Background
The HIV pandemic is among the most critical public health challenges facing the African continent. Observational studies and three randomized controlled trials (RCTs) have reported that male circumcision can prevent HIV acquisition heterosexually by men [
1‐
3]. Williams et al [
4] have conducted mathematical models showing that wide-scale implementation of MC has the potential of reducing 2.0 million (1.1–3.8 million) new HIV infections in the first ten years of implementation in sub-Saharan Africa.
Several studies have reported on the acceptability of male circumcision for the prevention of HIV in sub-Saharan Africa [
5‐
7]. In a review, Westercamp and Bailey report that there is sufficient research evidence to suggest that male circumcision is acceptable in sub-Saharan Africa for the prevention of HIV transmission [
8]. However, Mills and Siegfried have suggested a "cautious optimism" approach towards male circumcision [
9]. There is on-going debate as to whether male circumcision should be routinely performed for the purpose of preventing heterosexual transmission of HIV in sub-Saharan Africa [
10‐
15].
While the literature has focused on the role of MC in the prevention of transmission of HIV in sub-Saharan Africa, we argue that there has not been commensurate interest in the estimation of safety and complications potentially associated with any scale-up in MC in Africa. In conducting this review, we were motivated to find out the available evidence regarding the reported prevalence of complications of MC in Africa. We therefore conducted a review of the published literature to attempt to answer the question: What has been the reported prevalence of complications of MC in sub-Saharan Africa? A secondary question is: Who is conducting MC in Africa?
Discussion
There is limited published literature on the complications of male circumcision in sub-Saharan Africa. The available evidence regarding the prevalence of complications in male circumcision is conflicting, with some studies reporting significantly high complications prevalence and at least one study reporting no complications. It is plausible to consider that a study that may not have reported a single complication may indeed have none to report or that complications may have been consider so minor as to be 'worth' reporting. In case of complications that may be experienced at home and there are significant barriers to access medical care, it is conceivable to expect that many patients will not present to health facilities for care following minor to moderate complications. Another explanation for no report of complications may be that the patients may have presented for management of complications at a different facility from where they obtained circumcision.
In virtually all the studies reviewed, the majority of complications reported were of minor clinical consequence. The exception was the study by Shittu and Shokunbi [
24] which reported on a special group of patients i.e. hemophiliacs, with extremely high risk of bleeding from minimal trauma. The interpretation of prevalence of complications in this study must be made within these special circumstances. Other than the report of bleeding, no other complication was reported. It is unlikely though that bleeding was the only complication experienced; rather it would seem that this was the main focus of the study.
Reports on complications of male circumcision also differ in so far as the time after the circumcision that complications were reported i.e. early versus late complications. Yegane et al [
27] for instance have reported on possible late complications of MC which include granuloma formation, penile rotation and secondary chordee [
27]. In some of the studies that were reviewed in our study like that of Bailey et al [
17] where patients were followed up for complications for 8 days, long term complications such as keloid formation may have been missed. Bailey et al's randomized controlled study however was of much longer duration and the assessment of long term complications was possible, but not reported. In general, most of the studies we reviewed reported on bleeding and infections only. Auvert's et al study however had reported an extensive list of possible complications and included zero reporting. Of the complications reported by Auvert et al, 13 (31.7%) reported pain, excessive bleeding (15%), infection (5%), damage to penis (5%), 1 anesthetic complications and 9 complaints of problems with appearance.
The prevalence of complications of MC in North America has been reported in the range of 0.2% to 0.5% [
28]. However, the true prevalence of complications is not known as ways of ascertaining these will always underestimate the true prevalence [
28]. Ben Chaim et al [
29] have reported on series of 19,478 male infant circumcision conducted in Israel, of which only 66 (1.3%) recorded complications. This study reported fewer complications than most of the studies we reviewed but prevalence was higher than the single study that reported no complications.
The study by Okafor et al [
22] which reported no complications, had potentially 119 neonates but 17 were excluded for a variety of reasons. This could suggest that proper selected of MC candidates will be necessary to minimize complications. However, such conclusion may not be justified in the absence of data on the criteria for exclusion i.e. the selection may have or may have not influenced the prevalence of complications.
There are always concerns about the safety of MC in sub-Saharan African health systems. Mattson et al reported on the feasibility of performing MC in health facilities in Kenya. The lack of basic instruments and inadequate supplies were identified as crucial limitations in facilitating provision of safe MC in that country [
30]. Ahmed [
31] studied circumcision practices in Anjouan, Comoros and reported that circumcisions by trained lay people were as safe as those carried out by physicians in hospitals. Training and supervision was emphasized in this series.
The special cases of complications in haemophiliacs deserve special mention. It has been reported that the use of fibrin glue or the "diathermic knife" may prevent bleeding and transfusion with blood factors [
32,
33]. These supplies will need to be considered if MC is to be scaled-up, but will increase the cost of the procedure.
It is reasonable to expect that prevalence of complications from MC in Africa is likely to be higher than in countries with well-resourced health systems. While that expectation is reasonable and perhaps will be realized, a recent publication by Archibald et al is also informative [
34]. Archibald et al compared contamination of blood culture specimens at Duke Medical Center (Durham, North Carolina, United States), Kamuzu Central Hospital (Malawi) and Muhimbili National Hospital (Tanzania). Contamination of specimens at both African centers was less than 2% while it was 28% at Duke Medical Center. The expectation that developing country health systems will always perform poorly when compared to developed nation health systems may therefore not be justified.
Conclusion
The literature on prevalence of complications following male circumcision in sub-Saharan Africa is limited. Most of the complications reported have been of minor clinical consequence. Reporting practices also have been varied such that comparisons among studies with regard to age of patients, indications for circumcision, duration of follow-up of complications and categories of circumcisers are difficult. There is need to develop and encourage standardized reporting of complications of male circumcisions. We believe that the finding that there is not enough data to suggest that MC is associated with more than the 'average' risk in Africa is important as public policy discussions gain momentum as whether to scale-up provision and accessibility of the procedure to prevent HIV transmission.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
ASM conceived the idea of the study, participated in identifying papers for review and drafting of manuscript. ASM is guarantor of manuscript.
HWP participated in identifying papers for review, analysis and drafting of manuscript. RM participated in identifying papers for review and drafting of manuscript.
JII participated in identifying papers for review, analysis and drafting of manuscript. All authors approved the manuscript submitted.