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The benefit of male circumcision in reducing HIV infection

Malcolm Potts, professor of population and family planning | December 16, 2009

One of the most important medical innovations of the 21st century- and one closely linked to UC Berkeley – is literally thousands of years old.

In the mid-90s a postdoctoral research fellow in anthropology at Berkeley, Daniel Halperin, asked if he could give a lecture in the course I teach on HIV/AIDS in the School of Public Health.  He talked about the evidence that male circumcision reduces the risk of HIV infection. I thanked him and invited him back next year. The third time Daniel spoke, I said ‘Wow!’  this person is saying something extremely important. Not long afterwards Daniel  published a landmark article in the Lancet called ‘Male circumcision in HIV infection: Ten years and counting”, where he and a co-author marshalled a compelling range of anthropological, clinical and epidemiological evidence supporting the protective nature of male circumcision.  I published a letter supporting the article, with a rough estimate that in those countries where men are circumcised there could have been as many as 8 million more HIV infections by the year 2000 if circumcision had not been practised. At about the same time, my colleague in Australia , Roger Short, published a paper on the presence of Langerhans cells in the male foreskin. These specialist cells are part of the immune system and HIV attaches to them directly. Removing the foreskin greatly reduces the risk of acquiring AIDS .

At the time, as a public health professional, I would have initiated programs telling men to use condoms, but also offering male circumcision. Unfortunately, no one was bold enough to do this, and even a thesis by one of my doctoral students on the acceptability of infant circumcision in Thailand if the parents knew about the relationship to HIV was rejected by all the journals she approached.

Dr. Halperin left the Bay Area and joined USAID in Washington. He organised a meeting on male circumcision, where experts from around the world agreed that if one of the random controlled trials then  taking place demonstrated a protective effect of male circumcision then UNAIDS, the WHO and others would put in place policies offering the operation.

Tragically, when the first random controlled trial was so successful that it had to be stopped prematurely (the results were so statistically powerful that it would have been unethical to continue it), the international organisations pussyfooted around and refused to initiate policies until a second trial was completed. This was also so successful that had to be stopped prematurely.

In case you are wondering how you do a random placebo-controlled trial of vasectomy – which after all is an operation the patient is likely to notice – it is done this way. Men at risk of HIV infection volunteer for trial and a coin is tossed. They are either circumcised  immediately or told to come back one year later. They also are told to use condoms. The rate of HIV infection in the two groups is then monitored.

I am on the board of Population Services International, a non-governmental organisation working around the world and using market forces to distribute contraceptives,  malaria bed-nets, oral rehydration tablets and working with health professionals in the private sector.  Using its own resources, PSI did start offering male circumcision in Africa, and recently the Bill and Melinda Gates Foundation has generously supported the expansion of this program.

Studies have shown that male circumcision reduces the risk of acquiring HIV by about 50%, every time a man is exposed to infection . Unlike a condom, circumcision once performed cannot be forgotten when the man goes away for the weekend, or omitted in a moment of sexual passion. Male circumcision has been called an ‘anatomical vaccine.’ Despite heavy investment, no vaccine exists but male  circumcision does.

Berkeley conducts world-class science. In this case common sense was used to pull together pieces of evidence. I am deeply disappointed in the way those working in HIV prevention were so slow to establish appropriate policy. I admit, like everybody else, that I was slow to see the potential of this intervention, but to delay action for so long when the evidence was so compelling simply condemned huge numbers of men to an otherwise preventable death.

Tragically, those controlling resources continue to learn slowly. Last year Daniel and I, along with other colleagues, published a Policy Forum in Science (320: 749, 2009) . We observed that the biggest investment in AIDS prevention prevention are targeted at those interventions where the evidence of a potential to slow a generalized heterosexual epidemic is weak – namely condoms, HIV testing, abstinence, and vaccines and microbicides – while the least investment is put in those strategies where the evidence of the powerful impact is strongest – namely male circumcision and reducing multiple concurrent sexual partners. Our article produced some defensive froth from international organisations, but it does not seem to have had the impact we hoped solid evidence in a premier journal might achieve.