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AIDSMAP: Circumcision's Effectiveness A Distant Third

Researchers from the British Columbia Centre for Excellence in HIV/AIDS have presented a study, based on mathematical modeling, to determine the level of efficacy in a high prevalence country from condom use, treatment, and male circumcision. They found, to their "astonishment," that male circumcision isn't anywhere nearly as effective as its promotors wish it to be. The results were presented at the International Aids Society 2009 conference in South Africa.

According to an Aidsmap summary, male circumcision rates were examined at 51%(current level), 75%, and 90% with an assumed protective effect of 53%. Condom use was examined at 14% (current level), 50%, 75%, 80% and 90%, assuming a 10% failure rate. Treatment coverage was examined at 21% (current level), 50%, 75%, 80%, and 90%, with a CD4 cell count of 200 cells/mm3 or lower as the primary criterion for initiating ART (antiretroviral treatment). See the article for a detailed description of the methodology and other variables considered.

Researchers determined that scaling up heterosexual condom use to 50% and treatment availability to 80% would avert nearly one million cases by 2019. The numbers were similar if condom use were scaled up to 80% and ART was made available to 50% of those who need it. Raising both condom use and ART to 50% would avert about 700,000 new cases. However, increasing circumcision to 90% would only avert an additional 48,000 cases during the same time period, which is less than a 7% reduction requiring a massive investment.

If the number of new HIV infections averted in South Africa over 10 years is only 48,000 with an adult prevalence rate at nearly 20%, what impact could be expected in developed countries with a prevalence rate of 0.6% or less and where female to male heterosexually acquired HIV is the least common mode of transmission?

The answer is far fewer than 48,000. The truth is that circumcision would change the face of the epidemic very little. Moreover, the massive costs of circumcision, both in money, adverse surgical consequences, and new education and reinforcement of the condom message to prevent disinhibition, etc., should be redirected to increasing condom use and treatment, which in turn would likely reduce additional infections far more than the projected <7% reduction from circumcision.

Condom use and ART coverage, alone or in combination, were found to reduce new HIV infections by from 64% to 95% by 2025 and to reduce mortality by 10% to 34%. Circumcision brought about a 3% to 13% reduction in new HIV infections and a 2% to 4% reduction in mortality; according to Lima, its impact “was overshadowed when combined with the other interventions."

“We were surprised by how little effect it had,” she said.

The solution to the HIV/AIDS epidemic has been well known for a long time. The early prevention efforts in Uganda and Brazil's leading example of universal access to HIV medications and widespread distribution of condoms has shown in the real world precisely what this mathematical model has shown in the virtual world.

Circumcision has no such real world corollary. In fact, there are examples of where it has had no discernable effect, such as in Lesotho, Malawi, and even parts of Kenya. In the United States, high levels of male circumcision and high levels of HIV conflict sharply with Europe and Japan where levels of both are very low.

Funds diverted to circumcision campaigns, especially those targeted at children who are not at risk, reduce resources for interventions that do work. This is a truth we have repeated often.

Coupled with the recent news from a randomized controlled trial in Kenya showing that male circumcision provides no protection in women and in fact likely increases their risk, male circumcision looks not only unattractive, but dangerous.


Lima V et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105, 2009.


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