Panoscope | 6 Aug 2008

By Kristin Palitza

Male circumcision is being toted as increasingly important in HIV prevention across the globe, but experts caution on the need to link to prevention education and counselling to be most effective. Recent studies have confirmed that male circumcision reduces HIV acquisition in heterosexual men by 60 per cent.

“The benefits are likely to be large, with one HIV infection averted for every five to 15 male circumcisions performed,” estimated UNAIDS research officer Nicolai Lohse. Women will benefit indirectly from male circumcision because the HIV infection rate of the men they engage in sexual behaviour with is likely to decrease over time.

The World Health Organisation (WHO) and UNAIDS now recommend that male circumcision be included as an additional important HIV prevention strategy. However, researchers are concerned about possible limitations to the positive effects of male circumcision, such as behavioural risk compensation, including reduced condom use and having more sexual partners.

“Circumcision needs to go hand in hand with sexual and productive health education,” explained Lohse. “If risk compensation occurs, the projected positive impact of male circumcision will be modest.”

Male circumcision is also likely to save overall health care costs. According to Richard White, mathematical epidemiologist at the London School of Hygiene and Tropical Medicine, it may lead to a reduction of health services costs by three percent annually. Due to these encouraging research findings, many Southern African countries are now developing national policies and strategies for male circumcision scale-up. 

... Another magic bullet?

While acknowledging that male circumcision is one prevention tool that needs to be considered, Dr.Pauline Russell Brown, a Caribbean researcher, expresses scepticism about replication in the region. Circumcision as protecting against HIV might well be interpreted by men (and their partners) as freeing them of the responsibility to practice safe sexual behaviours - ABC.

Why would a man undergo the procedure if he still has to use another prevention method – one that he has been very reluctant to use in the first place? The result very likely will be increased HIV infection rates,” Dr. Brown says.

She explains that given the socio-cultural dynamics of sexual partnering in the Caribbean, and the current vulnerabilities of girls and women and young men who have sex with men, introducing male circumcision will very likely increase their risks of HIV infection.

“They will be even more powerless than before to negotiate for the use of condoms. After all, the partners can argue that they had the ‘operation’ so ‘I can’t give you HIV’. Similarly, men who have sex with sex workers can point to their ‘operation’ as justification for not using protection. After all they are already protected.

“With one cut of the scalpel, we will have undermined the progress made to increase condom use among sex workers in the region.” She says to introduce male circumcision into the Caribbean would do more harm than good.

“First, will men be able to afford to procure circumcision services? Can countries add another expenditure that does not provide 100 per cent protection to their already limited health budgets? The data on safety and quality of care for male circumcision, especially pre- and post-operative care and asepsis, are of key importance. However, there is a dearth of accurate data on complication rates in clinical settings.”

Secondly, Dr. Russell Brown questions the potential effects on the self esteem of circumcised male adolescents. “Will circumcision or not become a ‘badge’ - another reason for stigmatisation, bullying and social alienation of boys and young men?”

In addition, she points out that if male circumcision is to have significant population level public health benefits for the region, all men in the sexually active age group will need to be circumcised. This would mean changing social norms and gets at the core of men’s sexual identities. 

“The experience of family planning programmes in the Caribbean with promoting vasectomy corroborates this opinion. “Apart from the fact that the family planning programmes and associations across the region have failed dismally to get acceptance of the method. The user rates are lower than 0.1per cent.”

She says a whole scale move to circumcise men would require large investments of resources – to reorient providers as well as to convince men to have the procedure and parents to authorise the procedure for their newborn sons.

Concerns were also raised yesterday by other delegates who attended the session. These included the implication for women and other cultural issues that have not been taken into consideration.