Male circumcision for protection against HIV infection in sub-Saharan Africa: The evidence in favour justifies the implementation now in progress

Abstract

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe

“…In the current article, Van Howe starts off by repeating speculative claims by himself and others disputing the proven benefits of MC in reducing the risk of HIV infection, while ignoring the critiques that have disproved such claims (Banerjee et al, 2011;Morris, 2012;Morris et al, 2012;Wamai, Morris, Bailey, Klausner, & Boedicker, 2015;Wamai et al, 2008;Wamai et al, 2012). For example, he repeats discredited claims that, 'multiple, complex and unidentified factors may influence how much HIV risk is attributed to circumcision status', going on to speculate, 'These may include differences in blood exposures (from health care and/or cosmetic and ritual practices), sexual practices, sexual mixing patterns, risk behaviour adjustment, the strain of HIV responsible for infection and cultural factors.'…”

Debating male circumcision for HIV prevention: A one-sided argument does not represent a legitimate ‘controversy’ analysis – Reply to de Camargo et al.

“…Our analysis of the scientific evidence has provided an affirmative answer to Q1 (Wamai, Morris, Bailey, Klausner, & Boedicker, 2015, 'Biomedical evidence of randomised controlled trials of MC for HIV prevention'). To answer Q2 requires assessment of behavioural, political, technical and systems elements by Eulerian deliberation of the interspersion of truth, knowledge and belief (Baron, 1969).…”

“…Rather their conclusions are based on spurious assumptions, so are fallacious. In relation to Q2, while the contest presented by opponents seems to have as its basis sociological constructivism (Martin & Richards, 1995), here too we find that the scepticism does not stem from empirical evidence (Wamai et al, 2015, 'Behavioural and contextual considerations in adopting voluntary medical male circumcision (VMMC)' and 'Public health policy considerations in adopting VMMC').…”

“…Propounding, however, that the biomedical intervention of MC should be more strongly promoted is, rather than being reductionist, consistent with good public health practice, because the best available evidence regarding all HIV interventions shows that MC is more effective on multiple grounds (Wamai et al, 2015).…”

“…That would result in a society, 'too awful to contemplate', as Collins (2009, p. 30) argues. Adoption of MC involved democratic deliberation (Wamai et al, 2015, 'Behavioural and contextual considerations in adopting VMMC' and 'Public health policy considerations in adopting VMMC').…”