk and Received on 24 May 2010.
cost. Given its long-term effectiveness, the measure Accepted on 2 September 2010.

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