A caution for male circumcision programmes: high complication rates highlighted outside a trial setting

4 February 2010. Related: HIV prevention and transmission.

Simon Collins, HIV i-Base

Important limitations to the protective benefits from circumcision, prompted by a 2008 WHO review by Robert Bailey and colleagues, of complications during male circumcision in Kenya [1], were discussed in a recent editorial article in the 2 January 2010 journal AIDS. [2]

The original study, available online without subscription, deserves reading in full by anyone rushing to roll-out circumcision programmes on a community level.

The WHO study prospectively followed approximately 1000 men (IQR ~13-15, range 5-21 years), who were circumcised in July-August 2004, who were interviewed about complications 30-89 days after surgery. Twenty-four men were directly observed during circumcision and after 3, 8, 30 and 90 days.

The participants had either a traditional circumcision performed in a village or within a household compound, or a medical circumcision performed by someone the participant considered to be a clinician in a hospital, health centre, dispensary or private office. The researchers also interviewed 21 traditional and 20 clinical people who carried out the circumcisions.

After interviewing approximately two-thirds of participants and directly following the 24 cases, the researchers found very high rates of complications and decided to directly examine and interview the remaining 298 men, (range 45 – 89 days after circumcision). One or more complications were reported by 35% men circumcised traditionally and by 17% men circumcised medically (OR 2.53; 1.89–3.38; p <0.001). These rates were significantly higher than the approximate 1-3% observed in clinical trials, or in infants circumcised in developed countries.

Although rates for each complication were not given, the most common self-reported complications were excessive bleeding, infections and excessive pain, with bleeding the most common. Pain upon urination, incomplete circumcision requiring repeat surgery, and lacerations of the glans, the scrotum and the thighs were also reported. Many traditional circumcisions continued to bleed and needed medical support.

Infections were equally common among subjects circumcised medically and traditionally. Those circumcised traditionally were more likely to report receiving antibiotics from local practitioners, often from “travelling nurses” with few or no qualifications. These informal practitioners often sold injections to address infections and bandaged the wound after applying gravacine (a talcum powder with penicillin). Whether it prevented infections we
cannot be sure, but it tended to cake in the wound, delay healing and result in thick scarring and, in a few cases, permanent discolouration.

In 24% of the traditional cases and 19% of the medical cases, the wound had still not healed after 60 days (p=0.056) in contrast to 96% healed by 30 days in the randomised male circumcision in Kisumu, Kenya.

In the interviews with 298 men, traditionally circumcision was much more likely not to have healed (21% vs 10%, AOR 0.43; 0.22–0.84, p=0.014), to have significant swelling (14% vs 5%, AOR 3.20; 1.27–8.07, p=0.014), to have a culturally unacceptable amount of foreskin remaining (12% vs 3%, AOR 5.32; 1.54–18.31, p=0.008); and to higher trend to have lacerations (17% vs 10%, AOR 1.91; 0.93–3.91, p=0.077), and keloid scarring (17% vs 10%, AOR 1.99; 0.98–4,06, p=0.059.

Compared to developed country settings, delayed healing, swellings and lacerations were also prevalent among those circumcised medically.

The researchers concluded that “extensive training and resources will be necessary to build the capacity of health facilities in sub-Saharan Africa before safe circumcision services can be aggressively promoted for HIV prevention” and that “the rate of serious complications from traditional circumcisions should also serve as an alarm to ministries of health and the international health community that focus cannot only be on areas where circumcision prevalence is low”.

References

1. 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 World Health Organ 2008;86 (9):669-677.
   http://www.who.int/bulletin/volumes/86/9/08-051482/en/index.html
2. Crabb C. Male circumcision to prevent heterosexual HIV transmission gets (another) green light, but traditional circumcision in Africa has ‘shocking’ number of complications. AIDS. 24(1):N1-N2, January 2, 2010. doi: 10.1097/QAD.0b013e32832faec0