DEBATE: Should South Africa pursue a mass circumcision drive?

“Opt out” of circumcision at birth? Who exactly is doing the opting?

“Thirty years from now we’ll be so glad we did it.” Who will be glad? The government? Surely not the individual who loses his foreskin and still becomes infected.

These are just some of the words spoken at the Third South African AIDS Conference. Fortunately, other points of view were heard.

“It’s all about cold steel – it’s more akin to sterilisation, it’s not like giving people clean water, it’s not like breastfeeding that we can all get warm and fuzzy about.”

“A mass circumcision programme is an experiment in disguise.”

Arguments that the procedure would not protect women and would dis-empower women were also heard. Other questions seemed to be left out, such as who is being targeted? Black South Africans who come from a culture of ongoing concurrent relationships or white South Africans who do not have this cultural background? How likely is it black South Africans will all end up circumcised and whites will not? What will this mean in terms of perpetuating divisions in society?

From all accounts, South Africa has a vast underclass of people living in poverty who are almost entirely black. The country has a minority white population who are far better off and hence have the advantage that whites in richer countries have, such as education, access to testing, condoms, treatment when necessary. It seems obvious this was what Timothy Quinlan of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu Natal was thinking of when he said prevention needs to focus on the two factors known to have the biggest effect on HIV transmission rates: concurrent partnerships and high viral load during primary infection [paraphrase directly from the article].

Update: IRIN has a big front page article on the above conference session. It’s bias is obvious giving scant coverage to the opposition. South Africa has a history of questionable approaches to the HIV fight. It is interesting to watch the hysteria around circumcision. It’s like a mania. However, it is entirely understandable under the circumstances of a 29% infection rate. What is puzzling is that the white medical establishment seems so sold in that country. I think it must have its roots in circumcision rates of men of a certain age, much like the rest of the English-speaking world of that generation. It’s all so explainable … and lamentable. AIDS will continue to ravage SA until they face facts. Denial and something akin to superstition so far has been their reaction.

Full Aidsmap article next page.

Should South Africa pursue a mass circumcision drive?

The Third South African AIDS Conference yesterday heard calls for a mass circumcision drive to become an integral part of public health policy in the Republic as soon as possible, but also strong disagreement about the best way for circumcision to be introduced in South Africa as a component of national prevention campaigns.

Experts, community activists and health workers from all over South Africa exchanged views at a debate on circumcision organised by the South African HIV Clinicians Society, because, said Dr Neil Martinson of the University of Witwatersrand, “There’s been a deafening silence from policy people in this country, and in sub-Saharan Africa.”

Circumcision is now being debated as an HIV prevention intervention because three randomised clinical trials in different parts of Africa have shown that circumcision of adult males reduces the risk of HIV infection for the man by around 60% during a follow-up period lasting up to two years.

“The effect was long-lasting, there wasn’t disinhibition [increased sexual risk-taking], they didn’t screw around more, they didn’t use condoms less,” said Neil Martinson.

Epidemiological studies have shown a similar reduction in the risk of HIV infection among circumcised men in populations across Africa, and this information stimulated the clinical trials funded by the US and French governments.

The World Health Organization recently published guidelines for the promotion of circumicision as a potential prevention measure, emphasising the need for the operation to be carried out by trained medical personnel, with proper consent for the operation, and as an integrated part of a wider HIV prevention campaign.

Neil Martinson said that reluctance to engage with circumcision as an HIV prevention intervention is because of its undeniably clinical nature.

“It’s all about cold steel – it’s more akin to sterilisation, it’s not like giving people clean water, it’s not like breastfeeding that we can all get warm and fuzzy about.”

“There’s no question that we need a male circumcision programme, but a mass programme is more debateable. Operationalising it is going to be complicated,” said Professor Alan Whiteside of the University of KwaZulu Natal.

He advocated routine opt-out male circumcision at birth. “Thirty years from now we’ll be so glad we did it.” He believes that “if we’d started 25 years ago we wouldn’t be in this godawful mess.

“Aren’t the arguments we hear against it – it’s too expensive, we can’t do it for everyone – just the same as those used against ARVs in South Africa in 1999?,” he asked.

An audience member suggested that op-out circumcision should also become standard practice for adult males who attend sexually transmitted infection clinics.

However Professor Timothy Quinlan of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu Natal was sceptical about the need for a mass programme, arguing that the evidence doesn’t justify it.

“A mass circumcision programme is an experiment in disguise,” he said. “It’s not focusing on the real problem.”

Instead, he said, prevention needs to focus on the two factors known to have the biggest effect on HIV transmission rates: concurrent partnerships and high viral load during primary infection.

“There’s a need for clearer messages to communicate these facts,” he said. “We need to promote serial monogamy.”

Audience members raised some of the practical issues that are likely to arise in the implementation of any sort of circumcision programme. Traditional healers in particular will need to be brought on board, said numerous speakers.

“Don’t talk about circumcision in isolation from the initiation processes going on in all the different cultures in South Africa,” said one male audience member.

But there was general agreement that traditional healers who carried out circumcision during the initiation of young males into adulthood had a captive audience for passing on important prevention messages, and that this potential wasn’t being exploited.

The threshold of adulthood is an important time to reach young men, agreed another speaker. “Young males currently have no contact with health workers; promoting circumcision might bring them in to contact with health workers and give the opportunity for counselling about behaviour change,” he said.

The relationship between circumcision and behaviour change was touched on repeatedly, especially by women.

“My worry about circumcision is that it is one prevention intervention that has the potential to disempower women – we’re going to tell all the males in the country that it’s OK to sleep around without a condom,” said one woman speaker.

Prof. Alan Whiteside reinforced this point. “Circumcision protects men. But if that man is not using a condom, the woman is still at risk. Let’s not lose sight of that.”

There was confusion about who would be targeted with messages about circumcision. Would it be young men, or would it be their parents? Or must their future sexual partners be targeted, “so that they say `I won’t sleep with you unless you’re cut’,” asked Neil Martinson?

But there was clear agreement about one aspect of messaging. “Avoid a billboard that is not based on sound science, consultation and consensus,” said one audience member.

Reference

Acorn, Keith. Should South Africa pursue a mass circumcision drive? Aidsmap. June 7, 2007.

http://www.aidsmap.com/en/news/ED63A187-56F0-4069-9F0A-35D262087DFC.asp?type=preview

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