Circumcision and smoking bans: Can policies nudge people toward healthy behaviors?


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Walking through river. Mali. Photo: © Curt Carnemark / World Bank

The scaling up of voluntary medical male circumcision, particularly in high HIV prevalence settings, is a highly cost-effective intervention to fight the epidemic—randomized controlled trials have found a 60% protective effect against HIV for men who became circumcised.

But, the supply of this medical service is just one part of the picture. Without active involvement from individuals and communities to deal with social and cultural factors that influence service acceptability, the demand for this common surgical procedure will be low.

Indeed, on a recent visit to Botswana, a country with high HIV prevalence and low levels of male circumcision, my World Bank colleagues and I had a good discussion with the National HIV/AIDS Commission about ways to address the low uptake of voluntary, safe male circumcision services in spite of a well-funded program by the government.  It was obvious to all that if the demand for, and uptake of, this service were not strengthened through creative mechanisms that foster acceptance, ownership, and active participation of individuals and community organizations, the program would not help control the spread of HIV through increased funding of facilities, equipment, and staff alone.

So, what do we need to do to ensure that need, demand, utilization, and supply of services are fully aligned to improve health conditions?

The good news is that evidence from different countries can be used for designing effective policies to empower people to make informed decisions and do what’s in their best interests.


In Poor Economics, a wonderful new book by Abhijit Banerjee and Esther Duflo of MIT, the authors present evidence  on how firmly held beliefs by the poor, who often lack critical information (e.g., how HIV is transmitted or prevented), contribute to decisions and behaviors that put them at risk of or contribute to the spread of communicable diseases. 


But the authors also argue that information alone will not do the trick. What’s needed are those “policy nudges,” such as free services or rewards as done under conditional cash transfer programs (e.g, Bolsa Familia in Brazil, Oportunidades in Mexico), which encourage people to demand and utilize preventive and treatment services (e.g., prenatal care and institutional deliveries, taking pills over the course of treatment to prevent the onset of multi-drug resistant TB).


Similarly, as we agreed with the Ministers of Health of Angola and Namibia during my visit to the region, there is also ample evidence from across the globe that shows that fiscal measures (e.g., higher excise taxes for tobacco), regulatory measures (e.g., smoking bans in public places to prevent the negative effects of secondhand smoke), or measures by the police (e.g., enforcement to deter drunk driving) are critical tools in the public health arsenal that lead to lower rates of lung cancer, heart attacks, road traffic deaths, as well as reduced use of related high-cost treatment and trauma care services.


As more countries pursue the goal of universal health coverage, which is high on the global health agenda, we need to focus not only on how to expand financial protection and access to needed services, but also to rethink how public policy is structured and geared to “nudge” people to improved health-related decision making and actions, and to regulate social and environmental factors that contribute to ill health, premature mortality and disability.



Blog: Tobacco Kills: So What to Do in Africa?

World Bank and HIV/AIDS

World Bank and Tobacco



Patricio V. Marquez

Senior Associate, Johns Hopkins University Bloomberg School of Public Health

Join the Conversation

May 23, 2012

I have not found the actual paper, but the second summary,, does not refer to "a 55 per cent reduction in HIV prevalence and a 76 per cent reduction in HIV incidence in circumcised men" only "in men", which of itself proves nothing about the effectiveness of circumcision, and is what you would expect after an intensive HIV publicity campaign, whether it included circumcision or not.

This study was lead by Bertram Auvert, who was lead author of the first circumcision and HIV trial. It seems that this whole campaign is being pushed by remarkably few people.

Meanwhile Wawer et al. (Lancet 374:9685, 229-37) started to find that circumcising men might INcrease the risk to women. Following couples with HIV+ men, of "92 couples in the intervention [circumcised] group and 67 couples in the control group ... 17 (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up (p=0·36)." But having failed to find any benefit, they cut the trial short "for futility" before any ill-effect of circumcision could be confirmed.

Circumcision has been a "cure" in search of a disease, an intervention looking for an excuse, for generations, and people are much too ready to think that whatever the question, circumcision must be the answer.

Patricio V Marquez
May 22, 2012

Thanks for your references. It should be noted, however, that on the basis of the first global study of real-world circumcision rollout conducted over 3-year period in South Africa amongst 110,000 adults that showed a 55 per cent reduction in HIV prevalence and a 76 per cent reduction in HIV incidence in circumcised men, the UNAIDS Executive Director Michel Sidibe concluded in 2011 that "scaling up voluntary medical male circumcision services rapidly to young men in high HIV prevalence settings will help reach the 2015 goal of reducing sexual transmission of HIV by 50 per cent.


The scaling up of voluntary medical male circumcision for HIV prevention is now gaining further momentum. At the country level, for example, Swaziland's King Mswati III has urged the men of his country to get circumcised to help prevent the spread of HIV infection (AFP, 15 July 2011). Similarly, in South Africa, with strong support from President Zuma, a vast expansion of HIV testing and other HIV/AIDS services, including male circumcision for HIV prevention, has been underway since 2010--the effort to provide male circumcision to millions of men began in the province of KwaZulu-Natal, home to the Zulu ethnic group to which President Zuma belongs (The New York Times, 14 May 2010).

At the international level, in her November 2011 remarks on "Creating an AIDS-Free Generation", US Secretary of State Clinton, also strongly advised countries and international agencies to "step up our use of combination prevention" that have been proven most effective – ending mother-to-child transmission, expanding voluntary medical male circumcision, and scaling up treatment for people living with HIV/AIDS.


For additional information on topic, please see: Clearinghouse on Male Circumcision for HIV Prevention:

May 21, 2012

“What does the frequently cited “60% relative reduction” in HIV infections actually mean?
Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive”, so the absolute decrease in HIV infection was only 1.31%, which is not statistically significant.” (Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J Law Med 2011; 19:316-34.) See:

Denied, withheld, and uncollected evidence and unethical research cloud what really
happened during three key trials of circumcision to protect men…

From the USAID report "LEVELS AND SPREAD OF HIV SEROPREVALENCE AND ASSOCIATED FACTORS: EVIDENCE FROM NATIONAL HOUSEHOLD SURVEYS"- Findings from the 18 countries with data present a mixed picture of the association between male circumcision and HIV prevalence (Table 9.3) . . . In 10 of the countries—Cameroon, Guinea, Haiti, Lesotho, Malawi, Niger, Rwanda, Senegal, Tanzania, and Zimbabwe—HIV prevalence is higher among circumcised men.”
(page 109) See:

The one randomized controlled trial into male-to-female transmission showed a 61% higher rate among females in the group where the men had been circumcised. See:…

Danish Study- Male circumcision leads to a bad sex life

November 14, 2011

Circumcised men have more difficulties reaching orgasm, and their female partners
experience more vaginal pains and an inferior sex life, a new study shows.

Ron Low
May 21, 2012

NOT ONE national medical association on earth (not even Israel's) endorses routine infant circumcision.

Dave Llewelly
May 21, 2012

So what Ms. Marquez is suggesting is a "tax" on men with natural bodies or a bribe to those who will undergo genital mutilation pushed by equally mutilated Americans?? How about ABC??? Equating circumcision with cessation of smoking is entirely bogus. Let's tax the circumcisers and see how long they continue to push mutilation. Be abstinent or faithful or use condoms every time and you need not fear HIV!

Patricio V Marquez
May 22, 2012

The United Nations Joint Programme on HIV/AIDS (UNAIDS) recommends scaling up of early infant, adolescent and adult voluntary medical male circumcision as a critical intervention to reduce the future burden of HIV in eastern and southern Africa.

Please see "Joint Strategic Action Framework to Accelerate the
Scale-Up of Voluntary Medical Male Circumcision for HIV
Prevention in Eastern and Southern Africa" endorsed by different countries and internationa agencies:

Patricio V Marquez
May 22, 2012

Thanks for your comments. Indeed, the ABC set does contribute to HIV prevention. Please see my comments above on the value of voluntary, medical male circumcision.

Perhaps some clarification is required on your comments. On one hand, the blog highlights the need for developing new strategies to promote demand and utilization of essential health services not only by facilitating access but more importantly by generating acceptance and support for the programs among governments, political parties and communities--the later is critical to overcome social and cultural norms and political opposition that may hinder their implementation and sustainability.

On the other hand, the blog argues for population-wide prevention measures, which aims to change disease-related risk behaviors, environmental factors, and their social and economic determinants in an entire population. Accumulated evidence at the international level indicates that measures such as some of those included in the WHO-Framework Convention On Tobacco Control, are highly cost-effective for disease prevention and control.

Patricio V Marquez
May 23, 2012

Colleague--Please note that accumulated scientific evidence that shows that male circumcision significantly reduces the incidence of HIV infection among men is from three landmark clinical trials in South Africa, Kenya and Uganda (all duly published in peer reviewed journals such as The Lancet). These findings were reinforced by the results of a second trial in South Africa led by Auvert et al that were presented at the International AIDS Society conference in Rome in 2011 that provided the basis for the UNAIDS recommendation. The new analysis by Auvert et al involved 1,198 South African men, aged
15 to 49, randomly sampled, interviewed and tested for HIV
in 2007, before the circumcision programme began, and
1,178 men of the same age studied in late 2010, three years
into the circumcision programme. Among men 15 to 49 years
old, adjusted HIV prevalence was 55% lower in the 2010
group than in the 2007 group (adjusted prevalence ratio
0.45, 95% confidence interval [CI ] 0.30 to 0.63). Among
men 15 to 34 years old, adjusted HIV incidence was 76%
lower in the 2010 group (adjusted incidence ratio 0.24,
95% CI 0.00 to 0.66). The investigators calculated that
without the intervention (if no men were circumcised), HIV
prevalence among 15- to 49-year-old men would have been
25.1% higher than with the intervention (95% CI 13.1% to
39.1%), and HIV incidence among 15- to 34-year-old men
would have been 57.9% higher (95% CI 17.0% to 131%). The report of the 2011 IAS conference is at:…

Auvert B, Taljaard D, Rech D, et al. Effect of the Orange Farm (South Africa) male circumcision roll-out (ANRS) on the spread of HIV. IAS 2011 Rome (Italy), Abstract number WELBC02

There are other benefits from male circumcision as well. As published in the NEJM (see below), in addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure. ( numbers, NCT00425984 and NCT00124878.)

Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Eff ect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Tobian AA, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 360: 1298–309

Other references of interest:

Weiss HA, Hankins CA, Dickson K. Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis 2009; 9: 669–77

Orange Farm, South Africa. J Infect Dis 2009; 199: 14–19.

Hallett TB, Alsallaq RA, Baeten JM, Weiss H, Celum C, Gray R, Abu-Raddad L. Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions. Sex Transm Infect 2011, 87:88-93.

May 23, 2012

There is NO evidence whatsoever that circumcising babies has ANY effect on HIV.

The (non-double-blinded, non-placebo controlled) trials were all conducted on paid adult volunteers for circumcision, in a context of intense counselling and provision of condoms. If, for example, the experience of being circumcised focussed the minds of the men on the other measures, that would explain the difference in HIV they found as readily as circumcision itself.

In 10 out of 18 countries for which USAID has figures, more of the circumcised men have HIV than the non-circumcised. This needs to be explained before blundering on with mass circumcision campaigns - let alone cutting the genitals of babies, where it can certainly not have any of those indirect effects.

Patricio V Marquez
May 23, 2012

Males can be circumcised at any age, however, there are significant benefits in performing MMC in early infancy (pl. see Manual for early infant male circumcision under local anaesthesia. WHO/Jhpiego.

Why? The procedure is simpler and less painful than that performed on older boys and men because the penis is less developed and the foreskin is thinner and less vascular. The wound typically does not need to be sutured. Healing is quicker with complete healing usually within 14 days, and complication rates are lower compared to adult circumcision. The procedure is also less costly when carried out in early infancy. A comparison in Rwanda showed that neonatal MMC was four times less expensive than adult MMC, and highly cost-effective (pl. see Binagwaho A et al. (2010) Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study. PLoS Med 7(1): e1000211. doi:10.1371/journal.pmed.1000211).

In addition, early infant circumcision ensures that the wound will be healed before sexual activity begins, and that the protective effect of the circumcision against HIV and other STIs is available when sexual activity starts. Also, early infant MMC leads to reduced risk of urinary tract infections in the first 6 months of life. In many countries, there is local expertise in routine neonatal MMC since it is sometimes medically indicated for the health of the baby, and sometimes more widely practiced by some religious and ethnic groups.

When it comes to MMC of infants, parents act on behalf of their children’s health. Therefore, parents need to be provided with information derived from evidence-based medicine about the risks and benefits of MMC so that they can make an informed choice for their children.

Most importantly, routine early infant MMC will prevent resource-intensive “catch-up” MMC campaigns in the future. It will significantly contribute to East and Southern African countries’ long-term objectives of decimating the HIV epidemic.

As USAID figures are cited in the comment, perhaps it would be good to take into account US PEPFAR assessments as well. For example, a comparison in Rwanda showed that neonatal MMC was not only four times less expensive than adult MMC, but also highly cost-effective
(Pl. see US PEPFAR presentation: Voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa – cost, impact, service delivery models and progress update. September 2011).

An alarmed economist
May 25, 2012

The goal of universal health coverage is tantamount to fiscal suicide if people are not persuaded to avoid diseases through prevention.

Why should taxpayers finance a lifetime of HIV treatment for someone who will not get circumcision or use a condom? Or cancer treatment for smokers? Or medications for a range of obesity-associated illnesses? Public money can be spent on many more beneficial programs (like universal access to clean water and prevention of diseases where an ounce of prevention is worth a pound of cure).

Publicly-mandated coverage should be for illnesses that are a stroke of bad luck, not self-induced by foolish and irresponsible behaviors.

The only sure result of the move to universal coverage is more jobs and incomes for doctors and others supplying the disease-care sector. Their self interest in a bigger and more costly health care sector is too evident, as they have adopted universal coverage as a goal at a time of huge and mounting fiscal pressures.

Why do they not strive for more health, even "universal health", instead? The universal coverage goal points to the disease-care sector wanting more customers and to be paid. A goal of universal health would make the circumcisions, smoking bans, taxes on harmful junkfood and meat, taxes on alcohol, etc. far easier to implement, resulting in more health and less "health care".

Patricio V Marquez
May 29, 2012

Thanks. I agree with several of your observations. The challenge nowdays in developed and developing countries alike is exactly as you suggest: to strike a better balance between the public health and medical care paradigms as both are complementarity and reinforce each other.

May 30, 2012

Your reply completely fails to answer my points. There is NO EVIDENCE AT ALL that INFANT circumcision has any effect on HIV. As above, the only studies have been on adult volunteers. There is NO evidence that infant circumcision is simpler or less painful. The foreskin may be "less vascular" but the frenular artery is still nearby and a baby can afford to lose only 35ml of blood (two tablespoons) before he is in danger. An adult can monitor his own pain relief and quickly report any complications, unlike a baby. There is greater risk of complications, such as poor aesthetic outcome, because the infant penis is so tiny, and any flaw is magnified in adulthood.
The only "advantage" of infant circumcision is that babies can't resist being circumcised. That raises severe ethical issues that are starting to be addressed in the Western world, with the Royal Dutch Medical Association (KNMG) holding back from recommending an outright age-restriction only because of the strong feelings of religious groups and the risk of clandestine infant circumcisions.

You mention Rwanda. Rwanda is one of the 10 out of 18 countries for which USAID has figures where more of the CIRCUMCISED men (2.5% in 2010) have HIV than the non-circumcised (2.2% in 2010).

May 30, 2012

I'm sorry but that summary, the same as in the document you link to, does not actually say that HIV was lower in the circumcised men than the non-circumcised, only that it was lower after the circumcision campaign. This is the fallacy of "post hoc ergo propter hoc" - after this, therefore because of this. We may certainly hope that circumcision was not carried out without a concurrent campaign of education of both the circumcised and non-circumcised men, about the use of condoms etc. If it was, we have no way of knowing that it was circumcision that made the difference. I should like to see Auvert's calculation that it was.

As I mentioned, Weiss, Gray, Auvert, Hankins, Dickson et al. are all members of a remarkably small group in the world scene dedicated to promoting circumcision. (There are papers carrying all their names, along with Bailey, Halperin, Morris, Klausner and a few others we see again and again on this topic.) Because of the enormous amount of cultural baggage it carries, circumcision is not like other surgical interventions, and people's passion for it is not always rational. It is more than usually subject to the human biases that can beset any branch of science, and therefore need needs more than the usual amount of correction for these biases. This it has not had.