Report on Male Circumcision: an Arguable Method of Reducing the Risks of HIV Transmission

 III The place of male circumcision in strategies aimed at fighting AIDS

Male circumcision and unclear communication

It may be somewhat surprising to see that the WHO has published its recommendations so quickly, while at the same time stressing the need for supplementary research [37]. The media resonance that has surrounded the publication of the study results on male circumcision by the ANRS is harmful, even though it declares that further studies are required. The act of encouraging male circumcision must not follow on from the fatigue or partial failure of the fight against the spread of HIV/AIDS [38]. The impact of this discovery has even been compared to that of multiple treatments, or even of a vaccine, and in so doing confuses the issue. There have even been reports in the medical press with titles such as «Male circumcision protects men from HIV» [39]. Nevertheless, in these eleven recommendations, the WHO appears more cautious, principally reiterating the fact that male circumcision must form part of a full raft of preventative measures, and that healthcare services must be reinforced in order to ensure the safe delivery of high-quality services [40]. But it is the message of a «miracle cure» that has taken precedence in the media, despite the WHO’s reservations. If the promotion of male circumcision were to cause a relaxation in preventative behaviour with less use of condoms, then the results would be dramatic. The dangers of reducing efforts relating to prevention are real if communication is not handled correctly.

Male circumcision is no substitute for antiretroviral treatments

The strengthening of health care services requested by the WHO is countered by the issue of a crisis in terms of human resources in developing countries [41]. Medical personnel are already too few and far between to provide the necessary care to the fight against HIV, and it would seem difficult to add the extra burden which would arise from the circumcision of several million men. The same goes for South Africa where, although treatment is more accessible than in other countries, it is estimated that only a third of people needing treatment actually receive it, primarily as a result of a shortfall in medical personnel. Moreover, for the entire fight against the epidemic in 2008, the evaluated available resources will be no more than 10 billion dollars [42], whereas the estimated demand for 2008 will be 22 billion dollars [43]. Added to these anticipated needs would be the extra funding required to facilitate the more widespread implementation of male circumcision [44]. This cost issue, together with that of human resources, will therefore have a knock-on effect on the priorities to be implemented within the context of health care policies. Antiretroviral treatments, as well as their curative effects, can facilitate a significant reduction in the risks of HIV transmission [45]. Studies show that, between serodifferent couples, the start of treatment has effected a reduction of between 50% and 85% in the transmission of HIV [46]. To date, the WHO has encouraged the start of treatment on as wide a scale as possible, a practice propagated by the member states of the United Nations who are committed to universal access to treatment, care and support services by 2010. This programme therefore facilitates the implementation of a network of care, but also a greater reduction in the risk of transmission for the population as a whole compared to male circumcision. The promotion of male circumcision must not become a lower-cost policy in the fight against the epidemic in developing countries to the detriment of access to drugs.

Male circumcision cannot be a means of prevention on its own

Current prevention policies are essentially centred, beyond fidelity and abstinence, around the use of condoms. Individual prevention involves adopting measures that should allow each individual to avoid becoming infected, such as the use of condoms or abstinence if this is acceptable. Because male circumcision does not provide total protection against infection, it cannot be considered as an individual method of prevention. It is a means of reducing risks aimed at lowering the risks of transmission of infection among a population in the same way as reducing the number of partners or providing treatment for infected individuals. The aim is not to impose a sole method of prevention, one that is 100% reliable, and which, if it is not used all the time, will lose its effectiveness. Male circumcision should therefore form part of a raft of preventative measures, including this means of risk reduction among others. In countries with high prevalence, male circumcision could benefit the male population where the use of condoms would not be sufficiently widespread. On the other hand, women cannot benefit directly from this potential advantage. In any case, they do not have to consent to a sexual relationship with a man without using a condom, just because he is circumcised. Male circumcision should form part of a system that offers access to screening and treatment and care for infected individuals, combined with an education and information programme aimed at encouraging changes in sexual behaviour. The ultimate goal of this programme would be to promote the use of condoms by the entire population.

Male circumcision as a means of risk reduction is aimed solely at countries with high prevalence

The same measures are not applicable to the Northern countries. The recommendations of the WHO state that this strategy is aimed at countries with high prevalence, and not at countries with low prevalence or in countries where it relates specifically to one part of the population such as in France or the United States [47]. Moreover, the results on male circumcision relate solely to heterosexual, vaginal sex. As reiterated at the 4th Francophone Conference on HIV/AIDS, we must «think of means of intervention not just solely from the point of view of their legitimacy or relevance such as we see them..., but rather from the point of view of the way in which they are perceived and accepted, rejected or adopted» [48]. The New York Times has also stated, somewhat misguidedly, that the city’s health care services were preparing a campaign aimed at encouraging «men at high risk» to get themselves circumcised [49]. The city’s health chief is reported to have said that «the risk of catching HIV from anal penetration is practically the same as for vaginal penetration... hence the protection offered by male circumcision could thus be the same as that found in the African studies» [50]. In France, Sida Info Service has begun receiving calls from people wanting to find out whether, if the man is circumcised, it is still necessary to wear a condom, and whether there was a need for men to have themselves circumcised. In the same way, the website The Warning has published numerous articles highlighting the fact that, at first glance, France is not implicated as a result of the low prevalence among the general population, but that «it would probably be worthwhile considering a possible recommendation for people who travel regularly to countries with high prevalence». The author adds that this recommendation could also be of interest to homosexuals and that the choice should be left to the individual [51]. However, no research has shown that male circumcision reduces the risk of transmission within the context of sexual relationships between men. This interpretation of the results suggested by certain sources is not borne out by any data. It does not take account of the fact that the majority of the American homosexual population is already circumcised and yet it still has a high prevalence.

The current results of studies on male circumcision illustrate the need for supplementary research in order to better define the real impact that male circumcision could have on the epidemic’s dynamics. Within the context of the strategies used in the fight against infection with HIV, the implementation of male circumcision as part of a raft of preventative measures could destabilise health care delivery and at the same time confuse existing prevention messages. Experience has shown that it is extremely difficult to communicate prevention using several means, and the addition of a new ‘tool’ could actually cause a result opposite to that which was originally intended. As the recommendations by the WHO highlight, this strategy is not aimed at countries with low prevalence or where it relates specifically to one part of the population such as in France or the United States [52]. To date, the WHO has encouraged the start of treatment on as wide a scale as possible and male circumcision should not sway this commitment.Male circumcision must not become a lower-cost solution that has a detrimental effect on drug-based treatments in developing countries.

Table of contents

• I The relationship between male circumcision and HIV prevalence [page 2]
• II The dangers of an affirmed policy of male circumcision [page 3]
• III The place of male circumcision in strategies aimed at fighting AIDS [page 4]
• List of individuals interviewed [page 5]