As HIV continues to spread, the search for new and effective methods of prevention continues. Male circumcision is one of the proposed strategies, and shows potential in countries where circumcision rates are low and HIV prevalence is high. In a post April 5, Masimba Biriwasha mentioned some of the dangers he sees in establishing policies of male circumcision for HIV prevention. I want to go deeper into the issue.
In the past few years, many studies have indicated a reduced rate of transmission of HIV in men who have been circumcised compared to uncircumcised men of similar characteristics; some studies were even stopped due to ethical reasons because of the lower transmission rate identified in the groups of circumcised men. The results of these trials show an important reduction in HIV transmission (approximately 50%), not only within observational studies, but also in a randomized trial conducted in South Africa.
Although there continues to be doubts regarding how circumcision prevents HIV from being transmitted, some experimental evidence suggests understandable biological mechanisms for the lower transmission rates. This makes the results of these observations and trials all the more promising.
Statistical modeling for wide programs of circumcision in southern Africa estimate that 2 million infections could be prevented! And a cost-effectiveness analysis suggests that in sub-Saharan Africa this could also save money in the long run.
So … what do we make of all this? Should we start mass circumcision programs in countries with low circumcision rates and high HIV prevalence, such as Namibia, Zimbabwe and Botswana? Are there any other factors that should influence our decision?
The epidemiological benefits of circumcision as a public health policy are becoming quite clear, and the World Health Organization endorses it as an "efficacious intervention for HIV prevention". There are, however, a few issues that still need clarification, such as risk compensation of individuals who are circumcised, and how to deal with this. Risk compensation is the potential increase in risky behavior that individuals have when they feel their vulnerability to a disease reduced. In this case for example, this could mean the decrease in condom use amongst circumcised individuals, or the increase in the number of sexual partners, since the risk of HIV infection is thought to be no longer present or drastically reduced.
The problem is that it will be difficult to create public health campaigns that at the same time induce men to get circumcised and continue using condoms. However, this should not be a sufficient reason to completely halt the development of public health policies, but should point to efforts in developing novel risk reduction interventions and messages that are consistent with this kind of intervention.
The biggest problem however with a public health policy of mass circumcision is not on the epidemiological data, but on the ethical issues that may arise from such a policy. Circumcision is a normal procedure in the United States, where approximately 58% of newborns are circumcised. It is also a common procedure in the Jewish population, since it symbolizes a covenant with god and is mandated by him, and of course also in Muslim populations, where although it is not present in the Koran it is part of the sunnah (the laws based on the life of the Prophet) and is further justified as a hygienic procedure. However, by WHO estimates, the procedure is far from common in the rest of the world (certainly not common in Latin America!), and apart from the possible prevention of HIV and STDs, there is no medical reason for routine circumcision.
Ethical issues arising from such a policy need to be extensively debated before starting a massive intervention. Ideals of bodily integrity should be taken into account when the institution of such a policy is planned. Circumcision may be considered a violation of the human being's wholeness, and the integrity of the body is something that should be respected. The studies that have been conducted to provide the data on the effectiveness of circumcision only involved individuals who were 18 or older, so an informed consent took place and they accepted the procedure. However, it is not hard to imagine a situation like in the United States, where for supposed hygienic reasons circumcision is done to many newborns. Circumcision in the United States has become a cultural procedure, since no medical society endorses routine circumcision.
The situation here in Chile is quite different. The permanent removal of tissue from an individual that does not consent to this is not easily justifiable without falling into religious or cultural arguments There are many men who were circumcised as children that object to this practice, and there are increasingly more organizations raising awareness that circumcision is a violation of a child's human rights (see for example the work of the National Organization of Restoring Men, Doctors Opposing Circumcision and even a petition to the International Court of Justice in The Hague which includes it as torture and mutilation of children).
It is hard to disregard the importance that an intervention that has long term effectiveness and is not dependant on behavioral change could have; the confirmation of a health benefit alters the ethical perspective, since it is no longer a routine procedure with no scientific reasoning behind it. In my opinion, there is enough evidence to move forward regarding male circumcision as a public health policy, although careful monitoring of risk compensation should take place, and an open debate that involves the communities where this will happen should be started. This should not be only a top-down strategy to stop HIV transmission, but the ethical and cultural issues attached to it should also be addressed.
There is much to discuss on how such a policy should be implemented, what age groups will be part of the intervention, and of course, where the funds will come from. This last point is extremely important. Funds for such an intervention should not come from other preventive strategies already in place, or from funds dedicated to researching new strategies. We should not forget that even though male circumcision may save money in the long term, two thirds of the African population is already circumcised, and HIV continues to batter the continent.