Hostname: page-component-788cddb947-wgjn4 Total loading time: 0 Render date: 2024-10-16T03:50:46.169Z Has data issue: false hasContentIssue false

Comment on ‘Changing relationships between HIV prevalence and circumcision in Lesotho’, and ‘Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa’

Published online by Cambridge University Press:  20 May 2024

Brian J. Morris*
Affiliation:
School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
Joya Banerjee
Affiliation:
Be the Change Group, Vancouver, BC, Canada
*
Corresponding author: Brian J. Morris; Email: brian.morris@sydney.edu.au
Rights & Permissions [Opens in a new window]

Abstract

Two articles by Garenne (2023a,b) argue that voluntary medical male circumcision does not reduce human immunodeficiency virus transmission in Africa. Here we point out key evidence and analytical flaws that call into question this conclusion.

Type
Debate
Copyright
© The Author(s), 2024. Published by Cambridge University Press

Contrary findings ignored

In Garenne (Reference Garenne2023b), six countries with circumcision ‘prevalence’ of 12.7–71.2% were studied. However, these prevalence figures incorrectly conflate voluntary medical male circumcision (VMMC) with traditional male circumcision (TMC), which can increase risk of human immunodeficiency virus (HIV) infection through use of unsterilised contaminated instruments on multiple youths, some already infected (Brewer et al. Reference Brewer, Potterat, Roberts and Brody2007, Reference Brewer, Potterat, Roberts and Brody2009; Ndiwane Reference Ndiwane2008). TMC of 16–20-year-olds is common in Lesotho where VMMC, but not TMC, is associated with HIV risk reduction (Coburn et al. Reference Coburn, Okano and Blower2013; Carrasco et al. Reference Carrasco, Rosen, Maile, Manda, Amzel and Kiggundu2020; Makatjane et al. Reference Makatjane, Hlabana and Letete2016). These observations render the study’s finding of no association questionable.

Confounding

These studies ignore confounding from antiretroviral therapy (ART). ART was rolled out alongside VMMC in sub-Saharan Africa concurrently with VMMC. While ART can reduce HIV infection, it increases HIV prevalence because people who previously would have died from acquired immunodeficiency syndrome-related illnesses now live with HIV (Shafer et al. Reference Shafer, Nsubuga, Chapman, O’Brien, Mayanja and White2013; Zaidi et al. Reference Zaidi, Grapsa, Tanser, Newell and Bärnighausen2013). The articles should have documented incidence. A modelling study found VMMC was the third most effective intervention after ART and condoms (Johnson et al. Reference Johnson, Meyer-Rath, Dorrington, Puren, Seathlodi, Zuma and Feizzadeh2022). Furthermore, uptake of VMMC has been high in young adolescent boys who are not yet sexually active (UNAIDS and WHO 2021), leading to a delay between VMMC and reduction in new HIV cases.

Data limitations

The primary data sources use self-reported circumcision status. Self-reporting is unreliable. This could affect any study using such data, but it seems to be a particular issue with Lesotho, which is a country Garenne focused on in the first paper we criticise. A study in Lesotho found that only half of men claiming to be circumcised actually were, and a further 26.6% were only partially circumcised (Thomas et al. Reference Thomas, Tran, Cranston, Brown, Kumar and Tlelai2011). Partial TMC is also common in Malawi (Renne et al. Reference Renne, Perry, Corneli, Chilungo and Umar2016).

Selective and misleading literature citations

The studies ‘cherry-pick’ often dated opinion pieces that fail to consider some of the issues described above. The articles ignore reviews of >30 studies linking VMMC to HIV risk reduction (Siegfried et al. Reference Siegfried, Muller, Volmink, Deeks, Egger, Low, Weiss, Walker and Williamson2003; Addanki et al. Reference Addanki, Pace and Bagasra2008). The studies also fail to point out that most subjects in Connolly et al. (Reference Connolly, Simbayi, Shanmugam and Nqeketo2008) had TMC, not VMMC. And findings in Rosenberg et al. (Reference Rosenberg, Goméz-Olivé, Rohr, Kahn and Bärnighausen2018) are attributed to self-selection, not ineffectiveness of VMMC.

Van Howe’s meta-regression analyses in 2015 are cited (Van Howe Reference Van Howe2015), but not the detailed critique undermining his statistics (Morris et al. Reference Morris, Barboza, Wamai and Krieger2018). Van Howe’s reply in 2018 (Van Howe Reference Van Howe2018) was rebutted (Morris et al. Reference Morris, Barboza, Wamai and Krieger2017). A meta-analysis (Van Howe Reference Van Howe1999) was discredited (Moses et al. Reference Moses, Nagelkerke and Blanchard1999; O’Farrell & Egger Reference O’Farrell and Egger2000) and became a textbook example of how not to do a meta-analysis (Borenstein et al. Reference Borenstein, Hedges, Higgins and Rothstein2009). Yet the articles cite it (Garenne & Matthews Reference Garenne and Matthews2019; Garenne Reference Garenne2023a,Reference Garenneb). All other meta-analyses confirm VMMC is effective against female-to-male HIV transmission (O’Farrell & Egger Reference O’Farrell and Egger2000; Weiss et al. Reference Weiss, Quigley and Hayes2000; Byakika-Tusiime, Reference Byakika-Tusiime2008; Lei et al. Reference Lei, Liu, Wei, Yan, Yang, Song, Yuan, Lv and Han2015; Sharma et al. Reference Sharma, Raison, Khan, Shabbir, Dasgupta and Ahmed2018; Farley et al. Reference Farley, Samuelson, Grabowski, Ameyan, Gray and Baggaley2020) but these are ignored.

Conclusion

These recent articles on VMMC and HIV are problematic. The issues described above are well-known to researchers in the field but are ignored. Unfortunately, the articles are now being cited (Garenne Reference Garenne2023c) to support an opposition to VMMC. Most authorities find that VMMC is biologically- and cost-effective against HIV infection in Africa (Farley et al. Reference Farley, Samuelson, Grabowski, Ameyan, Gray and Baggaley2020; Bershteyn et al. Reference Bershteyn, Mudimu, Platais, Mwalili, Zulu, Mwanza and Kripke2022; Bansi-Matharu et al. Reference Bansi-Matharu, Mudimu, Martin-Hughes, Hamilton, Johnson, ten Brink, Stover, Meyer-Rath, Kelly, Jamieson, Cambiano, Jahn, Cowan, Mangenah, Mavhu, Chidarikire, Toledo, Revill, Sundaram, Hatzold, Yansaneh, Apollo, Kalua, Mugurungi, Kiggundu, Zhang, Nyirenda, Phillips, Kripke and Bershteyn2023).

Funding statement

None.

Competing interests

Brian J. Morris is a member of the Circumcision Academy of Australia, a not-for-profit, government registered, medical society that provides accurate, evidence-based information on male circumcision to parents, practitioners, and others, as well as contact details of doctors who perform the procedure in Australia and New Zealand. This author’s interest in male circumcision for disease prevention began after he co-invented and competitively patented the first use of PCR for viral detection, applying this technology to human papillomavirus detection in screening for cervical cancer, the prevalence of which is lower in women with circumcised male partners.

Ethical standard

Not applicable.

References

Addanki, KC, Pace, DG and Bagasra, O (2008) A practice for all seasons: male circumcision and the prevention of HIV transmission. Journal of Infection in Developing Countries 2(5), 328334.Google ScholarPubMed
Bansi-Matharu, L, Mudimu, E, Martin-Hughes, R, Hamilton, M, Johnson, L, ten Brink, D, Stover, J, Meyer-Rath, G, Kelly, SL, Jamieson, L, Cambiano, V, Jahn, A, Cowan, FM, Mangenah, C, Mavhu, W, Chidarikire, T, Toledo, C, Revill, P, Sundaram, M, Hatzold, K, Yansaneh, A, Apollo, T, Kalua, T, Mugurungi, O, Kiggundu, V, Zhang, S, Nyirenda, R, Phillips, A, Kripke, K and Bershteyn, A (2023) Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models. Lancet Global Health 11(2), e244e255.CrossRefGoogle ScholarPubMed
Bershteyn, A, Mudimu, E, Platais, I, Mwalili, S, Zulu, JE, Mwanza, WN and Kripke, K (2022) Understanding the evolving role of voluntary medical male circumcision as a public health strategy in Eastern and Southern Africa: opportunities and challenges. Current HIV/AIDS Reports 19(6), 526536.CrossRefGoogle ScholarPubMed
Borenstein, M, Hedges, L, Higgins, JPT and Rothstein, HR (2009) Introduction to Meta-Analysis. John Wiley and Sons: West Sussex.CrossRefGoogle Scholar
Brewer, DD, Potterat, JJ, Roberts, JM Jr and Brody, S (2007). Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania. Annals of Epidemiology 17, 217226.CrossRefGoogle ScholarPubMed
Brewer, DD, Potterat, JJ, Roberts, JM and Brody, S (2009) Unhygienic male circumcision procedures and HIV transmission. South African Medical Journal 99(1), 11.Google ScholarPubMed
Byakika-Tusiime, J (2008) Circumcision and HIV infection: assessment of causality. AIDS Behavior 12(6), 835841.CrossRefGoogle ScholarPubMed
Carrasco, MA, Rosen, JG, Maile, L, Manda, R, Amzel, A and Kiggundu, V (2020) Medically, traditionally, and dually circumcised men in Lesotho: population–based measurements of HIV/STI infections, sexual risk behaviors, and service use patterns. AIDS and Behavior 24(7), 21122118.CrossRefGoogle ScholarPubMed
Coburn, BJ, Okano, JT and Blower, S (2013) Current drivers and geographic patterns of HIV in Lesotho: implications for treatment and prevention in Sub-Saharan Africa. BMC Medicine 11, 224.CrossRefGoogle ScholarPubMed
Connolly, C, Simbayi, LC, Shanmugam, R and Nqeketo, A (2008) Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002. South African Medical Journal (SAMJ) 98, 789794.Google ScholarPubMed
Farley, TMM, Samuelson, J, Grabowski, MK, Ameyan, W, Gray, RH and Baggaley, R (2020) Impact of male circumcision on risk of HIV infection in men in a changing epidemic context – systematic review and meta-analysis. Journal of the International AIDS Society 23, e25490.CrossRefGoogle Scholar
Garenne, M (2023a) Changing relationships between HIV prevalence and circumcision in Lesotho. Journal of Biosocial Science 55(3), 463478.CrossRefGoogle ScholarPubMed
Garenne, M (2023b) Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa. Journal of Biosocial Science 55(6), 11561168.CrossRefGoogle ScholarPubMed
Garenne, M (2023c) HIV prevention in Africa: is VMMC useful and acceptable? International Journal of Impotence Research 35, 279281.CrossRefGoogle ScholarPubMed
Garenne, M and Matthews, A (2019) Voluntary medical male circumcision in Zambia: expectations and observations. Journal of Biosocial Science 52(4), 560572.CrossRefGoogle ScholarPubMed
Johnson, LF, Meyer-Rath, G, Dorrington, RE, Puren, A, Seathlodi, T, Zuma, K and Feizzadeh, A (2022) The effect of HIV programs in South Africa on national HIV incidence trends, 2000–2009. Journal of Acquired Immune Deficiency Syndrome 90(2), 115123.CrossRefGoogle Scholar
Lei, JH, Liu, LR, Wei, Q, Yan, SB, Yang, L, Song, TR, Yuan, HC, Lv, X and Han, P (2015) Circumcision status and risk of HIV acquisition during heterosexual intercourse for both males and females: a meta-analysis. PLoS One 10(5), e0125436.CrossRefGoogle ScholarPubMed
Makatjane, T, Hlabana, T and Letete, E (2016) Male circumcision and HIV in Lesotho: Is the Relationship Real or Spurious? Analysis of the 2009 Demographic and Health Survey. Rockville, Maryland, USA: ICF International.Google Scholar
Morris, BJ, Barboza, G, Wamai, RG and Krieger, JN (2017) Expertise and ideology in statistical evaluation of circumcision for protection against HIV infection. World Journal of AIDS 7(3), 179203.CrossRefGoogle Scholar
Morris, BJ, Barboza, G, Wamai, RG and Krieger, JN (2018). Circumcision is a primary preventive against HIV infection: critique of a contrary meta-regression analysis by Van Howe. Global Public Health 13(12), 18891899.CrossRefGoogle ScholarPubMed
Moses, S, Nagelkerke, NJ and Blanchard, J (1999) Analysis of the scientific literature on male circumcision and risk for HIV infection. International Journal of STD & AIDS 10(9), 626628.Google ScholarPubMed
Ndiwane, A (2008). Laying down the knife may decrease risk of HIV transmission: cultural practices in Cameroon with implications for public health and policy. Journal of Cultural Diversity 15, 7680.Google ScholarPubMed
O’Farrell, N and Egger, M (2000) Circumcision in men and the prevention of HIV infection: a ‘meta-analysis’ revisited. International Journal of STD & AIDS 11, 137142.CrossRefGoogle ScholarPubMed
Renne, S, Perry, B, Corneli, A, Chilungo, A and Umar, E (2016) Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malawi. Global Public Health 10(5–6), 679691.CrossRefGoogle Scholar
Rosenberg, MS, Goméz-Olivé, FX, Rohr, JK, Kahn, K and Bärnighausen, TW (2018) Are circumcised men safer sex partners? Findings from the HAALSI cohort in rural South Africa. PLoS One 13(8), e0201445.CrossRefGoogle ScholarPubMed
Shafer, LA, Nsubuga, RN, Chapman, R, O’Brien, K, Mayanja, BN and White, RG (2013) The dual impact of antiretroviral therapy and sexual behaviour changes on HIV epidemiologic trends in Uganda: a modelling study. Sexually Transmitted Infections 90, 423429.CrossRefGoogle Scholar
Sharma, SC, Raison, N, Khan, S, Shabbir, M, Dasgupta, P and Ahmed, K (2018) Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta-analysis. BJU International 121, 515526.CrossRefGoogle ScholarPubMed
Siegfried, N, Muller, M, Volmink, J, Deeks, JJ, Egger, M, Low, NN, Weiss, HH, Walker, SA and Williamson, PR (2003). Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews 3, CD003362.CrossRefGoogle Scholar
Thomas, AG, Tran, BR, Cranston, M, Brown, MC, Kumar, R and Tlelai, M (2011) Voluntary medical male circumcision: a cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho. PLoS One 6(11), e27561.CrossRefGoogle ScholarPubMed
UNAIDS and WHO (2021) Voluntary Medical Male Circumcision. Geneva, Switzerland: UNAIDS & WHO.Google Scholar
Van Howe, RS (1999) Circumcision and HIV infection: review of the literature and meta-analysis. International Journal of STD & AIDS 10(1), 816.CrossRefGoogle ScholarPubMed
Van Howe, RS (2015). Circumcision as a primary HIV preventive: extrapolating from the available data. Global Public Health 10(5–6), 607625.CrossRefGoogle ScholarPubMed
Van Howe, RS (2018). Expertise or ideology? A response to Morris et al. 2016, ‘circumcision is a primary preventive against HIV infection: critique of a contrary meta-regression analysis by Van Howe’. Global Public Health 13(12), 19001918.CrossRefGoogle ScholarPubMed
Weiss, HA, Quigley, MA and Hayes, RJ (2000) Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 14(15), 23612370.CrossRefGoogle ScholarPubMed
Zaidi, J, Grapsa, E, Tanser, F, Newell, M-L and Bärnighausen, T (2013) Dramatic increases in HIV prevalence after scale-up of antiretroviral treatment: a longitudinal population-based HIV surveillance study in rural Kwazulu-Natal. AIDS 27(14), 23012305.CrossRefGoogle Scholar