Arizona State University
Circumcision, Not Drugs, Could Be The Best Short-Term Answer
To Solving The AIDS Pandemic In Africa
BIS302: Interdisciplinary Inquiry
By Evan Mills
"Routine circumcision of all men in Africa could prevent 2 million new HIV
infections and avert 300,000 deaths over the next 10 years, according to
an analysis published by an international team of researchers in July." 7
- The Journal of the American Medical Association, August 2006
The article cited above goes on to mention that the real benefits of this procedure
would be seen over a long period of time, preventing an estimated 2.7 million
deaths and 3.7 million new infections over 20 years. But before we examine both
this journal article (and several others) on the topic further, a few essential
questions must be quickly answered and then thoughtfully applied, such as:
What Is The Problem?
AIDS is not only a devastating pandemic in Africa but is also a complicated
interdisciplinary puzzle for a vast and varied collection of researchers around the
world. For example, in 2005 alone there were 2.4 million deaths and 3.2 million
new HIV infections. According to AidsandAfrica.com, the life expectancy in Africa is
a mere 62 years but a shocking 47 years for those with AIDS. Of course there are
the obvious medical implications, but also deep connections to everything from
sociology to labor shortages, family psychology to the African gross national
product, politics to drug company profits, and much, much more.
What Is Its Significance?
As Joseph Stalin said, "The death of one man is a tragedy, the death of one million
- a statistic." It's estimated that over twenty percent of South Africa is infected, or
a statistic of approximately 90 million people.11 In all-too-real terms, that's a death
sentence for the entire population of America's 10 largest cities (including New York
and Los Angeles) without even coming close to the millions more already infected.
In Botswana, about thirty-three percent of the population has HIV/AIDS which
means that a family of six there can obviously expect to lose two members by this
disease alone - a mother and daughter, a father and son, newborn twins.
What Do We Know? What Else Do We Need To Know?
An infected South African judge, Edwin Cameron, stated at the XIIIth International
AIDS Conference that Africa "has, at almost every conceivable turn, mismanaged
the epidemic." In defending his policies, President Thabo Mbeki insisted poverty is
the biggest cause of poor health and suffering, not a virus. The conference chair,
Jerry Coovadia, stated that poverty simply magnifies the issue but isn't the main
cause.11 So when we're asked "What do we know?" or "What else do we need to
know?" concerning this human catastrophe, one can see that it often depends of
the person being asked. Hopefully that person is both knowledgeable and free of
personal bias.
What Do I Want To Say? What Else Might Be Said?
Besides noting the ethical and practical application of a standardized circumcision
procedure for all African males prior to reaching sexual maturity, there’s still over
thirty percent of those polled that wouldn’t be willing - even if it protected them
from HIV infection. In addition, the education all Africans that the procedure doesn’t
prevent infection entirely and that the socially accepted implementation of condom
use must be part of the discussion. And finally, sensitivity to tribal rituals that
include circumcision but done under safe, sterile conditions. In one tribe alone, 20
boys died due to botched procedures and because they used the same knife for the
ritual without being cleaned properly.9
A Literature Review on the Circumcision & HIV Infection Correlation
There were several different ways to tackle an intellectual conversation about this
concerning issue, but perhaps the best option to illustrate both how opinions
change while examining the interdisciplinary aspects involved is through a literary
timeline. Fortunately, one doesn’t have to travel back very far to make the
necessary connections. From “Male Circumcision Could Help Protect Against HIV
Infection” in The Lancet (July 2000) to “Finally, Level 1 evidence of significantly
decreased mortality with urological surgery” BJU International (August 2007) and
beyond, one might wonder why it took over 7 years for concrete scientific
confirmation (even longer since this connection was initially made in the mid1980’s) while reviewing the following samples:
“Male Circumcision Could Help Protect Against HIV Infection”
The Lancet (July 2000)
Anne Buvé and her associates from the Institute of Tropical Medicine in Antwerp,
Belgium, made observational studies on how circumcision effects the number of HIV
cases in two cities with both “high” and “low” rates of infection. In low-prevalence
cities, ninety-nine percent of the males were circumcised while only nine to twentyeight percent in the high-prevalence cities had the procedure.11
As mentioned earlier, other experts in this field should have been asking
themselves “What Else Do We Need To Know?” to move forward with an effective
program based on these results and those of multiple observational studies done
earlier. The next study, referenced below, took over five years to be published in
Science Magazine.
“Male Circumcision Thwarts HIV Infection”
Science Magazine (August 2005)
Noted as the first experiment to collect prospective evidence, clinician Bertran
Auvert with the University of Versailles stopped the study because “the protection
effect of male circumcision was so high that it would have been unethical to
continue.” 10 The results were based on over 3000 men between the ages of 18 to
24 that volunteered for the procedure, with half being performed at the very
beginning of the study. In short, only 18 circumcised men contracted HIV while 51
uncircumcised men did.
The article points out that they didn’t study if the rate of transmission is reduced if
an HIV positive male has been circumcised. To an outside observer, the correlation
seems exceedingly obvious and won’t be confirmed for another two years. From an
interdisciplinary perspective, perhaps there’s other factors involved – such as
profits lost by drug companies if circumcision proves to be a faster, cheaper shortterm solution or politicians without the personal ability, or lack of support, to act.
“Caution On Circumcision Cuts South Africa’s AIDS Researchers”
Nature Medicine (November 2005)
“International agencies urged caution! Wait for results from further studies!” Even
in the face of over 40 scientific biological and observational studies, Jimmy Volmink,
director of the Cochrane Centre with the South African Medical Research Council,
feels that additional controlled trials are needed to produce the evidence needed to
implement policy changes. Francois Venter, director of the South Africa
Reproductive Health Unit, disagrees, “If we had an AIDS vaccine this good, we
would roll it out tomorrow.” 9
There appear to be biological reasons why circumcision reduces HIV exposure, such
as the elimination of Langerhans immune cells under the foreskin and the moist
breeding ground between the foreskin and glans. We’ll find out that a BJU
International article, published almost two years later, confirms these suspicions.
Francois Venter ends up moving on the following year to a prevention and behavior
change advisory position for the South Africa Regional HIV/AIDS Programme the
following year, one of very few discovered to have a clear and rational global view.
“Demand For Male Circumcision Rises In A Bid To Prevent HIV”
Bulletin for the World Health Organization (July 2006)
In Zambia, the University Teaching Hospital went from one adult circumcision per
month to fifteen, causing a three-month waiting list. In Swaziland, 60 nurses and
doctors were trained in circumcision in a workshop sponsored by their health
ministry in an effort to keep up with demand. But, there are risks involved as men
might see circumcision as an “invisible condom” and a license to take part in risky
sexual behavior. 8 An additional concern is the healing time, typically 3 to 4 weeks,
where circumcised men should avoid sex because they’re at a higher risk of
infection due to the open wound.
But the financial reality paints a more optimistic picture. Each circumcision in Africa
averages $25 while the cost of each HIV infection averages $1052, making it a wise
investment not only for the recipient but provides a tangible reason for the African
government to back the procedure publicly and financially. Like Wal-Mart and global
warming, sometimes business and “going green” can be more effective.
“WHO Recommends Circumcision To Combat HIV Infections In Men In
Africa”
British Medical Journal (April 2007)
The World Health Organization (WHO), during an international symposium in
Montreux, Switzerland, published the results of a study on the relationship between
circumcision and AIDS. With the results of three random, controlled trials in-hand,
WHO finally concludes that “there is now strong evidence” and “supports the
findings of numerous observational studies” suggesting the correlation between
circumcision and HIV infections. Kevin De Cock (sic), WHO’s HIV and AIDS director,
stated that their “recommendations represent a significant step forward in HIV
prevention.” 5
While the article goes on to point out that circumcision is only a part of the total
HIV prevention strategy, absent was the number of people that passed away during
the 20 years in took from the initial correlation to WHO’s conclusion. Granted, we’re
all bound by personal, political and financial barriers, but it seems that there should
have been no greater concern for the WHO than HIV/AIDS and they should be
embarrassed by the lack of a timely response to the devastation.
“Finally, Level 1 Evidence Of Significantly Decreased Mortality With
Urological Surgery”
BJU International (August 2007)
Citing the New York Times, the “holy grail” for AIDS has always been a miracle drug
that’s never become a reality versus the oldest and cheapest urological procedure
known (with there being only one option between the two).3 Hugh Hampton Young,
in 1906, published the first description of a radical prostatectomy but lacked the
evidence that the procedure increased the likelihood of survival. Now, over 100
years later, it has been proven. By eliminating the inner foreskin’s mucocutaneous
epithelium, which is more susceptible than keratinized skin, millions of lives will be
saved.
Mirroring earlier warnings, J. Stephen Jones with the Glickman Urological and
Kidney Institute in Cleveland, Ohio, states that the potential still lies in equipment
that hasn’t been sterilized properly and the likelihood of promiscuous sex due to a
“perceived invulnerability.”
Conclusion
Because of the wide variety of quality differences in the medical facilities of third
world countries and lack of education programs to communicate the dangers
effectively, interdisciplinary solutions are needed to solve difficult problems like the
ones illustrated above. In sub-Saharan Africa, areas of high HIV infection are only
made worse by under-resourced health care infrastructure that produces an
estimated ninety percent of the 800,000 children infected each year.2
Another area of concern that most are aware of, but isn’t fully realized someone
does this type of review, revolves around the seriousness of the issues, the lack of
a real consensus about a plan of attack, the knowledge of how it will be carried out
and the funding necessary to ensure a successful conclusion. One gets a real sense
of hopelessness, especially when the “experts” are seemingly lost. If there’s ever
been a better case for the funding of interdisciplinary studies, the pandemic caused
by HIV/AIDS must be near the top of the list.
In the meantime, an estimated 21 million people died of AIDS from 1987 to 2008 –
a death toll equivalent of over 154 Iraqi wars.
Research Proposal
Because the evidence is already overwhelming that circumcision helps to
significantly prevent the spread of AIDS, my focus would be on the process of
verifying and implementing treatment strategies in pandemic situations. In this
case, it has taken years of medical research and has cost millions of lives when a
clear relationship between AIDS and circumcision had already been established.
When the numbers get so high, one loses the importance of both individual lives
and timeline reduction. In short, if the medical community or the politicians
involved would have acted a day, a week, a month, or a year faster, could they
have saved the life of their own mother (or her daughter, the one that would have
become a doctor and went on to find a cure for AIDS – if she would have lived)?
To me, asking “What if?” questions like these are at the very core of
interdisciplinary studies. Focusing research on not only the problem, but more
importantly in this case, the process would have far-reaching social, medical and
ethical implications…
Citations & References
(This Paper Follows The Chicago/Turabian Style)
1
Gray, Glenda E. 2008. "Walking the Tightrope in Prevention of Mother-to-Child
Transmission of HIV Infection." Clinical Infectious Diseases 46, no. 4: 622-624.
2
Stringer, Elizabeth M., Chi, Benjamin H., Chintu, Namwinga, Creek, Tracy L.,
Ekouevi, Didier K., Coetzee, David, Pius Tih, et al. 2008. "Monitoring effectiveness
of programmes to prevent mother-to-child HIV transmission in lower-income
countries." Bulletin of the World Health Organization 86, no. 1: 57-62.
3
Jones, J. Stephen. 2008. "Finally, Level 1 evidence of significantly decreased
mortality with urological surgery." BJU International 101, no. 3: 270-270.
4
Karim, Quarraisha Abdool. 2007. "Prevention of HIV by male circumcision." BMJ:
British Medical Journal, July 07. 4-5.
5
Moszynski, Peter. 2007. "WHO recommends circumcision to combat HIV
infections in men in Africa." BMJ: British Medical Journal 334, no. 7596: 712-713.
6
Flynn, Patricia, Havens, Peter, Brady, Michael, Emmanuel, Patricia, Read,
Jennifer, Hoyt, Laura, Henry-Reid, Lisa, Van Dyke, Russell, and Lynne Mofenson.
2007. "Male Circumcision for Prevention of HIV and Other Sexually Transmitted
Diseases." Pediatrics, April . 821-822.
7
Kuehn, Bridget M. 2006. "Routine Male Circumcision Could Prevent Millions of HIV
Infections in Africa." JAMA: Journal of the American Medical Association 296, no. 7:
755-755.
8
Wise, Jacqui. 2006. "Demand for male circumcision rises in a bid to prevent HIV."
Bulletin of the World Health Organization 84, no. 7: 509-511.
9
Beukes, Lauren. 2005. "Caution on circumcision cuts South Africa's AIDS
researchers." Nature Medicine 11, no. 12: 1261-1261.
10
Cohen, Jon. 2005. "Male Circumcision Thwarts HIV Infection." Science 309, no.
5736: 860-860.
11
Clark, Stephanie. 2000. "Male circumcision could help protect against HIV
infection." Lancet 356, no. 9225: 225.