Where to begin with this one? The breathlessness is reminiscent of the hysteria surrounding masturbation that caused the circumcision panic in the United States in the late 19th century.
Even before making the case, the WHO and UNAIDS spokespersons have already discredited the premise, stating “circumcision must not be relied upon as the sole means of protection against HIV,” and “[it] does not replace the need for promotion of safer sexual practices.”
Nevertheless, it is commendable that they narrow the focus. “Only “[h]igh HIV prevalence, low circumcision prevalence countries with high rates of heterosexual transmission” should consider this measure. “We are primarily talking about the countries of southern and eastern Africa.”
Yet, they completely shunt aside ethics while recognizing the near impossibility of measuring real world outcomes, stating “[a]lthough circumcision in babies and young children is an important consideration, it will take 15 to 20 years to see the benefits.” Gee, thanks. That’s reassuring not at all.
Not satisfied with the knots they’re tying us up in, they then state, “[i]n the case of adolescents, it’s important that parents and health care providers recognise their evolving capacity to assent or withhold consent for the procedure,” more likely than not knowing full well this is not how the real world works, especially in traditional cultures, such as those targeted in Africa.
“Scale up will take a long time and for this to have a population-level effect, coverage will have to be very high – we’re talking about [rolling this out over] the next ten to twenty years.” Thus we are to understand this is little more than an experiment, and we are not to have any too grand expectations.
And if anyone has any illusions that this is not a political push intended to refocus attention on a more skeptical and resistant Western mind, this statement that is patently illogical and false. “For individual men there can be a real benefit immediately.”
Any college level statistics student knows that you can generalize to groups. You cannot generalize to individuals. The incidences required for one transmission may be many on average, but it takes just one incidence for a given infection to occur. As an example, if infection was calculated at one per 1,000 vs. two per 1,000, it could occur on the first or the last incident, or any one of them in between. Therefore, circumcised or intact, the risk is not appreciably different. And a man would be foolish to game those odds.
Clearly, “[w]idespread changes in cultural attitudes would be needed … . However, it was important that any changes did not affect the human rights of males.” Except in the case of babies? No one should be reassured.
The World Health Organization and UNAIDS are to recommend that circumcision programmes should become part of HIV prevention programmes in countries seriously affected by HIV, following an expert consultation earlier this month.
But experts warned that circumcision must not be relied upon as the sole means of protection against HIV, and Dr Kevin De Cock of the World Health Organization’s HIV department said that it will take “a number of years” before money spent on circumcision programmes will translate into any slowing of the epidemic.
Circumcision provides “important but incomplete protection” against HIV, said Dr De Cock, and is an “important but additional strategy” for HIV prevention programmes.
“It is partial protection for men, it’s not to be scoffed at. We haven’t had news like this in a long time,” said Catherine Hankins of UNAIDS. “But it does not replace the need for promotion of safer sexual practices.”
“High HIV prevalence, low circumcision prevalence countries with high rates of heterosexual transmission should consider adopting circumcision as a priority,” said Dr De Cock. “We are primarily talking about the countries of southern and eastern Africa.”
“The first consideration should be to scale-up circumcision for adolescents and young sexually active men. Although circumcision in babies and young children is an important consideration, it will take 15 to 20 years to see the benefits.”
“Scale up will take a long time and for this to have a population-level effect, coverage will have to be very high – we’re talking about [rolling this out over] the next ten to twenty years,” Dr De Cock went on.
Asked whether circumcision should be recommended for all HIV-negative men, not just men in countries with high HIV prevalence, Catherine Hankins said: “For individual men there can be a real benefit immediately.”
Widespread changes in cultural attitudes would be needed, said Kim Dickson of WHO. However, it was important that any changes did not affect the human rights of males.
“It’s very important that we don’t create a new stigma around circumcision status,” said Catherine Hankins. “In the case of adolescents, it’s important that parents and health care providers recognise their evolving capacity to assent or withhold consent for the procedure.”
Spokespersons for WHO and UNAIDS stressed that it would be up to individual countries to decide how to implement circumcision programmes. Once national assessments have been conducted, said Catherine Hankins, “PEPFAR, the Global Fund and the World Bank have all indicated they would be willing to fund.”
WHO and UNAIDS are recommending that circumcision should be provided at no cost or at the lowest possible cost, and that it should be performed by medically trained personnel in order to reduce the risk of complications.
The evidence for circumcision
There is now strong evidence from three randomised controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda (funded by the US National Institutes of Health) and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually acquired HIV infection
in men by approximately 60%.
It has also been shown to reduce the risk of HIV transmission from HIV-positive men to their uninfected female partners by around one-third. in one study, although Dr Kevin de Cock stressed that more data were needed before the procedure could be recommended for HIV-positive men.
A similar degree of reduction in risk has been seen in population studies comparing the risk of HIV acquisition between circumcised and uncircumcised men, and regions of Africa in which circumcision is widely practiced tend to have much lower HIV prevalence.
“Many epidemiologists comment that they are very struck by the consistency of all the data, both epidemiological and clinical,” said Kevin de Cock, noting that results in clinical trials often fail to be attained in the field due to implementation problems.
“Here we are in the unusual situation of having real-world epidemiologic data before the clinical trial data.”
Recent evidence from the Rakai circumcision study suggests that men with multiple partners may get the greatest benefit from circumcision, partly because it reduced the risk of ulcerative sexually transmitted infections. However, the study also showed that the protective effect grew over time, possibly due to the hardening of the skin on the head and shaft of the penis after circumcision.
Evidence from another study carried out in Kenya also suggests that circumcision does not result in an increase in risky sex over time, a concern that has been raised by researchers, advocates and politicians reacting to early study results. In addition, epidemiological modeling based on the South African Orange Farm study has shown that even if condom use among circumcised men fell dramatically, mass circumcision would still reduce the HIV infection rate over time.
Epidemiological modeling has suggested that mass implementation of circumcision could avert up to 5.7 million HIV infections and 3 million AIDS deaths by 2026.
The recommendations and other background material can be obtained from the WHO website.
Alcorn, Keith. WHO & UNAIDS recommend circumcision as HIV prevention tool in Africa. Aidsmap. March 28, 2007.