HIV is a global pandemic. Worldwide, about 37 million people are living with the virus, and there are between 3 and 5 thousand AIDS deaths every day. More worrying is that, despite intensive public health and safe sex campaigns, there are a further 3 to 5 thousand new HIV infections occurring every day, and despite decades of effort, scientists still have not yet managed to develop an effective vaccine. But one very powerful way to prevent infection is for men to be circumcised, which reduces their risk of picking up the virus by up to 80%. So is this a cost effective strategy to halt HIV spread? Marika Ottman spoke with John Stover who’s been studying the impact of a circumcision programme in Zimbabwe...
John - Back in 2007-2008 some scientific studies showed that medical male circumcision can reduce male susceptibility to HIV infection. As a result of those studies a number of donors are providing funds to countries to scale up circumcision programmes. That's been going on since 2008. We conducted this study in order to estimate the impact that those programs are having on reducing new HIV infections.
Marika - Biologically, what is the connection between circumcision and preventing HIV?
John - So men can get HIV from intercourse when the virus enters cells on the penis; and with an intact foreskin there is a lot of surface area that allows for virus to enter. Circumcision reduces the surface area and therefore reduces the chances of the virus entering.
Marika - How do you promote voluntary circumcision in these young men?
John - So it's done through a variety of ways. There are community events; also programme people work with community leaders to inform them of the benefits of the circumcision, and how it happens. And then there's community health events, and also activities at schools. Information is given both to the young men and boys themselves as well as to their parents.
Marika - And what is the most common age group that's been partaking in voluntary circumcision?
John - Yeah, the circumcision is available to all boys and men; but primarily it's boys and young men between the ages of 10 and 24 that have been coming forward for circumcision. So this is actually a good thing, because many of these boys are not yet sexually active. So that means that once they've had the circumcision they're protected for their entire sexually active lives.
Marika - That makes me wonder what is the circumcision process like for this age group?
John - There are different approaches to doing the circumcision. Each one involves pain medications so that the pain during the actual operation is minimal. And then there's a recovery period up to six weeks while the wound completely heals. But in most cases the level of pain is quite low and actually a major issue reported by recipients.
Marika - Oh excellent. So how many circumcisions have been performed since this effort was started?
John - In Zimbabwe, where we did our analysis, there have been over 1 million circumcisions conducted since 2008.
Marika - How many infections do you think that has prevented?
Today, so by 2018, 80000 new infections. But that's only the tip of the iceberg since many of them are not sexually active. So we estimate that, even if no new circumcisions were conducted after today, over the next 15 years there would be about 400,000 to 500,000 new infections averted. The programme has a target of reaching 80 percent of men and boys between the ages of 10 and 29 by 2020. If we do that the benefits would be huge going into the future. And we've also calculated that the cost of the programme would more than be paid for by the savings, in the future, of not having to provide antiretroviral treatment to those who don't become infected.
Marika - And with the success of this programme, in the future do you see the potential for encouraging circumcision in newborns?
John - Many countries do neonatal circumcisions as a normal practice. There's been a debate in countries that are scaling up this circumcision for boys and young men as to whether, once they finish the catch up phase, once 80 percent of these young men are circumcised, whether they should switch the programme and then start doing circumcisions for neonates. Circumcision for neonates is easier, with fewer side effects. But of course you have to wait 15to 20 years before you start to see the impacts for the HIV epidemic. So those debates are going on now and over the next several years we'll see what programmes actually decide to do...