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.
- Stuart Rennie

Labels: circumcision, Clinton, HIV, Uganda, UNAIDS

posted Jan 16, 2007 | link | jump to the comments (19)

comments

The push for circumcision among Indian and African men is another example of just how upside-down global HIV prevention has become. Instead of attacking the problem at its sources: inadequate HIV education resources, religious resistance to frank sexual talk, views of condom-users as diseased, and massive poverty and inequality between men and women, current prevention is now trying to get men to cut their foreskins off. Is 50 to 60 percent efficacy worth the decreased penile sensitivity and the stigma that will almost certainly be attached to circumcision in those countries. A man who gets circumcised will be viewed as a man who sleeps with prostitutes and diseased women, just as a man or woman who uses condoms is viewed now. It would be far simpler to change peoples minds than it is to alter peoples bodies.

- by Ray Broadway on Jan 16, 2007 at 3:11 PM | link

It would be far simpler to change peoples minds than it is to alter peoples bodies.
This comment is so out of touch with the reality of public health work on the ground that I have trouble thinking it's not a parody.
The previous writer seems to be implying that it's relatively easy to change the religious beliefs of hundreds of millions of people, and relatively easy to alleviate the most crushing poverty that exists in the world today. Relatively easy, that is, compared to administering a simple surgery.
The writer will no doubt also oppose rotavirus vaccines in the developing world, because really, it's so much easy to clean up the water supply of an entire continent than it is to give a shot to children.
No one is suggesting that the massive structural problems of Africa shouldn't be addressed. But if those problems are addressed to the exclusion of nearly as massive problems like the 40 million people with HIV, then the long term solutions may become impossible to implement, if not moot.

- by Anonymous on Jan 17, 2007 at 12:38 AM | link

Is this a parody? Or a troll? It's hard to take seriously.
I'm not going to bother trying to educate Mr. Broadway about why, for instance, performing a simple surgery on a large number of individuals is easier on a useful (ie, massively life-saving and infection-avoiding) than solving "massive poverty and inequality between men and women" in the whole continent of Africa.
If Mr. Broadway doesn't understand that male circumcision is very likely to save millions of people from HIV, AIDS, and an early death - at a very low cost - and that opposing male circumcision is arguing in favor of the deaths of those individuals - then he is either (a) not thinking very hard, or (b) an idiot. Or actively malicious. Just like people who oppose condoms, for the same, specious reasons.
He closes with this stunner:
It would be far simpler to change peoples minds than it is to alter peoples bodies.
If the utter inanity of this statement doesn't rear up and clamber all over your brainpan like a rabid spider-monkey, then you must, truly believe that it's easy to change entrenched religious and cultural judgments.
In which case, I invite you, Mr. Broadway, to join the US forces currently trying to win the hearts and minds of Iraqi civilians. You're obviously the man we need over there.

- by Anonymous on Jan 17, 2007 at 12:52 AM | link

Why dont we just do surgery a little to each side of the foreskin and remove the testicles; thus removing the innate desire to copulate?
The human desire to mate is second only to the desire to live. Unfortunately, in this situation, the consequence to copulation is too far removed. Lending no affect on our desire for survival.

- by Joyce on Jan 22, 2007 at 9:58 PM | link

I can see how circumcision can decrease the risk of HIV. However, I don't think that it should be mandatory for several reasons. First, certain religions/ cultures are opposed. Second, it is a simple surgery, but surgery has expenses. If a poverty stricken country can't afford to even eat, can they really afford to have a simple surgery? Who would pay for the surgeries? Isn't it far much cheaper to educate on abstinence, monogamy and the use of condoms (if culturally acceptable)?

- by Heather G on Jan 23, 2007 at 5:43 PM | link

The whole idea seems so odd to me, however I can see the logic in a simple procedure saving potentially millions of lives. Because this is turning into a political and controversial battle I think that one needs to remember the cultural and religious beliefs of those whom are not circumcised. The individuals that reside in the heart "HIV land" can barely afford to feed and clothe themselves, would this surgery be paid for by their government or a grant?

- by Julia P. on Jan 24, 2007 at 1:47 AM | link

I guess I don't see where the foreskin could harbor the HIV infection (it is outside of the body). To my understanding, HIV does not live outside of the body.
I have no position on whether or not circumcisions should be preformed. I see both sides of the story. For instance, some believe that it is cleaner to not have foreskin. Where as other researchers believe that it acts as a protective layer from infection.
Another thing that I learned recently was that foreskin enhances sexual orgasms. Not that this has anything to do with infection, but...
Do you think that maybe the male human body was made with foreskin for a reason?

- by T. Przybysz on Jan 26, 2007 at 2:00 PM | link

I would have to agree about the fact of HIV being prevented by circumcision. I have been under the impression that HIV must be inside the body with a host and I just don't see that the foreskin can harbor such and infection. Also, I do feel that there would be a mixed message sent in that someone who is already circumcised would feel that there chances of having or getting HIV are decreased. I feel that there would be mixed messages between the male and his partner whether that be male or female and especially female. I feel that some males may actual feel as though it is cleaner to have the foreskin versus not having the foreskin and being completely protected from infection. I feel that there would be a lot of politics involved in this one as well.

- by Coleman on Jan 26, 2007 at 8:25 PM | link

With viruses you can never be too careful about anything. I do think that by reading this, it may make circumcised males think they are invinsible to HIV. HIV is a problem in the United States, whether the male is circumcised or not and it is being spread either way. I guess I'm a little septical that this would even make a difference, other than helping with cleanliness. They should be pushing for monogamy, abstinence, or condom use.

- by Diane Annarino-Kot on Jan 27, 2007 at 1:57 AM | link

My brother in law and nephew are from Germany and they are uncircumcised and although it is not my personal preference I respect theirs. Do they know about unsafe sex and increased risk of HIV if un circumcised? I doubt it.... I think schools should talk about unsafe sex and this possibility but we know sex education is poor in this country because we are afraid to talk out loud yet the radio is full of sexual junk that all of our kids have privy to...

- by Diane on Jan 28, 2007 at 3:04 PM | link

Circumcision is NOT the answer to reduce AIDS infections. Supporting this idea is truly masking the real problem of unprotected, premiscuous sex that leads to the infection. I also agree that it would give the person a false sense of protection from the disease which could utimately lead to an increase in the spread of the disease thus defeating the whole idea.

- by Lisa (Gearhart) Campbell, RN on Jan 28, 2007 at 9:56 PM | link

I have to admit, this is the first time I have heard of the relationship between circumcision and HIV prevention. When I first read the blog, I was automatically against the idea of mass circumcision. I told myself: this is absurd. But then I have spent the last hour or so reading other research articles and now Im not sure if it is such a bad idea. For now at least, I will reserve any judgment on the issue, whether for or against, until further investigation. So far, I know there is a lot of scientific evidence that prove that males who are circumcised reduce their risk of getting HIV by as much as 60%. The evidence was so apparent that the researchers were ethically bound to stop the research, because if a researcher notice evidence of the benefit of an intervention, they are obligated to provide the same intervention to the control group. Im just afraid of a slippery slope effect of this intervention. You start with the foreskin, then what? The penis? Like most people, Im also concern about this giving people a false sense of security. But after everything is said and done, circumcised or not, the value of sex education can never be over emphasized! Even if circumcision is proven to prevent 99.9% of HIV, people still need to be educated on the benefits so they would agree to circumcision. Unless they are planning on forcing people to be circumcised.but I think that issue would be for another blog.

- by Althea on Jan 29, 2007 at 4:08 PM | link

I find this information misleading. The choice to be circumcised (or not) has been mostly based on cultural or religious beliefs, and some may make the decision based on cleanliness. Circumcising to prevent HIV is a complete misconception and since there is a lack of education regarding HIV and AIDS, it is frightening to see information like this circulating out there for the next uninformed person to believe.

- by A. Patton on Jan 30, 2007 at 3:54 AM | link

I just can't see how a man with a circumcision would be less likely to spread HIV than a man who does not have circumcision. That just seems rediculous. Both men would be infected and the only difference would be one had some extra skin at the end of his penis. How would this have anything to do with the way HIV is transfered?? I would need to be informed of just how this lowers the transmission of HIV before I would go around promoting circumcisions on people that would normally stray away from the surgical procedure.

- by Samantha on Jan 30, 2007 at 4:44 AM | link

I can see how male circumcision my be more hygenic, but I don't see how it will help slow the transmission of HIV. Informing both men and women how HIV is spread and how their actions effect their health and use of condoms and promoting monogomous relationships would be an easier sell.

- by Ruby Fultz on Jan 31, 2007 at 6:24 AM | link

Why is safer sex education not a priority? Why are they trying to give a false security to men who are circumcised? If we are truly concerned about HIV rates provide the education and the condoms. The "perfect protection" would be prevention by education. Both men and women need to be informed of the ways HIV is transmitted to make better judgements.

- by maberg on Feb 5, 2007 at 1:01 AM | link

I think this is a tough situation. I believe that this should be a personal choice and not required. I am not that knowledgeable about this topic but if the participants are willing then they should give it a try.

- by Melissa Scott on Feb 7, 2007 at 11:09 PM | link

Forgive me but let's not kid ourselves into thinking that circumcision is the answer to the world wide epidemic of AIDS. I mean really! It's one thing to want to begin a campaign for male circumcision. Perhaps that may help with other transmissions of STD's and infections. Circumcision in the name of AIDS education is nonsense and in an area of the world so devastated as Africa by this epidemic, why waste time with anything than what we know works- education, protection, and HIV testing.

- by Jill Braver on Feb 8, 2007 at 3:31 AM | link

This seems to be a band-aid approach to a hemorrhaging problem. How will it be perceived by the people being slated to receive this treatment? How effective is it at preventing the spread of HIV? There are a lot of what-if's and maybes here that may add up to nothing in improving the containment and eradication of a this disease.

- by rbilan on Feb 12, 2007 at 2:55 PM | link