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Research Article

The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda

  • Godfrey Kigozi,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Ronald H Gray mail,

    To whom correspondence should be addressed. E-mail: rgray@jhsph.edu

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Maria J Wawer,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • David Serwadda,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Frederick Makumbi,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Stephen Watya,

    Affiliation: Department of Surgery, Urology Unit, Mulago Hospital, Makerere University, Kampala, Uganda

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  • Fred Nalugoda,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Noah Kiwanuka,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Lawrence H Moulton,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Michael Z Chen,

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Nelson K Sewankambo,

    Affiliation: Department of Medicine, Makerere University, Kampala, Uganda

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  • Fred Wabwire-Mangen,

    Affiliation: School of Public Health, Makerere University, Kampala, Uganda

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  • Melanie C Bacon,

    Affiliation: National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America

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  • Renee Ridzon,

    Affiliation: Bill & Melinda Gates Foundation, Seattle, Washington, United States of America

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  • Pius Opendi,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Victor Sempijja,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Absolom Settuba,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Denis Buwembo,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Valerian Kiggundu,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Margaret Anyokorit,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • James Nkale,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Nehemia Kighoma,

    Affiliation: Rakai Health Sciences Program, Entebbe, Uganda

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  • Blake Charvat

    Affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America

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  • Published: June 03, 2008
  • DOI: 10.1371/journal.pmed.0050116

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RE: The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda

Posted by plosmedicine on 31 Mar 2009 at 00:26 GMT

Author: Adamson Muula
Position: Dr
Institution: Department of Community Medicine and Public Health, University of Malawi, College of Medicine and Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill
E-mail: muula@email.unc.edu
Submitted Date: June 04, 2008
Published Date: June 5, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

RE: The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda
Adamson S. Muula
Department of Community Medicine and Public Health, University of Malawi, College of Medicine and Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill

The paper by Kigozi et al [1] is a welcome addition to the literature on the safety of male circumcision (MC) in resource-limited settings. These authors concluded that wound healing was delayed among HIV infected compared to non-infected men, and adverse events increased with earlier resumption of sexual intercourse. Overall however, the adverse events rate was similar between HIV infected and those not infected.
While Kigozi et al have contributed to filling the knowledge gap that existed regarding safety of MC among HIV infected men, a few issues still remain to be further explored. The studies enrolled men median ages 23 y and 32 y. Yet with the MC debate roll-out, there are proposals to encourage circumcision within the neonatal period at least circumcision up to early adolescence [2]. While data in the developed nations and elsewhere suggest neonatal circumcision as safe if not safer than adult MC [3], and cost less than if MC done in adults, similar data are probably unavailable in sub-Saharan Africa. Secondly, physicians carried out the MC in the studies reported by Kigozi et al, and yet in the countries where MC may be most needed to prevent HIV acquisition, the physician health cadre may be limited in numbers [4]. Although data exists to support the notion that clinical outcomes for surgery performed by medical assistants and clinical officers may be comparable to physicians [5], this may not always mean better outcomes as no difference will be obtained if both physicians and clinical officers have worse outcomes. The finding by Kigozi et al that HIV infected men had similar adverse event outcomes to non-infected should encourage us to also ask: Was the rate of adverse events also similar to what is obtained in the developed nations? I would suggest the developed nation outcomes be the standard. This should not delay scaling-up of MC until it is as safe as in the developed nations. Comparisons of adverse event rates between African country against another, HIV infected versus non-infected while certainly useful, need to be complemented with comparisons of what is the best outcomes in the world
Competing Interests
I have no competing interest to declare.

References
1. Kigozi G, Gray RH, Wawer MJ, Serwadda D, Makumbi F, et al (2008) The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda. PLoS Med 5: e116 doi:10.1371/journal.pmed.0050116

2. Rennie S, Muula AS, Westreich D (2007) Male circumcision and HIV prevention: ethical, medical and public health tradeoffs in low-income countries. J Med Ethics, 33:357-61.
3. Circumcision Policy Statement. Task force on circumcision (1999) American Academy of Pediatrics. Pediatrics 103:686-693
4. Ozgediz D, Riviello R (2008) The “Other” Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa. PLoS Med 5: e121 doi:10.1371/journal.pmed.0050121
5. Chilopora G, Pereira C, Kamwendo F, Chimbiri A, Malunga E, Bergström S (2007) Postoperative outcome of caesarean sections and other major emergency obstetric surgery by clinical officers and medical officers in Malawi. Hum Resour Health 5:17.

Competing interests declared: No, I don't have any competing interests to declare