Male Circumcision and HIV Risk Reduction: An Example of Public Health Problem Solving
Editor’s note: The Public Health 101 blog series aims to keep users of Public Health 101up to date on changes in public health and public health education. The articles in this series will be published in the fall and spring, leading up to publication of the 5th edition of Public Health 101 in spring 2028.
Each article will highlight a change using a case study or key content that can be used in teaching. The series will inform instructors on how the content relates to the 4th edition of Public Health 101and to the upcoming 5th edition.
The first article highlights the Council on Education for Public Health (CEPH) change that will alter the undergraduate public health curriculum and assessment criteria in the coming years.
The Council on Education for Public Health (CEPH) is adding “Public Health Problem Solving” as a core skill to be taught and assessed as part of an accredited undergraduate public health program. A recent survey by the American Association of Colleges and Universities found that problem solving is the No. 1 skill sought by employers when hiring entry-level bachelor’s degree graduates. Nearly 90% of employers ranked this quality as important.
Central to public health problem-solving approaches is evidence-based public health. Male circumcision and its association with HIV/AIDS risk reduction is an example of an evidence-based public health approach. Let us take a look at how evidence was used to investigate a possible intervention to prevent HIV/AIDS.
Efficacy and Safety in Research
Male circumcision is considered the oldest surgical procedure. Egyptian tomb art from before 2000 BC depicts adult males undergoing circumcision.
Approximately 30% of males are circumcised globally, and the rate varies widely by geography, religion and culture. When practiced under surgical conditions, it has been proven safe in the newborn period and early in adolescence, as practiced in Africa.
When the HIV/AIDS pandemic swept through much of sub-Saharan Africa in the 1980s, the high volume of new cases and fatalities prompted public health researchers to take a problem-solving approach. They found that countries with low rates of HIV/AIDS also had higher prevalence of male circumcision.
Subsequent observational studies, including case-control and cohort studies, found that the probability of HIV/AIDS was approximately 2.5 times higher in males who were not circumcised. These studies established the first two criteria for cause and effect or contributory cause: The “cause” and the “effect” occur together more often than expected by chance alone, and the “cause” precedes in time the “effect.”
Despite the evidence supporting a cause-and-effect relationship between male circumcision and reduced HIV/AIDS, contributory cause had not yet been established. Definitive evidence for contributory cause also requires a third criterion: Altering the “cause” alters the “effect.” Randomized controlled trials are the ideal method for establishing this definitive criteria for contributory cause.
Three randomized, controlled trials involving high-risk African populations confirmed that male circumcision during adolescence, as practiced in Africa, reduced HIV/AIDS by more than 50% with acceptable side effects. Thus, research established contributory cause as well as efficacy. Efficacy implies that the intervention improves outcomes under research conditions. By observing acceptable side effects in research, the public health investigators established what is known as “safety in research.”
Effectiveness and Safety in Practice
Together, findings of efficacy and safety in research provide the basis for balancing benefits and harms and making initial evidence-based recommendations.
However, efficacy and safety in research are just the start. Public health research also requires evidence of effectiveness — in other words, that an intervention works in practice. It’s also necessary to establish safety in practice — evidence that the intervention’s benefits far exceed its harms when used in actual practice.
After efficacy and safety in research were established in the early 21st century, evidence-based recommendations encouraged male circumcision as a standard part of HIV/AIDS prevention, especially in Africa. Once these recommendations were accepted, a new round of public health research was needed to examine implementation methods and to evaluate effectiveness and safety in practice. Researchers also sought to determine the feasibility and desirability of male circumcision for populations beyond those studied in Africa.
Evidence from Africa supported the effectiveness of male circumcision for HIV/AIDS prevention in males, but male circumcision did not reduce HIV/AIDS in females, at least in the short run. The evidence also proved safety in practice as long as males avoided sexual intercourse for 6 weeks after circumcision, which could be difficult to implement. Male circumcision did not increase high-risk sexual exposures as long as health education made it clear that male circumcision does not guarantee HIV prevention.
Effectiveness in other countries was not as encouraging. In India, for instance, male circumcision is often used to distinguish between Hindus and Muslims. The resistance of Hindus to male circumcision meant that the practice was not an acceptable intervention. In recent years, new interventions with increased effectiveness and increased safety are replacing male circumcision for prevention of HIV/AIDS.
The P.E.R.I.E. Framework for Evidence-Based Public Health
The history of male circumcision and HIV/AIDS prevention illustrates the use of the P.E.R.I.E. framework, which forms the basis for evidence-based public health. As explained in the 4th edition of Public Health 101, P.E.R.I.E. is the acronym for an approach to public health problem solving: Problem, Etiology/Efficacy, Recommendations, Implementation, and Evaluation.
Male circumcision and HIV risk reduction can be used in teaching to illustrate the steps in the P.E.R.I.E. framework.
- Problem: Requires data on disease incidence, the prevalence and distribution of risk factors, and an understanding the course of a disease.
- Etiology/Efficacy: Ideally requires establishing all three definitive criteria for contributory cause. This can often be accomplished using the same types of studies used in the male circumcision research.
- Recommendations: Must initially be based on findings that include evidence of safety in research. Balancing harms and benefits is key to developing evidence-based recommendations. Recommendations often need to be revised later, after use of the intervention in practice provides further information.
- Implementation: Requires researching the use and acceptance of an intervention, and examining how well it works and its safety in practice. Research must focus on the intended population(s) as well as other populations that may or may not benefit from the intervention.
- Evaluation: Measures success by examining effectiveness and safety in practice in the intended population and identifying additional populations that the intervention can successfully reach. This requires studying short-term acceptance as well as changes that affect the long-term use of the intervention.
Public Health Problem Solving and Public Health 101
As illustrated with male circumcision and HIV/AIDS, evidence-based public health requires a step-by-step framework for addressing a public health problem. The 4th edition of Public Health 101 provides a detailed review of the P.E.R.I.E. framework and case studies illustrating its application. These case studies range from sudden infant death syndrome (SIDS) to Reye’s syndrome to the effect of folic acid on spina bifida risk. These case studies provide material that can be used now to teach evidence-based public health.
The 5th edition of Public Health 101 will include a new section with a series of case studies that illustrate frameworks for public health problem solving. Each case study will summarize the framework and provide discussion questions and sample answers for faculty, as well as objective questions that can be used for assessment. Together they will provide a comprehensive set of exercises to teach students public health problem solving and address the new public health problem solving expectations of CEPH.
Public health is rapidly changing and evolving. The Public Health 101 blog series will provide insights into ways to integrate these changes into public health education.
About the Author: Richard Riegelman, MD, MPH, PhD, is the series editor for Jones and Bartlett Learning’s Public Health 101 series. Dr. Riegelman is Professor of Epidemiology, Medicine, and Health Policy, and Founding Dean of the George Washington University Milken Institute School of Public Health. He led the development of the Educated Citizen and Public Health initiative, which brought together arts and sciences and public health education associations to implement National Academy of Medicine’s vision for undergraduate public health education.
Dr. Riegelman earned an MD from the University of Wisconsin, and an MPH and PhD in Epidemiology from Johns Hopkins University. He practiced primary care internal medicine for more than 20 years. Dr. Riegelman has authored or edited more than 70 publications, including six books for students and practitioners of medicine and public health.