A yellow light for male circumcision

In the past few years, a series of randomized controlled trials indicated that male circumcision reduced the risk of men acquiring HIV from women during hetrosexual intercourse. This finding seemed to confirm two decades of less rigorously controlled studies, and has turned out to be a rare success in the world of HIV prevention research, a world still reeling from failed HIV vaccine, diaphragm and microbicide trials. Male circumcision has always been a contested practice, so findings of the randomized controlled trials on male circumcision predictably sparked a great deal of debate. Some critics have argued that the findings were untrustworthy for a variety of reasons: because the trials were stopped prematurely or because not all possible confounders had been controlled for. Some of these criticisms were motivated by sincere concerns about scientific standards, but many times it seemed that criticisms of the trials were driven by a priori ethical views about the irrationality and harmfulness of male circumcision as such. In the meantime, emerging news items about male circumcision and HIV prevention are invariably accompanied by verbal battles among pro- and anti-circumcisionists in their comments sections.

The world has moved on. Or, at least, the biomedical research establishment in developed countries -- and in some developing ones -- seem to have moved on. The methods and findings from the randomized controlled trials are no longer the main event. The focus now is on how to implement male circumcision as an HIV prevention strategy in high HIV-prevalence countries with low-circumcision rates, mainly in sub-Saharan Africa. And the wallets are starting to open. To use a traffic metaphor, the strategy is getting a 'yellow light': proceed, but with caution. Caution for surgical risks in resource-poor clinics. Caution for diversion of scarce resources from other important health needs to circumcision initiatives. Caution for risky sex behavioral change among the recently circumcised. And a variety of other vexing and challenging hurdles. But there is the overwhelming sense of rolling up one's sleeves, that this is a fight worth fighting.

In the interests of full disclosure, my colleagues and I published a 'proceed with caution' piece about HIV and male circumcision last year in the Journal of Medical Ethics. But that piece does not have the same sort of authority or significance as last week's commentary article in Journal of the American Medical Association or the perspective piece in the New England Journal of Medicine: these are prestigious journals with a large and influential readership, and these are some well-known authors. Initiatives to promote male circumcision seem to have gotten the official yellow light, and join the increasingly crowded and messy world of HIV prevention.