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 Org 2008;86:669-77.
The WHO and UNAIDS recommend that countries in which male circumcision is not widely practiced and where there is also high HIV prevalence and generalized epidemics should scale up programs to provide circumcision.(1) These recommendations are based upon strong data from clinical trials that demonstrated the efficacy of circumcision in preventing acquisition of HIV among circumcised men.(2,3,4) Adverse events from circumcision in these trials was low because the conditions under which the procedure would be provided routinely are likely to differ from trial conditions. Knowledge is needed about the frequency and types of complications outside of the tightly controlled setting of a trial.
To determine the frequency and types of complications following circumcision
Bungoma district, Western Province, Kenya
a) Boys scheduled for ritual circumcision between April and June 2004 in two of the seven divisions inhabited primarily by Babukusu, an ethnic group that universally practices male circumcision; and b) traditional and clinical practitioners of circumcision.
Participants were recruited using a two-stage cluster sampling scheme. Two of the seven divisions inhabited by Babukusu were included, and within these divisions, 75 households were randomly selected within 15 villages. Research assistants identified all households in which a boy was scheduled to be circumcised in the study period, resulting in 1,103 boys from 1125 households. Of these boys, 1,099 were re-contacted after August 2004, and 1,007 (91.6%) had been circumcised and included in the study.
The first 24 circumcisions were directly observed. Half were medical (performed in hospital, clinic, dispensary, or private medical office settings) and the remainder were traditional (performed within villages or household compounds). Follow-up with these boys occurred at three, eight, and 30 days post-procedure. Boys who experienced complications were seen again 90 days after circumcision.
The boys were interviewed to determine demographic characteristics, date and nature of the procedure, satisfaction with the procedure, complications, knowledge of peers who experienced circumcision-related complications, and sexual history before and after circumcision.
A convenience sample of traditional and clinical practitioners who performed circumcisions in August 2004 were interviewed to assess their experience with the procedure, degree of training, management of complications, and the amount charged for the procedure.
Inspection of three hospitals, one health center, and 14 private clinics was undertaken to determine the condition of the facilities and instruments used for circumcisions. A sample of boys who had "traditional" circumcisions identified their practitioners. The setting and instruments used by these practitioners were inspected.
Of the 1,007 boys interviewed, 445 were circumcised traditionally and the remainder, medically. Interviews were conducted an average of 60 days after the procedure (range 30-89 days). Thirty-five percent of the traditionally circumcised boys reported complications, which was 2.53 times more than the medically circumcised boys. Over 17% of the medically circumcised boys reported complications. Sixty-three percent of the traditionally circumcised boys were sexually active prior to circumcision, compared with 36% of medically circumcised boys.
The most commonly reported complications were bleeding, infections, and pain. Excessive bleeding was reported more frequently among traditionally circumcised boys but infection rates were similar between the groups. Medically circumcised boys received antibiotics more frequently for their infections than did traditionally circumcised boys. At 60 days post-circumcision, 24% of traditionally circumcised boys and 19% of medically circumcised boys had wounds that were not completely healed.
Among the 24 circumcisions that were directly observed, 11 of the 12 medical procedures and 10 of the 12 traditional procedures resulted in complications. Adverse events ranged from mild to severe. Follow-up interviews with these 24 boys found a higher frequency of reported problems among the traditionally circumcised boys.
Traditional circumcisers reported an average of 6.8 years of education compared with 15.4 years among the medical circumcisers. Traditional circumcisers reported more procedures in the previous two years than did the medical practitioners. Both traditional and medical practitioners indicated that they felt adequately trained. The cost of circumcision was lower among traditional circumcisers (345 Kenyan shillings) than among medical providers (564 Kenyan shillings). Complication rates were higher from private facilities (22.5% of procedures observed) than from public settings (11%).
Training and resources are needed before circumcision can be provided in sub-Saharan Africa
The study appears to be well-designed in terms of sampling an appropriate population and following-up; however, measures are inadequately described and subject to bias. There is insufficient information on the comparability of the two groups of boys or the two types of practitioners. As well, information on the training of research assistants to assess clinical complications is not described.
The reported rates of complications from both traditional and medical practitioners was unacceptably high and higher than those reported from the clinical trials)(2,5) from circumcisions performed on infants, or from other reports from African settings.(6,7) The degree of complications reported in this study highlights the need to ensure that practitioners are adequately trained and monitored and that safe and sterile facilities and instruments are available before expanding circumcision as an HIV prevention effort.
- WHO and UNAIDS announce recommendations from expert meeting on male circumcision for HIV prevention. UNAIDS & WHO; 2007. [Accessed on July 24, 2008].
- Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2:e298.
- Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.
- Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-66.
- Mayatula V, Mavundla TR. A review on male circumcision procedures among South African blacks. Curationis 1997;20:16-20.
- Manji KP. Circumcision of the young infant in a developing country using the Plastibell. Ann Trop Paediatr 2000;20:101-4.
- Magoha GA. Circumcision in various Nigerian and Kenyan hospitals. East Afr Med J 1999;76:583-6.