It’s not often two areas of great interest to me come together. It happened on May 7, 2007, when the Council on Foreign Relations took up the issue of male circumcision and HIV. The Council presented a program entitled, “Is Male Circumcision the Key to Stopping the AIDS Epidemic?” that primarily focused on Africa with Dr. Thomas Friedan of the New York Health Department and Mark Dybul, the Global AIDS Coordinator for the US Department of State.
This was a fascinating presentation for several reasons.
First, the panel discussion showcased the confusion that the dual, contradictory messages that 1) circumcision protects and 2) safe(r) sex practices must still be adhered to, presents even to an educated audience. The discussion clearly had a few essential take-away points, which I will get to in a minute, but let me talk about the second reason it was fascinating.
Mark Dybul gave the impression to the audience, as evidenced by the questions that followed, that male circumcision was not a “silver bullet” by any means — or even very much worth the probable confusion and message dilution it could produce. But he then proceeds to … what’s the word? Reassure the audience that the US government (PEPFAR) and the HIV/AIDS community are on board with it. Dr. Frieden was late (stuck in traffic) and didn’t add much worthwhile to the overall discussion. When he did speak, he focused on New York City’s situation, and the controversy viz. application to gay sex.
These are the points that made Dybul sound skeptical.
1. This is not a vaccine and will not provide the prevention of a vaccine. Hence, there will be nowhere near the widely disseminated 50-60% protective effect that the studies’ authors claimed. Rather, perhaps a 20-30% effect over 20-30 years could be expected.
2. Other prevention technologies believed to possess great promise have disappointed. Dybul said that the herpes suppression medication Acyclovir hasn’t changed the transmission rates “much at all” in ongoing clinical trials. Genital herpes and other ulcerative diseases and conditions greatly increase the level of HIV transmission. The implications for male circumcision are huge, particularly since the trials were stopped short of completion — which he mentioned — and the foreskin has been blamed for harboring ulcerative conditions to explain the protective effect of circumcision.
3. Disinhibiting behavior can overcome any protective effect. An increase in sexual partners can overcome any protective effect as well. There is some evidence that men who are coming in for circumcision are doing so because they think “they can’t get infected.” He went to great pains to stress this and spent considerable time talking about the other methods and their importance. He even discussed the successes of the proven prevention techniques in the absence of male circumcision. Most importantly along these lines, he said that male circumcision could undo progress in the area of gender equality, which is an area that has helped in reducing HIV transmission. One could be forgiven for wondering why circumcision is even being considered as it would appear to muddy the waters both in terms of delivering the over all prevention message and in getting men to adhere to it.
4. Convincing men to get circumcised is proving more difficult than anticipated. Apparently, male circumcision is not proving to be as popular as the proponents believed it would be. And the positive numbers depend a great deal on its reach. And this is where the audience questions prompted a discussion on the encouragement and introduction of infant circumcision as a more “acceptable” method of introduction, which is a very disturbing and possible direction this thing could take if men don’t take it up in great enough numbers.
Mark Dybul mentioned something else that I have so far not heard yet in the mainstream discussions: numbers needed to treat. He mentioned that the procedure has to be targeted to be most effective. He didn’t quite say “cost effective.” But that message was implicit.
I would conclude that much of the world will have these concerns, and more, if (likely) circumcised American officials are having them. I was disappointed in the failure to address (truly) informed consent in light of the recent studies on the effects of male circumcision, and especially that the issue of infant circumcision reared its ugly head.
A small confession is in order here. I read the transcript and have not listened to the complete presentation. Time constraints … If readers detect something in the video that comes across at odds with my assessment, please note it in the comments. Thank you.
Here is a link to the transcript.
See the presentation on the Council for Foreign Relations’ website.
You can also listen to the audio in mp3 format.
Or see it below: