Male Circumcision

Project Archive

Sonke Gender Justice is involved in research and advocacy related to male circumcision.

Some of the areas that Sonke Gender Justice is working around are:

  • the impact of male circumcision on women,
  • how to integrate gender equality training into MC interventions,
  • scale up challenges and health systems capacity, and
  • the role of traditional circumcision schools.

Sonke Gender Justice staff have conducted qualitative research in both Swaziland and Lesotho and participated in many UNAIDS and WHO meetings on the issue. In 2008 Sonke will be working closely with Constella Futures Health Policy Initiative and the National Department of Health to develop national policies on men and sexual and reproductive health including a focus on male circumcision.

Male Circumcision and HIV Prevention

Recent improvements in antiretroviral treatment coverage for people living with AIDS have not been replicated in the area of HIV prevention. While surveys across the region show substantial increases in knowledge about the causes of HIV infection and improvements in condom use, almost all countries continue to show rapidly escalating numbers of new HIV infections, with South African studies reporting 1500 new infections a day or nearly 500,000 new infections a year.[i] The April 2006 editorial of the South African Medical Journal provides a snapshot of how this context shaped perceptions and expectations related to male circumcision:

“We need some brave thinking on prevention – conventional approaches alone do not seem to work, and acknowledgment of this is long overdue…We need massive and creative interventions, including looking at controversial but seemingly effective interventions such as male circumcision.”[ii]

With two decades of observational studies and meta-analyses suggesting a link between male circumcision and increased protection against HIV transmission,[iii iv] and a number of studies indicating high levels of potential acceptability,[v vi vii viii ]three experimental studies on male circumcision were undertaken in Orange Farm, near Johannesburg in South Africa, Rakai, Uganda and Kisumu, Kenya.[ix x] The results of the first randomized control trial carried out in Orange Farm were released in June 2005. The study of 3,274 men was stopped at the interim analysis stage due to compelling evidence that men in the intervention arm were 61 per cent less likely to have become infected with HIV. The investigators concluded that male circumcision,

“provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa.”[xi]

Given the limited impact of other HIV prevention methods across the region, these findings led to considerable excitement about the potential for male circumcision to significantly reduce new infections. In some countries, news of the probable protective effect of circumcision combined with donor and NGO advocacy led to sudden waiting lists for circumcision.[xii] At the same time, concern was raised about whether publicity about the results might lead to “disinhibition”, with men misinterpreting the results and reaching the conclusion that the increased protection offered by circumcision allowed for more risky sexual behaviour—especially less consistent condom use and more concurrent partners.[xiii] In March 2007, the WHO and UNAIDS jointly issued a set of recommendations on male circumcision which included guidance on how best to integrate male circumcision into other HIV services. The relevant section reads:

“Male circumcision should never replace other known methods of HIV prevention and should always be considered as part of a comprehensive HIV prevention package, which includes: promoting delay in the onset of sexual relations, abstinence from penetrative sex and reduction in the number of sexual partners; providing and promoting correct and consistent use of male and female condoms; providing HIV testing and counselling services; and providing services for the treatment of sexually transmitted infections.”[xiv]

[i] Venter F. The failure of HIV prevention is South Africa’s biggest health crisis. South African Medical Journal, 2007; 97(20003): 194.[ii] Venter F. The failure of HIV prevention is South Africa’s biggest health crisis. South African Medical Journal, 2007; 97(20003): 194.[iii] Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. Aids, 2000; 14: 2361–2370.[iv] Fink AJ. A possible explanation for heterosexual male infection with AIDS letter. N Engl J Med, 1986; 315:1167.[v] Kebaabetswe P, Lockman S, Mogwe S, Mandevu R, Thior I, Essex M, Shapiro RL. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sexually Transmitted Infections, 2003; 79, 214. [vi ]Lagarde E, Taljaard D, Puren A, Rain-Taljaard R, Auvert B. Acceptability of male circumcision as a tool for preventing HIV infection in a highly infected community in South Africa. AIDS, 2003; 17, 89.[vii] Halperin DT, Fritz K, McFarland W, Woelk G. Acceptability of Adult Male Circumcision for Sexually Transmitted Disease and HIV Prevention in Zimbabwe. Sexually Transmitted Diseases April 2005; 32:4:238-239.[viii ]Mattson CL, Muga R, Poulussen R, Onyango T, Bailey RC. Feasibility of medical male circumcision in Nyanza Province, Kenya. East African Medical Journal, 2004; 81(20005): 230.[ix] Scott BE, Weiss HA, Viljoen JI. The acceptability of male circumcision as an HIV intervention among a rural Zulu population, KwaZulu-Natal, South Africa. AIDS Care, 2005; 17(20003): 304.[x] Mattson CL, Bailey RC, Muga R, Poulussen R, Onyango T. Acceptability of male circumcision and predictors of circumcision preference among men and women in Nyanza Province, Kenya. AIDS Care, 2005; 17(2000 2): 182.[xi ]Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med, 2005; 2(200011): e298.[xii ]Timberg C. “In Swaziland, science Revives an old Rite – Circumcision Makes a Comeback to Fight AIDS in Virus-Ravaged African Nation; December 26, 2006; Washington Post.[xiii] Cassell M, Halperin D, Shelton J, Stanton D. HIV and risk behaviour: Risk compensation: the Achilles’ heel of innovations in HIV prevention? BMJ, 2005; 332(200011).[xiv ]New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming, Montreux, 6- 8 March 2007.

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