Bloodborne HIV: Don't Get Stuck!

[return to first circumcision page]

Hundreds of thousands of men in Africa — several percent of the more than 18 million men circumcised in VMMC (Voluntary Medical Male Circumcision) programs during 2007-18[1] — have suffered temporary or permanent health damage from the operation. Circumcision can go wrong in many ways.

WHO and others report men’s problems from circumcisions as “adverse events” (see Tool 23 in [2]): mild adverse events (eg, pain, swelling) do not require medication; moderate events require some treatment (eg, antibiotics); while serious adverse events require surgery or extensive treatment or result in permanent damage (eg, disfigurement, sexual problems, death). (Note: Adverse events are not men’s only damage from circumcision. Even safe and successful operations remove sensitive tissues, affecting men’s and partners’ sexual experiences.[3] I don’t discuss such effects here.)

In 2007, when WHO recommended circumcising 20 million men in Africa,[4,5] anyone who looked knew it would hurt many men in Africa. When VMMC programs got underway in 2008, many clinics did not do a good job monitoring and reporting adverse events. In recent years, populations at risk are paying more attention to harms from circumcisions.

What WHO managers knew in 2007

Four studies of adverse events after 100s to 1,000s of circumcisions in Africa during 2002-5 report rates of adverse events of 2.1-17.7 per 100 circumcisions (Table 1). Were the studies biased? Unlikely. Authors of all four studies support WHO’s recommendation to circ millions of men in Africa.

Table 1: Adverse events after adult circumcisions in Africa, 2002-5

*After ≥ 1 year 3 men had problems urinating, 4 were dissatisfied with the appearance of their  penis, and 4 reported mild or moderate erectile dysfunction. †The study team recognized 4 HIV infections one month after circumcision but did not acknowledge them as possible adverse events from unsterile conditions during circumcision.

HIV infections from circumcisions: Using data from national surveys, Brewer and partners report HIV infections were more common in circumcised vs. intact virgin boys and men in Kenya (1.8% vs. 0%), Lesotho (6.1% vs. 1.9%), Tanzania (2.9% vs. 1.0%), and Mozambique (2.1% vs 1.0%).[11,12] As reported in Table 1, above, one study reported new HIV infections in 4 (0.3%) of 1,334 men one month after circumcising them (without acknowledging the infections as adverse events).[7] But it’s unlikely anyone would see blood-borne infections — HIV, hepatitis B, or hepatitis C — after circumcisions because VMMC programs have not been testing for them as adverse events.

WHO and UNAIDS advice to avoid unsafe healthcare in Africa: UNAIDS advises UN employees in Africa (p 4 in [13]: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment.” In other words, UNAIDS urges millions of men to get circ’d in facilities in Africa that it considers to be dangerous for UN employees.

Surveys of infection control in hospitals and clinics: Beginning from 1999, USAID has paid for random sample surveys of clinics and hospitals in Africa. During 2004-7, surveys in Kenya, Tanzania, Uganda, and Zambia — countries where the US pays to circumcise millions of men —  reported that only 60%-75% of hospitals and clinics had equipment to sterilize instruments; Rwanda was the best, with 83% of facilities equipped to sterilize instruments.[14]

Early circ program: Lots of adverse events, but weak monitoring

As VMMC programs got underway in 14 countries beginning from 2008, responsibility for reporting adverse events fell to the same staff responsible for circumcising men. At least three studies critically reviewed these reports; two found more adverse events than staff had reported, while a third provided a first estimate based on clinic documents. In these three studies, rates of severe plus moderate adverse events were 2.9, 6.9, and 8.4 per 100 circumcisions (see italicized data in Table 2).

Table 2: Reports of adverse events by clinic staff vs. reports after review

Kenya, 2008-10: A study in Kenya[15] reassessed reported adverse events in men circumcised during 2008-10 in 16 aid-financed clinics that did nothing but circumcise men. A home-based survey with genital exams 28-45 days after circumcision reported 437 adverse events in  a sample of 1,449 of the 3,705 men (30.2 per 100 circumcisions for all adverse events, of which 6.9 per 100 circumcisions were serious or moderate).

Swaziland, 2011: A telephone hotline diagnosed adverse events, referring callers to clinics. Because many callers did not subsequently go to clinics, clinics did not record and report their adverse events.[16] Including adverse events diagnosed by phone but not reported by clinics, there were a total of 772 adverse events in 8,862 (7.8 per 100 circumcisions), including 283 severe and moderate events (2.9  per 100 circumcisions).

Malawi 2012: A study team reviewed clinic records for 3,000 aid-supported circumcisions at a hospital in Lilongwe.[17] The study team identified 257 adverse events (8.6 per 100 circumcisions), almost all of which were moderate or severe (Table 2). The study also found mismanagement of adverse events and poor record keeping.

2012-18: Increasing awareness of adverse events

 As VMMC programs continue, people are becoming more aware of the dangers of circumcision. Here are some recent events and issues.

Deaths from tetanus: During 2012-2016, five countries reported 13 cases of tetanus in men within 14 days after VMMC circumcisions. Eight of the 13 men died – 1 each in Kenya, Rwanda, Tanzania, and Zambia and 4 in Uganda.[18] WHO in 2015 advised governments to require men to get vaccinated for tetanus before circumcision.[19] Subsequently, Uganda required two tetanus vaccinations before circumcision; whether men became more aware of risks or were deterred by the need to be vaccinated, fewer men in Uganda chose to get circumcised in 2016 compared to 2015.[20]

Botswana baby dies after a research circumcision: A US-funded study tested different methods to circumcise babies in Botswana.[21] One baby, circumcised when he was 2 days old, died the next day. Without seeing the body, the study team and committees responsible to protect participants decided “it was extremely unlikely that the baby’s death was related to the circumcision procedure.” Here’s what Jim Thornton, former editor of the British Journal of Obstetrics and Gynecology writes about that decision: “Am I going mad? ‘Extremely unlikely’! How can any sane doctor possibly conclude that?[22] Researchers’ lame response to the baby’s death shows that power beats evidence; thugs with money run the show.

Kenyan newspaper reports circumcision deaths, penile damage: In March 2018, the Standard reported five deaths after circumcision, five boys with penile damage, a tetanus infection, and other serious outcomes during 2014-17.[23]

References

1. WHO. WHO progress brief: voluntary medical male circumcision for HIV prevention, July 2018. Geneva: WHO, 2018. Available at: https://www.malecircumcision.org/resource/who-progress-brief-voluntary-medical-male-circumcision-hiv-prevention-july-2018 (accessed 22 October 2018).

2. WHO. Male circumcision services: quality assessment toolkit. Geneva: WHO, 2009. Available at: http://apps.who.int/iris/bitstream/handle/10665/44040/9789241597517_eng.pdf?sequence=1 (accessed 8 May 2018).

3. Doctors Opposing Circumcision. The sexual impact of circumcision. 2018. Available at: https://www.doctorsopposingcircumcision.org/for-professionals/sexual-impact/ (accessed 8 May 2018).

4. WHO, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. Geneva: WHO, 2007. Available at: http://apps.who.int/iris/bitstream/handle/10665/43751/9789241595988_eng.pdf;jsessionid=6762A21EE4E0FC3BC2647D4F2045D317?sequence=1 (accessed 9 May 2018).

5. Currran K, Njeuhmeli E, Mirelman A, et al. Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa. PLoS 2011; 8: e1001129. Available at  http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001129(accessed 10 April 2018).

6. Auvert B, Taljaard D, Lagarde E, et al. Randomized controlled intervention trial of male circumcision for reductxion of HIV infection risk: the ANRS t1265 trial. PLoS Med 2005; 2: 1112-1122. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1262556/pdf/pmed.0020298.pdf(accessed 2 May 2018).

7. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-656. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321310(accessed 2 May 2018).

8. Kreiger JN, Bailey RC, Opeya J, et al. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. BJU international 2005; 96: 1109-1113. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-410X.2005.05810.x (accessed 9 May 2018).

9. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized controlled trial. Lancet 2007; 369: 657-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321311(accessed 3 May 2018).

10. Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull WHO 2008; 86: 669-677. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18797642 (accessed 9 May 2018).

11. Brewer D, Potterat J, Roberts JM, Brody S. Male and Female Circumcision Associated With Prevalent HIV Infection in Virgins and Adolescents in Kenya, Lesotho, and Tanzania. Ann Epidemology 2007; 17: 217.e1–217.e12. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17320788 (accessed 9 May 2018).

12. Brewer D. Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth. WebmedCentral 2011, Article ID: WMC002206. Available at: http://www.webmedcentral.com/article_view/2206 (accessed 9 May 2018).

13. UNAIDS. Living in a world with HIV and AIDS: information for employees of the UN system and their families. Geneva: UNAIDS, 2004. Available at: http://data.unaids.org/publications/irc-pub06/jc975-livinginworldaids_en.pdf (acccessed 6 May 2018).

14. USAID. The DHS Program: survey types. Available at: https://dhsprogram.com/What-We-Do/survey-search.cfm?pgtype=main&SrvyTp=type (accessed 9 May 2018).

15. Herman-Roloff A, Bailey RC, Agot K. Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya. Bull WHO 2012; 90: 773-781. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3677080/(accessed 9 May 2018).

16. Ashengo TA, Grund J, Mhlanga M, et al. Feasibility and validity of telephone triage for adverse events during a voluntary medical male circumcision campaign in Swaziland. BMC Pub Health 2014: 14: 858. Available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-858 (accessed 9 May 2018).

17. Kohler PK, Namate D,Barnhart S,et al. Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training. BMC Health Services Research 2016: 16: 61. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26888178 (accessed 9 May 2018).

18. Dalal S, Samuelson J, Reed J, et al. Tetanus disease and deaths in men reveal need for revaccination. Bull WHO 2016; 94: 613-621. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27516639 (accessed 10 May 2018).

19. WHO. WHO informal consultation on tetanus and voluntary medical male circumcision. Geneva: WHO, 2015. Available at: http://apps.who.int/iris/bitstream/handle/10665/181812/9789241509237_eng.pdf?sequence=1 (accessed 10 May 2018).

20. Managembe L. Uganda registers a decline in male circumcision numbers. Daily Monitor, 8 February 2016. Available at: http://mobile.monitor.co.ug/News/Uganda-registers-a-decline-in-male-circumcision-numbers/2466686-3804288-format-xhtml-rc5c7az/index.html (accessed 10 May 2018).

21. Plank RM, Ndubuka NO, Wirth KE, et al. A Randomized Trial of Mogen Clamp Versus Plastibell for Neonatal Male Circumcision in Botswana. J Acquir Immune Defic Syndr 2013; 62: e131-e137. Available at: https://ripetomato2uk.files.wordpress.com/2013/03/plank-botswana-circ-trial.pdf (accessed 11 May 2018).

22. Thornton J. Boston/Botswana circ. trial update. Blog, 11 October 2013. Available at: https://ripe-tomato.org/2013/10/11/bostonbotswana-circ-trial-update/ (accessed 24 April 2018).

23. Gathura G. How negligence, untrained staff led to five boys losing their manhood. Standard, 11 March 2018. Available at: https://www.standardmedia.co.ke/health/article/2001272720/boys-loss-of-manhood-due-to-negligence-untrained-staff (accessed 11 May 2018).