To cut or not to cut: should the Caribbean region adopt male circumcision as an HIV prevention tool...or not
Pauline A. Russell-Brown
Kingston, Jamaica (2010 Features): At first glance, the news that greeted us in the Caribbean on the morning of World AIDS Day 2007 seemed wonderful. The official announcement from the World Health Organization, as relayed by the announcer, was that a new weapon in the ‘fight against HIV’ had been identified. Male circumcision, it was reported, was to be promoted as an effective way to reduce HIV infection rates.
I experienced a moment of sheer panic followed by a wave of sadness. My initial response was, ‘Here we go again, another magic bullet!’ followed, as I thought more about the directive, by ‘what a set back for our primary prevention efforts in the region which are beginning to show promise!’
Why would I think that?
First, let us look at the evidence on which this directive is based?
One of the most often cited sources is a systematic review and meta-analysis of 28 studies by the London School of Hygiene and Tropical Medicine published in 2000 in the journal AIDS. That meta-analysis found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men . A sub-analysis of the 10 African studies in that group found a 71 percent reduction in infection among higher-risk men. When questions were raised about the selection of studies and the analysis methodology , another re-analysis of the same 28 studies, plus an additional 10 studies was conducted (September 2002). This reanalysis had similarly robust findings even after controlling for various potentially confounding religious, cultural, behavioural, and other factors.
Evidence from laboratory studies of HIV uptake in the inner foreskin tissue compared to cervical tissue is also compelling . And, three randomized controlled trials conducted more recently in Kenya, South Africa, and Uganda to systematically assess whether circumcision of adult males protects against HIV also showed such promise that the South Africa trial was stopped and men in the control group offered circumcision.
What is the value for Caribbean males?
Without doubt these are very exciting and ‘robust’ findings of the protective effect of male circumcision. But, HIV transmission is still possible in men who are circumcised. The question then is, what is the value added, for the individual Caribbean male and for Caribbean societies as a whole, of male circumcision?
One might argue that for national HIV programmes the added value is having another choice in the menu of prevention strategies. There is no question that HIV prevention requires a multifaceted, multilayered response and male circumcision is one of the components that needs to be considered. But the costs to men and to the society of including male circumcision in the mix may outweigh the benefits.
The promotion of male circumcision as protecting against HIV might well be interpreted by men (and their partners) as freeing them of the responsibility to practice safe sexual behaviours - ABC. Why would a man undergo the procedure if he still has to use another prevention method – one that he has been very reluctant to use in the first place? The result very likely will be increased HIV infection rates.
Circumcision and culture
Given the socio-cultural dynamics of sexual partnering in the Caribbean, and the current vulnerabilities of girls and women and young men who have sex with men, introducing male circumcision very likely will increase their risks of HIV infection. They will be even more powerless than before to negotiate for the use of condoms. After all, the partners can argue that they had the ‘operation’ so ‘I can’t give you HIV’. Similarly, men who have sex with sex workers can point to their ‘operation’ as justification for not using protection. After all they are already protected. With one cut of the scalpel, we will have undermined the progress made to increase condom use among sex workers in the region .
It seems to me, for us in the Caribbean to go down the road of male circumcision will, in the short term, do more harm than good. To my mind, the short term costs far outweigh any long term benefits that may accrue.
Apart from the fact that the method does not offer 100 per cent protection from HIV for the user or his sex partner, there are associated social and economic costs of requiring adult men to be circumcised.
First, will men be able to afford to procure circumcision services? Can countries add another expenditure that does not provide 100 per cent protection to their already limited health budgets? What about the safety of the procedure? The data on safety and quality of care for male circumcision, especially pre- and post-operative care and asepsis, are of key importance. However, there is a dearth of accurate data on complication rates in clinical settings.
Second, in the short term what are the potential effects of choosing circumcision, or not, for male adolescents on their self esteem and self worth? Will circumcision or not become a ‘badge’ - another reason for stigmatisation, bullying and social alienation of boys and young men? Bioethical concerns must be addressed and cultural self-determination must be respected to avoid the perception that the practice is imposed through cultural hegemony.
Male sexual identity
Third, if male circumcision is to have significant population level public health benefits for the region, all men in the sexually active age group will need to be circumcised. This venture is one of changing a social norm and gets at the core of men’s sexual identities. As a urologist from one of Jamaica’s private hospitals observed in a June 15, 2008 article in the Daily Gleaner: "Anything that has to do with men's virility and private parts is a no-no."
The experience of family planning programmes in the Caribbean with promoting vasectomy corroborates this opinion. National family planning programmes and associations across the region have failed dismally to get acceptance of the method. The user rates are lower than 0.1 per cent. Although some of the low use of vasectomy (compared to other male-directed methods and to female sterilisation) is related to negative provider attitudes, and though there is evidence that targeted education that appeals to the emotions can increase acceptance of the method, the level of effort that would be required to increase circumcision rates to levels that would effect HIV transmission rates is going to require large investments of resources – resources to reorient providers as well as to convince men to have the procedure, and parents to authorise the procedure for their newborn sons.
Where would these resources come from? What component of existing programmes would be sacrificed? Is it treatment? Care and support? Or would it be prevention? Can we as a region afford this sacrifice?
Male circumcision no doubt can be one of the many ways of helping to reduce the incidence of HIV infection. However, given the social, economic and cultural factors attendant to sexual behaviours and to the adoption of this innovation, and the current rates of HIV infection in the Caribbean region, is this a wise investment? My opinion is that it is not.
Let’s take a stand. Ensure your personal safety first and that of your partner next. And remember the experiences with the other ‘magic bullets’./2010 Features
About the Author
Dr. Pauline Russell Brown is a researcher and public health consultant based in Jamaica. She has done extensive work in HIV and AIDS in the Caribbean region specifically among adolescents and at-risk youth.
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