Questions on UNAIDS/WHO Male Circumcision Consultation

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Questions on Male Circumcision

The World Health Organization and UNAIDS are holding a consultation

March 6 to 8 on male circumcision, the stated purpose of which is to

examine the current evidence and discuss the implications for policy

and programmes.

GNP+ welcomes any prevention intervention that proves to be

effective, safe and acceptable to people. However, the hype around

male circumcision still seems premature given (1) the limitations of

the evidence and (2) the existence of prevention strategies that are

under-used or not optimally scaled up. There is a danger that instead

of increasing overall prevention resources, the current attention for

circumcision will divert resources from other, proven prevention

strategies.

Below is a number of concerns and considerations about male

circumcision that GNP+ will bring to the WHO / UNAIDS consultation

and we would like to get an initial reaction on this from you. Please

review the issues below and consider sending us your comments,

additions and especially where you disagree with us. Note that these

are questions meant to stimulate discussion – we don't have the

answers.

Please send your comments to infognpgnpplus (DOT) net before Sunday,

March 4.

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Male Circumcision – Policy and Programme Considerations

An addition to or distraction from existing prevention strategies?

Will male circumcision be implemented complementary to other

prevention strategies, including treatment? We know that condoms work

and we know that treatment reduces transmissibility of HIV.

Furthermore, community-based strategies for support for people who

test either positive or negative for HIV have been shown to provide a

sustainable approach to constructive change. Therefore, how should

circumcision – if implemented as a public health measure – be

regarded as one part of a holistic approach to HIV prevention?

Will the implementation of male circumcision in any way inhibit the

scale up of condom use, treatment or other essential services as part

of universal access?

Is a 50% reduction in infection good enough to warrant full-scale

circumcision?

If condoms were to reduce infection rates by only 50%, would we

advocate their use? The answer to this would probably be yes, but

only if there were no alternative.

Condoms, when used properly and are available, have a 95% chance of

reducing infection. Circumcision has not only a lower rate of

effectiveness, it also has potentially serious adverse effects.

Capacity of the health system

Can the health system take on the task of circumcising the numbers of

men required to make a difference and will the scale-up of

circumcision divert funds from the scale-up of treatment and other

prevention strategies?

If the health system does not take on circumcision, who will?

Freelancers? Traditional healers? What kind of support will they get

to avoid infections, bleeding, mistaken amputations, etc.?

What kinds of pre-surgical and post-surgical support will be in place

for men who undergo circumcision? Who will perform this type of

counselling and how can the quality be assured?

Consent

Male circumcision is a medical procedure that requires consent from

people who choose to undergo this surgery. Therefore:

What measures must be taken to ensure that informed consent is given

by people who understand both the risks and benefits of the surgery

and who can help men understand that circumcision does not absolve

them from practising safer sex?

How can we balance competing ethical and cultural issues?

Rights of the child versus public health benefit. At what point does

the child's right to not have to undergo a surgical procedure become

overshadowed by public health concerns? Is a 50% reduction in

infection enough?

How do communities that do not usually practice circumcision decide

how and when to implement it? How are parents involved and how is the

child involved?

At what age should circumcision be offered? At birth? Before sexual

debut? If the latter, how do communities deal with discussing this?

What about women?

Are women protected by circumcision? If so, to what degree? Is it

worth diverting funds into circumcision that could otherwise be used

for condoms, treatment or research into other, women-controlled

prevention strategies (e.g. microbicides) ?

Is there a risk that men who undergo circumcision surgery will be

under the impression that they can no longer be infected by HIV and

that other prevention strategies are no longer necessary? Will this

make the negotiating position more difficult for women who want their

partners to use condoms?

Risks

Will men be told about the physical risks, including infection and

bleeding?

Will men be told about the sexual risks, including the decrease of

sensitivity which could lead to decreased sexual pleasure?

Will men be told that, unlike condoms, male circumcision protects

against only some types of STIs?

More research needed

More research is needed to find the proper place of male circumcision

in the race to scale up services towards universal access.

Specifically the following questions remain:

What are the benefits to women?

What are the benefits for people living with HIV living in discordant

relationships?

Will men who are circumcised continue to employ other prevention

strategies?

Will attention given to circumcision research, policy and programme

implementation add to or detract from resources to scale up services

intended to reach universal access of treatment, prevention and care?

Moody

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