Dr. Rebeca Plank is the Principal Investigator of a new clinical trial, Infant Male Circumcision in Gaborone, Botswana, and Surrounding Areas: Feasibility, Safety and Acceptability. Plank is an Infectious Disease and HIV specialist who trained at the Brigham and Women’s Hospital in Boston. She recently spoke with Martha Henry, Editor of Spotlight
What is the history of circumcision in Botswana?
Plank: Circumcision had traditionally been practiced into the 19th century to mark the transition from boyhood to manhood. This practice was discouraged through the influence of Western medical missionaries. As of a few years ago, up to 15% of men in Botswana were circumcised, only rarely as infants.
Why do we need this study?
Plank: Botswana has one of the world’s highest rates of HIV infection. Education programs and campaigns to promote condom use have done little to decrease the prevalence of HIV there. Finding effective prevention measures is essential.
In three randomized controlled trials, circumcision reduced a man’s risk of HIV infection through heterosexual sex by 60%. Circumcising a baby is easier, safer, cheaper and faster than circumcising an adolescent or adult, but we don’t know which method of infant circumcision is most appropriate for Botswana and other developing countries. That’s why we’re doing this study.
What are the aims of your study?
Plank: In the first phase, our aim was to determine if infant male circumcision is acceptable in Botswana. If parents are offered the option, what percentage will actually have their babies circumcised? In the second phase we are examining the feasibility and safety of two different infant circumcision techniques: Mogen clamp versus Plastibell. No study has ever compared the two methods.
You’ve finished the first phase. What were your findings?
Plank: Our study found that among mothers of newborn male infants interviewed in the maternity wards in four towns in Botswana, 92% responded that they would circumcise, primarily to prevent future HIV infection, if the procedure were available free of charge in a clinical setting.
Why spend money circumcising infants who are less than a month old when you could be circumcising men who are already sexually active?
Plank: That’s a very reasonable question. The government of Botswana aims to circumcise 80% of HIV-uninfected males aged 0–49 years over the next several years as part of the country’s HIV prevention efforts. Currently there are wait-lists for adolescents and adults seeking the procedure. Infant circumcision has not yet been scaled-up. The Ministry of Health is awaiting the results of our study before deciding which method to adopt for the national program.
Circumcising a baby is about one-tenth the cost of circumcising an adult. Not only is it cheaper, it’s also much safer to circumcise a baby than an adolescent or adult. Another factor to be taken into consideration is that if an adolescent or adult resumes sexual activity before the wound is fully healed, they have an increased risk of getting infected or of passing the infection on to someone else.
Although infant circumcision would have a delayed impact on the HIV epidemic, it would be one way to introduce the procedure in a safe, systematic, and sustainable way to Botswana and in other resource-limited settings. If you take all of those factors into consideration, infant circumcision makes a lot of sense.
Circumcision has been shown to reduce HIV infection in men by 60%. Does it have a significant effect in reducing infection for the female partners of infected males? Does male circumcision have any impact on women?
Plank: The evidence is not clear about whether the female partners of HIV-infected males have a reduced rate of infection if their male partners are circumcised. However, one should look at the larger picture. If fewer men get infected with HIV because of circumcision, fewer men will pass on infections to women. And when fewer women are infected, fewer babies will be born infected. Eventually circumcising enough men will reduce the population prevalence of HIV, which will reduce the number of women who get infected.
How will your study results be used?
Plank: The World Health Organization (WHO) and UNAIDS have stated that countries with severe, generalized HIV epidemics but low rates of male circumcision should offer this surgery as an important, evidence-based HIV prevention intervention, including among newborns. Governments now need to make decisions about implementing circumcision services. They must develop policies that are based on international best practice and respectful of human rights.
Our study will provide the WHO with data on the safety and sustainability of two established methods of circumcision. It is important to consider not only the cost and safety of each procedure, but also how easy it is to train people and maintain the supply chain.