4mar07[d] Questions on UNAIDS/WHO Male Circumcision Consultation
- 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
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
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
Please send your comments to infognp@gnpplus. net before Sunday,
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
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
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?
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
How do communities that do not usually practice circumcision decide
how and when to implement it? How are parents involved and how is the
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?
Will men be told about the physical risks, including infection and
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
Will men who are circumcised continue to employ other prevention
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?
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