NOTEBOOK: The majors convene this week in Europe to debate the meaning of the circumcision studies

March 6-8 will see a major convention of the world HIV/AIDS organizations to debate the meaning of circumcision. I found the issues outlined in the next page to be particularly compelling.

Click through to have a look. Reader comments would be particularly useful here.

From The Global Network of People Living With HIV/AIDS.

What do you think about male circumcision?

The World Health Organization and UNAIDS are holding a consultation March 6 to 8 on male circumcision, the stated purpose of which is to examine the current evidence and discuss the implications for policy and programmes.

GNP+ welcomes any prevention intervention that proves to be effective, safe and acceptable to people. However, the hype around male circumcision still seems premature given (1) the limitations of the evidence and (2) the existence of prevention strategies that are under-used or not optimally scaled up. There is a danger that instead of increasing overall prevention resources, the current attention for circumcision will divert resources from other, proven prevention strategies.

Below is a number of concerns and considerations about male circumcision that GNP+ will bring to the WHO / UNAIDS consultation and we would like to get an initial reaction on this from you. Please review the issues below and consider sending us your comments, additions and especially where you disagree with us. Note that these are questions meant to stimulate discussion – we don’t have the answers.

Check Read more >>> for the Policy and Programme Considerations

Male Circumcision – Policy and Programme Considerations

An addition to or distraction from existing prevention strategies?

  • Will male circumcision be implemented complementary to other prevention strategies, including treatment? We know that condoms work and we know that treatment reduces transmissibility of HIV. Furthermore, community-based strategies for support for people who test either positive or negative for HIV have been shown to provide a sustainable approach to constructive change. Therefore, how should circumcision – if implemented as a public health measure – be regarded as one part of a holistic approach to HIV prevention?
  • Will the implementation of male circumcision in any way inhibit the scale up of condom use, treatment or other essential services as part of universal access?

Is a 50% reduction in infection good enough to warrant full-scale circumcision?

  • If condoms were to reduce infection rates by only 50%, would we advocate their use? The answer to this would probably be yes, but only if there were no alternative.
  • Condoms, when used properly and are available, have a 95% chance of reducing infection. Circumcision has not only a lower rate of effectiveness, it also has potentially serious adverse effects.

Capacity of the health system

  • Can the health system take on the task of circumcising the numbers of men required to make a difference and will the scale-up of circumcision divert funds from the scale-up of treatment and other prevention strategies?
  • If the health system does not take on circumcision, who will? Freelancers? Traditional healers? What kind of support will they get to avoid infections, bleeding, mistaken amputations, etc.?
  • What kinds of pre-surgical and post-surgical support will be in place for men who undergo circumcision? Who will perform this type of counseling and how can the quality be assured?

Consent

  • Male circumcision is a medical procedure that requires consent from people who choose to undergo this surgery.
  •  Therefore, what measures must be taken to ensure that informed consent is given by people who understand both the risks and benefits of the surgery and who can help men understand that circumcision does not absolve them from practising safer sex?

How can we balance competing ethical and cultural issues?

  • Rights of the child versus public health benefit. At what point does the child’s right to not have to undergo a surgical procedure become overshadowed by public health concerns? Is a 50% reduction in infection enough?
  • How do communities that do not usually practice circumcision decide how and when to implement it? How are parents involved and how is the child involved?
  • At what age should circumcision be offered? At birth? Before sexual debut? If the latter, how do communities deal with discussing this?

What about women?

  • Are women protected by circumcision? If so, to what degree? Is it worth diverting funds into circumcision that could otherwise be used for condoms, treatment or research into other, women-controlled prevention strategies (e.g. microbicides)?
  • Is there a risk that men who undergo circumcision surgery will be under the impression that they can no longer be infected by HIV and that other prevention strategies are no longer necessary? Will this make the negotiating position more difficult for women who want their partners to use condoms?

Risks

  • Will men be told about the physical risks, including infection and bleeding?
  • Will men be told about the sexual risks, including the decrease of sensitivity which could lead to decreased sexual pleasure?
  • Will men be told that, unlike condoms, male circumcision protects against only some types of STIs?

More research needed

  • More research is needed to find the proper place of male circumcision in the race to scale up services towards universal access. Specifically the following questions remain:
  • What are the benefits to women?
  • What are the benefits for people living with HIV living in discordant relationships?
  • Will men who are circumcised continue to employ other prevention strategies?
  • Will attention given to circumcision research, policy and programme implementation add to or detract from resources to scale up services intended to reach universal access of treatment, prevention and care?
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