Research on the Safety of Male Circumcision for HIV Prevention

Studies of male circumcision show that the procedure is safest when it is performed in a clinical setting by well-trained providers who have the necessary equipment and supplies. When circumcision is provided in non-medical or ill-equipped settings, however, post-surgery complications are common and may be severe.

Neonatal male circumcision

Complications of neonatal male circumcisions performed in medical settings are rare and usually minor (1). In studies of neonatal circumcision in the United States and Israel, complication rates ranged from 0.2 percent to 2 percent. The most common complications were bleeding and infection (2).

Neonatal circumcision tends to be safer than adult circumcision because it does not require suturing to stop the bleeding and close the wound.

Circumcision of adult and adolescent males

The main complications of circumcision in adults and adolescents include delayed healing, infection, and bleeding. Complication rates of 2 percent to 10 percent have been reported in the literature (3, 4).

A review of 10 studies on complications of male circumcision in sub-Saharan Africa concluded that the available data were inadequate to make a reasonable assessment of the prevalence of such complications in the region. Definitions of complications vary widely across studies, and complication rates varied from zero to 24 percent, excluding one study among haemophiliac patients at high risk of bleeding, which had a complication rate of 50 percent. In all the other studies, only minor complications were reported (5).

When male circumcision is undertaken by an untrained individual in non-sterile conditions, without proper equipment and without appropriate follow-up, the complication rate can be high, and severe, potentially life-threatening complications may occur. These complications can include severe bleeding, bacterial infection, and even gangrene and mutilation of the penis. One study of such non-medical circumcisions in South Africa revealed that the complication rate was more than 11 percent (6).

A study in Bungoma, Kenya, found high rates of complications in both medical and non-medical settings. Thirty-five percent of 443 traditional circumcisions and almost 18 percent of the 559 circumcisions performed in clinical settings resulted in complications. Most of the health facilities did not have the appropriate instruments and supplies for performing the surgery, and providers lacked knowledge and training in how to provide male circumcision (7).

Studies have shown, however, that circumcision of adult and adolescent males can be provided safely in low-resource settings when it is performed by providers who are well-trained and have the proper equipment and supplies. For example, the rates of surgery-related complications observed in the three randomised controlled trials of male circumcision for HIV prevention were 1.7 percent in Kenya, 3.5 percent in South Africa, and 7.6 percent in Uganda (The differences among these rates can most likely be explained by different definitions of complications related to the procedure and the methods used for detecting and reporting them) (3).

Three different techniques — the forceps-guided, sleeve, and dorsal-slit methods — are most commonly used to perform adult and adolescent male circumcisions in clinical settings in sub-Saharan Africa. The surgeons in the Uganda trial used the sleeve technique, while the forceps-guided method was used in the other two trials. No randomised clinical trial has compared the safety of the different surgical techniques for adult male circumcision.

A prospective study of the safety of the typical adult male circumcision procedure used in Western Kenya also achieved low complication rates. In this study, conducted in Kisumu among 1.475 uncircumcised HIV-negative men ages 18 to 24, the complication rate using the forceps-guided method was 1.8 percent. Twenty-seven "adverse events," such as wound infections, bleeding and delayed wound healing, were judged to be definitely, probably or possibly related to the surgery (8).

Most of the information about the safety of male circumcision is from studies among infants and HIV-negative adults. One study in Rakai, Uganda, found that the safety of the procedure was comparable among 2,326 HIV-negative men and 420 HIV-positive men. The risk of moderate or severe complications was 3.1 percent among the HIV-positive men and 3.5 percent among the HIV-negative men. The results also suggest that the wound from a circumcision heals slightly slower in men who are infected with HIV compared to HIV-negative men (9).

Some circumcision devices have been proposed to make adult circumcision quicker and easier (for example, to avoid the need for sutures), but there are not enough data on the safety of such devices to recommend their use.

References

1. Joint United Nations Programme on HIV/AIDS. Neonatal and Child Male Circumcision: A Global Review (PDF, 667 KB). Geneva, Switzerland, 2010.
2. Alanis MC, Lucidi RS. (Abstract only) Neonatal circumcision: a review of the world's oldest and most controversial operation. Obstet Gynecol Surv 2004;59(5): 379-95.
3. Weiss HA, Halperin D, Bailey RC, et al. Male circumcision for HIV prevention: from evidence to action? AIDS 2008;22(5):567-74.
4. Ben-Chaim J, Livne PM, Binyamini J, et al. Complications of circumcision in Israel: a one year multicenter survey. Isr Med Assoc J 2005;7(6);368-70.
5. Muula AS, Prozesky HW, Mataya RH, et al. Prevalence of complications of male circumcision in Anglophone Africa: a systematic review. BMC Urol 2007;7:4.
6. Peltzer K, Nqeketo A, Petros G, et al. Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation. BMC Public Health 2008;8:64.
7. Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya (PDF, 2008, 891 KB) Bull WHO 2008;86(9):669-77.
8. Krieger JN, Bailey RC, Opeya JC et al. (Abstract only) Adult male circumcision outcomes: experience in a developing country setting. Urol Int 2007;78(3):235-40.
9. Kigozi G, Gray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med 2008;5(6):e116.