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4mar07[d] 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
    Message 1 of 1 , Mar 1 2:22 AM
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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 infognp@gnpplus. net before Sunday,
      March 4.
      _______________

      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?

      Kevin Moody
      e-mail: <k@...>


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