Is traditional male circumcision effective as an HIV prevention strategy? Evidence from Lesotho

Abstract

In many developing countries, male circumcision has been promoted as an effective HIV prevention strategy, and medical randomized controlled trials have indeed shown a causal link. However, there is limited empirical evidence to support this conclusion in countries where individuals can voluntary opt for different types of circumcision. The present study considers male circumcision in Lesotho, where HIV prevalence is among the highest in the world (23%). Here, men can opt for one of two types of circumcision: traditional male circumcision in initiation schools, or the medical option in health clinics. This paper investigates whether the former has medical effects on individual HIV status that are as beneficial as those shown for the latter. Controlling for the potential individual behavioral response after the operation, it was found that circumcision performed in initiation schools wholly offset the medical benefits of the surgical procedure. This supports anecdotal evidence that the operation performed by traditional circumcisers does not have the same protective effect against HIV transmission as the medical operation. No evidence of “disinhibition” behavior among circumcised men was found, nor differential risky sexual behavior among men circumcised, traditionally or medically. Considering that, in Lesotho, traditional male circumcision is undertaken by more than 90% of circumcised men, the findings highlight the need for further research into how the operation in initiation schools is performed and its medical benefits.

Mapping male circumcision for HIV prevention efforts in sub-Saharan Africa

“…Past research has found that self-reported MC status may be subject to misreporting errors due to confusion between medical and traditional circumcision practices [57]. Traditional circumcision is often performed in a non-clinical setting, and evidence of its protective effects against HIV transmission is mixed, largely due to discrepancies in defining MC when traditionally performed [27,29,30,58]. Our current analysis provides valuable information on the unmet needs of men who can be reached by VMMC given they have not undergone any form of MC.…”

The Penile Microbiota in Uncircumcised and Circumcised Men: Relationships With HIV and Human Papillomavirus Infections and Cervicovaginal Microbiota

“…On the other hand, traditional male circumcision (TMC) is usually performed by a medically untrained provider in a non-clinical setting, with either the foreskin partially or fully (completely) removed (46-50) using different cutting techniques (51). TMC is common in many settings within sub-Saharan Africa (45)(46)(47)(48)(49)(50)(51)(52)(53), and is performed as a ritual to initiate the males into manhood (46,49).…”

“…However, a population-based survey of predominantly traditionally circumcised sexually active South African men found no association between circumcision status and HIV infection (47). A more recent study investigating the association between the type of male circumcision (medical vs. traditional) and HIV status on a Basotho cohort noted that traditionally circumcised men were more likely to be HIV-infected than medically circumcised men (45).…”

“…There are two types of male circumcision: medical and traditional circumcision. MMC involves the surgical removal of the entire foreskin by a medical practitioner ( 44 , 45 ). On the other hand, traditional male circumcision (TMC) is usually performed by a medically untrained provider in a non-clinical setting, with either the foreskin partially or fully (completely) removed ( 46 – 50 ) using different cutting techniques ( 51 ).…”

“…The differences in the protective effect of TMC on HIV infection are presumably due to variations in the age of coitarche (sexual debut) and amount of foreskin removed during circumcision ( 45 – 47 , 50 , 51 , 54 ). A study that assessed the variations in TMC practices and their association with HIV status among South African men observed that partially circumcised and uncircumcised men had the same risk for HIV infection, which was significantly greater than that of fully circumcised men ( 63 ).…”