TAC, doctors warn against self-circumcision device

Voluntary Male Medical Circumcision is Safe and Effective

But beware of unsafe devices

Summary

The Southern African HIV Clinicians Society and the Treatment Action Campaign support the implementation of a country-wide voluntary male medical circumcision (VMMC) programme. Male medical circumcision reduces the risk of heterosexual men contracting HIV and the Human Papilloma Virus (HPV). Despite the effectiveness of VMMC, it is essential that circumcised men are encouraged to continue using condoms during sexual intercourse.

We welcome the steps the South African government is taking to implement VMMC. Kwazulu-Natal has run several events encouraging youth to have medical circumcisions and the Department of Health together with the South African National AIDS Council is developing circumcision guidelines. The continuous disturbing reports of traditional circumcisions that have resulted in deaths and penile mutilations show how important it is to implement a medical circumcision programme that is safe and in which adverse events are kept to an absolute minimum. The success of VMMC is dependent on public confidence in the programme's safety.

We are therefore deeply concerned that a Malaysian company, Taramedic Corporation, and its South African partner, Carpe Diem Enterprises, are aggressively marketing a circumcision device called the Tara KLamp (TK) to several sub-Saharan African countries, including South Africa, Lesotho, Kenya, Botswana and Zimbabwe. A randomised controlled trial in adolescents and adults found a very high rate of adverse events and much greater pain associated with this device compared to the standard forceps-guided circumcision technique.

The TK must be withdrawn from sale and distribution for adolescent and adult circumcision throughout sub-Saharan Africa until the device's safety concerns are addressed.

A review of the Tara KLamp (TK)

The TK is a circumcision device that is clamped onto the foreskin with the purpose of necrotising it. After approximately seven days the device, along with the foreskin, usually falls off. In some cases the device does not fall off forcing the patient to have the TK removed surgically.

The Orange Farm clinical trial showed that VMMC can reduce a heterosexual male's risk of contracting HIV by 60%. In 2005 the Orange Farm researchers performed a randomised controlled trial to see if the TK could be used as an alternative method of circumcision. 35 men were circumcised with the TK and 34 with the standard forceps-guided technique that was used during the original trial.

Adverse events from use of the TK were far higher: 37% compared to 3.4% for the forceps-guided method. This was a statistically significant result (p=0.004). Men circumcised using the TK also reported worse pain than men circumcised using the forceps-guided method. Furthermore, the device clearly causes consternation: 97 men refused to participate in the trial, 94 of them giving the reason that they did not wish to use the TK.

The TK trial was stopped early due to the unacceptably high rate of adverse events. The researchers concluded, "Given the high rates of adverse events in this study and the low number of available studies, we strongly caution against the use of the TK for young adults, and we recommend careful evaluation of the procedure when performed on children."

Safety must be proven before any new medical intervention is implemented. Currently, the balance of evidence shows that the TK is unsafe for use on adolescents and adults. We cannot find any published studies of the TK being shown to be safe for adolescents and adults. Two studies, neither of them randomised and consequently of questionable quality, indicate that the device might be safe for young children.

The marketing practices of Carpe Diem Enterprises

Carpe Diem Enterprises is the distributor of the TK in South Africa. The company has disregarded the safety concerns raised in the Orange Farm study. The device's website states, "This invention enables circumcisions to be performed not only safely and easily but also ----- for the first time in surgical history ----- enables circumcisions to be performed just as aseptically, at home, on the roadsides or out there in the bush, as in an operating theater. "

The device is marketed as a faster method of performing circumcisions, as it can be carried out in less than 10 minutes. This is not much faster than the medical forceps-guided method of circumcision and certainly does not outweigh safety concerns. It also does not take into account the additional time needed to surgically remove the device from some patients.

The TK is also more expensive than the forceps-guided method of circumcision. According to our discussions with the manufacturer, the TK is being sold to general practitioners for R160 excluding VAT. However the device only slightly reduces the number of surgical instruments needed in a circumcision. Consequently we estimate that using the TK adds significant cost, even without considering the extremely large additional cost that would be incurred from hospitalisations due to increased adverse events.

The attitude of the company towards critical research of its device is exemplified by Dr. G. Singh, the inventor of the TK, who made the following threat in an email exchange with one of the authors of the Orange Farm study, "All it needs is a simple withdrawal of your manuscript and gracefully accept the reality. I am even not asking for an apology, for I am a very forgiving man..... but there is a limit!"1

The TK has also been used throughout the region as a part of the evangelical mission of the marketers of the device, Tony Lawrence and Magda Van Der Walt. A book promoting the device and the work of Tony Lawrence states the following:

"Twice per year... young male initiates in South Africa alone take an important step toward manhood by undergoing circumcision during a time of initiation ... But what should be a glorious occasion for these teenagers often turns out to be a nightmare. One out of five boys end up with their genitals partially or fully amputated.... The Seize the Day foundation is rescuing these children in a holistic way. Among other things, Tony Lawrence and the seize the day volunteer distribute a pack to each initiate. (The pack contains a TK and a bible) ... The solution is to circumcise and evangelize."2

The TK is being aggressively marketed and, at times, with an inappropriate religious agenda. The marketers of the device make unsubstantiated claims and disregard safety concerns. They have threatened researchers who published data critical of the TK. The TK must be withdrawn from use throughout sub-Saharan Africa for adults and adolescents until its safety concerns are addressed.

1 This correspondence was forwarded to TAC by Carpe Diem Enterprises

2 W Cambell et al., ‘Be a hero: The battle for mercy and social justice.' 2004. Pg. 204

Joint statement by the Treatment Action Campaign (TAC), SECTION27 and the Southern African HIV Clinicians Society, July 8 2010

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responses to this article

ABC, not circumcision "Adverse events" in 36% of the subjects as well as more pain. Scary. Circumcision is a dangerous distraction in the fight against AIDS anyway. There are six African countries where men are *more* likely to be HIV if they've been circumcised: . .more Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn't happen. We now have people calling circumcision a "vaccine" or "invisible condom", and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups "believe that circumcised men do not need to use condoms". The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw. ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them. . .less by Mark Lyndon on July 08 2010, 16:10 Find this comment inappropriate? Report it

the kindest cut of all A better idea would be to invent a D-I-Y device that can cut off the whole thing. Then we will see a decline in rapes in this country. by The 13th Duke of Weybourne on July 08 2010, 21:00 Find this comment inappropriate? Report it

Evengelical tone Tony Lawrence is not the only one promoting circumcision with evangelical fervour. That has been the tone of the campaign from the beginning (and for decades before if truth be known, long before AIDS was heard of). Some influential people preach . .more circumcision with a zeal that must be motivated by something more than just health concerns - fear that other men may have more P**** than them, perhaps? The claim that circumcision offers "60% protection" has become a mantra, but the truth is less impressive. In the Orange Farm study, 1,500 men were circumcised and a similar number left intact, and after less than two years, 20 circumcised men had HIV and 45 of the control group. The trials in Kenya and Uganda yielded similar numbers of infected men, though the starting numbers were much greater. That is the whole basis of the claim - a total of 73 men who didn't get HIV less than two years after 5,400 were circumcised. But 327 circumcised men left the trials, easily enough to hide enough HIV men to render the trilals meaningless. A prestigious Cochrane review that gave its approval to the trials, overlooked this. . .less by Hugh7 on July 08 2010, 23:34 Find this comment inappropriate? Report it

Circumcision: More Harm Than Good "Despite the effectiveness of VMMC, it is essential that circumcised men are encouraged to continue using condoms during sexual intercourse." Why even get circumcised then? Why even put one's self through the risk if ultimately what will be protecting a . .more man is a condom? The claim that "circumcision reduces the risk of HIV transmission by 60%" conflicts with a very hard reality: More than 70% of the 87,710 HIV/AIDS sufferers in Malaysia, the birthplace of the TK, are Muslims (and therefore circumcised), according to Malaysian AIDS Council vice-president Datuk Zaman Khan. It looks like Dr. G. Singh is nothing more than a charlatan seizing the opportunity to make profit. These faulty devices aren't the only problem; endorsing circumcision as an HIV prevention method gives the go-ahead to many tribes for whom circumcision is a very important rite of passage, and who will not let their men get circumcised at a hospital, putting them at risk. The current circumcision death toll in South Africa is already at 47. Endorsing circumcision as HIV prevention is a huge mistake. The "benefits" of protection are dubious at best, quacks like Dr. Singh are taking advantage, and it is costing LIVES. Sooner or later, the WHO, UNAIDS and UNESCO will have to be held accountable. . .less by Joseph4GI on July 09 2010, 04:16 Find this comment inappropriate? Report it

"Circumcise and Evangelize"? This approach is interesting, given the fact that the Bible prohibits circumcision for gentiles. It is written very clearly. Perhaps the clearest of all is Galatians 5. "Behold, I Paul say unto you, that if ye be circumcised, Christ shall . .more profit you nothing." Galatians 5:2 It doesn't sound like Tony Lawrence and his Carpe Diem organization's hearts are in the right place. "Beware of dogs, beware of evil workers, beware of the mutilation!" Philippians 3:2 . .less by Joseph4GI on July 09 2010, 04:25 Find this comment inappropriate? Report it

Have i missed something? The HI Virus is transmitted by an exchange of body fluids, such as semen into the reproductive tract or anal canal, or by blood carrying the virus entering the blood stream of another person via transfusion, needle-stick injury, etc. It is difficult to . .more see how circumcision per se reduces the infection rate, unless it is argued that the virus is held in close contact with the inner surface of the prepuce - and, if the latter is intact, this is a highly dubious proposition. Simply wiping the P**** and prepuce clean immediately after intercourse would be just as effective, if not more effective, than circumcision in preventing infection. The considerable differences between various studies seems to suggest that the research protocols have been poorly formulated, that the results have been incorrectly interpreted, or that there is in fact no true correlation between circumcision and infection rate. . .less by Dr. Angelo Lambiris on July 09 2010, 07:41 Find this comment inappropriate? Report it

Circumcision It has been proved over and over that, if you lack common sense, your life will be full of suffering. It just makes no sense to cut off a smal strip of skin in order to achieve the claimed "benefits" but in the process risk infection, mutilation and . .more even permanent sterility. How stupid can people get? . .less by Jacko on July 09 2010, 07:58 Find this comment inappropriate? Report it

Why?? Who the hell would want to cut off the end of their own P****?? by Airwolf on July 09 2010, 09:25 Find this comment inappropriate? Report it

"Poorly Formulated Research Protocols"? In response to Dr. Angelo Lambiris: Usually, medical studies seek to preserve the human body. By finding cures and causes to diseases, scientists usually seek to avoid the loss of limbs or organs. This is true for say, the breasts, prostate, . .more kidneys, liver, colon, etc. Before amputating hands and feet, doctors usually try to save them first. Circumcision "researchers" and "studies" are unique in that they seek to vilify a particular body part to legitimize its destruction. Their interest seems to lie not in the prevention of disease, but in the preservation of a particular "cure." The backgrounds of some of these researchers present a flagrant conflict of interest, bringing into question the validity of their results. Robert Bailey, for example, has been a long-standing advocate of infant circumcision. Daniel Halperin is on record saying he wants to continue his grandfather's legacy (his grandfather was a mohel). These facts alone should reveal the agendas of the people heading these "studies," putting their research protocols into question. These "researchers" weren't looking to prevent HIV, they were interested in finding some correlation between circumcision and HIV transmission. Surprise, surprise, this is precisely what they found. . .less by Joseph4GI on July 09 2010, 10:54 Find this comment inappropriate? Report it

At first blush.... One would be inclined to agree with Dr. Lambiris. However, one is given to understand that an existing infection assists the HI virus in infecting the subject. So, if one factor assisting the HI virus in gaining a foothold is an infected foreskin, . .more then the absence of a foreskin would eliminate HI infection via that route? Is this not the case? Just wondering; I am by no means knowledgeable in these matters. . .less by mpho on July 09 2010, 14:04 Find this comment inappropriate? Report it

"At first blush..." One might think that mpho might have a point. However it's based on a few of dubious premises: 1. That all men with foreskins will indeed develop infection. 2. That circumcised men do not develop an infection that "assists" . .more HIV. 3. That a man is only vulnerable to HIV through sexual intercourse. 4. That only men need to worry about HIV prevention. 1. Not all men with foreskins will necessarily develop infections that "facilitate" HIV transmission. 2. Circumcised men can and do develop infections that would "assist" HIV transmission, including, but not limited to, canker sores due to herpes. 3. Assuming that circumcision works the miracles it is claimed, it would not do anything for a man who shares needles with HIV positive partners. 4. Circumcision would not prevent HIV semen from entering a woman's vagina or the anus in man or woman, putting a man's partner at risk. Circumcised or not, a man must learn to wear a condom, as being circumcised does not necessarily mean he is protected. This being the case, what's the point of circumcision? I believe, mpho, that you may know more than you lead on to believe. If not, I do hope you are inspired to learn more. . .less by Joseph4GI on July 09 2010, 18:56 Find this comment inappropriate? Report it

@Joseph4GI Nix Joe, I'm a simple fellow; I made no assumptions other than that if everything else is equal, and you have an extra bit of floppy skin the other fellow doesn't have, you have one more thing which can go wrong. The more extras you carry . .more about the more there is which can go wrong, hence the greater the probability of coming to grief. . .less by mpho on July 09 2010, 22:18 Find this comment inappropriate? Report it

@mpho - CORRECTION Well, your "assumption" is incorrect. You said that you are by no means knowledgeable in these metters? Well, now is your chance. The "floppy skin" at the end of people's penises isn't "extra." The foreskin is normal, healthy tissue that every . .more man is born with. Problems with the foreskin could develop, yes. But that goes for any other body part. The fact that a body part could develop problems doesn't make it "extra." Even AFTER a P**** has been circumcised, much can go wrong, increasing the probability of grief. To be sure, circumcised men are as vulnerable to any STD as anatomically correct men. A circumcised man can still get herpes, develop cancer, and yes, even contract HIV. There is no scientist, study, or medical organization that can refute this fact, which is why even they insist that circumcised men must still wear condoms. Actually, having testicles makes a man vulnerable to testicular cancer. Losing one's testicle(s) to cancer is the source of much grief for a man. You will find it difficult, however, to convince anybody that the testicles are "extra." Worthless surgical procedures on healthy men. The destruction of normal, healthy body parts; THIS is what is "extra." A waste of funds on a procedure that doesn't do anything. . .less by Joseph4GI on July 10 2010, 01:14 Find this comment inappropriate? Report it

Less Than Nothing... Circumcision is doing more harm than good. Endorsing a procedure with doubtful benefits puts men in tribal circles in danger, because their leaders use the supposed "benefits" as a green light to proceed with their dangerous circumcision . .more rituals. As it is seen as "unmanly" to be circumcised in a hospital, men are discouraged to go to a hospital when their circumcisions go wrong. As a result, many men DIE, and many others lose their penises to gangrene. Not to mention the danger of HIV transmission when using the same blade to circumcise many men. Furthermore, as evidenced by this very article, endorsing circumcision is proving to be a risk, as charlatans who are more concerned with making money than they are about people's healths, are already taking advantage to sell their product. The benefits are dubious at best, it puts men at needless risk, and it discourages the use of condoms, which would far supplant circumcision anyway It is a huge mistake to be endorsing a risky procedure with dubious benefits which will discourage the use of more effective means of HIV prevention, further endangering the lives of others. One of these days the WHO, UNAIDS and UNICEF will regret having ever endorced the quackery of circumcision for HIV prevention. . .less by Joseph4GI on July 10 2010, 02:51 Find this comment inappropriate? Report it

@Joseph4GI Gosh! What a lecture! I used the word "extra" jocularly and not as scientific fact. In my opinion circumcision, unless medically necessary, is a barbaric practice (which I was fortunate to escape). Tradition which requires healthy young men . .more to be circumcised is ill-conceived and anachronistic, and the practice should be made subject to statutory regulation; e.g. either to be carried out by a medical practitioner, or a suitably licensed person. But this seems to be dangerous territory as religious fundamentalists and traditionalists will not brook interference without a terrible fight! . .less by mpho on July 10 2010, 13:45 Find this comment inappropriate? Report it

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