Monday, January 15, 2007

Male circumcision and HIV: a hard sell

A hard sell: that is how Bill Clinton, at the last International AIDS conference in August, soberly described the use of male circumcision as way of reducing the risk of HIV transmission from women to men. He was not doubting the science. After a string of randomized controlled trials, the science looks about as promising as HIV prevention science can look. Clinton was suggesting there may be pitfalls in the actual implementation of the science into policy and practice in the countries where HIV is most prevalent. This last month seems to have proved him right, and also showed how different perspectives on male circumcision and HIV can be.

As an early Christmas present perhaps, UNAIDS executive director Peter Piot is reported to have declared on December 19th that African countries should prepare to perform male circumcisions on a large scale, starting with baby boys first, then adolescents, then adults. Strangely, Piot stated that UNAIDS had no plans to promote male circumcision in high-HIV prevalent India 'where the issue is sensitive for the Hindu and Muslim communities.' Hopefully UNAIDS will catch wind of the idea that male circumcision is a sensitive issue everywhere that circumcision is not traditionally performed, or everywhere it is performed but not on the schedule (with baby boys) that UNAIDS might prefer.

The New York Times also ran a piece on male circumcision and HIV by Tina Rosenberg that profiled male circumcision as the only sort of HIV vaccine we've got, and even if it does not provide perfect protection, we should be darn happy with it. Since there is no vaccine of the immunological sort around, according to Tina, we should promote mass circumcisions right away.

The cold shower on circumcision came from the Ugandan President, Yoweri Museveni. At a discussion with medical students in Kampala, he claimed that the recent science on circumcision and HIV gives a 'mixed message' to men: if you are circumcised, you stand less of a chance of getting HIV if you practice unsafe sex. As is well-known, Museveni (and his backers among religious conservatives in the USA) prefer the unmixed message of abstaining from sexual activity until married, and then being unfailingly faithful to your wife or husband. From that perspective on HIV prevention, it does not matter if you are circumcised or not.

International agencies and domestic journalists should draw a lesson from Museveni's statements: just because a study shows that an intervention would have a big public health impact, it does not mean that everyone will be sold on it. The persuasive power of science only goes so far. The rest will be messy, and involve politics, morality, economics and culture. A hard sell, as Bill said.


Blogger johnnyoooo said...

I am a male uncircumcised with normal loose foreskin not involved with men nor woman except my wife and see no reason to get circumcised .

10:04 AM  
Blogger Stuart Rennie, Editor said...


Thanks for this status report on your genitals. You are right: you probably have nothing to worry about, on the assumption that your wife is as faithful as yourself.

1:10 PM  
Blogger Beanie's Appa said...

Thanks for pointing out that the pure science about circumcision needs to be viewed in its context.

From a global perspective, circumcision may be a good idea, but from the individual's point of view, it may not. The ethical dilemma I see is that infant circumcision is done without consent. That boy may grow into a man that would have wanted his foreskin, for whatever reasons. The benefit of his circumcision with respect to HIV can only be seen if he has unsafe sex with HIV+ women when he grows older. There's plenty of time from now until then to either educate him on safe sex or for scientists to find a real vaccine or cure.

2:29 PM  
Blogger Stuart Rennie, Editor said...

Hi Beanie's Appa,

Thanks for your comments. Infant circumcision for HIV prevention is always going to be the most controversial kind, given the absence of consent and the fact that the intervention would only have a potential impact on individual and public health levels decades later. What would be your opinion on promoting circumcision among adolescents and adults in high-HIV prevalence settings?

5:28 PM  

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