I recently read Zimbabwe: Male Circumcision Combats Spread of HIV, which quotes James McGee, the U.S. Ambassador to Zimbabwe, as saying “Unlike other prevention methods, male circumcision is a one-time procedure that provides life-long protection. I am sold on this simple life-saving procedure.” Ambassador McGee’s enthusiasm for the snip is shared by plenty of others too. Just this week the Gates Foundation announced it is investing $50 million over five years in male circumcision programs in Zambia and Swaziland. To put it in perspective, that is more money than the United States spends through its President’s Emergency Plan for AIDS Relief (PEPFAR) in 15 countries over five years.
I’d like to caution: buyer beware.
It is true that adult male circumcision programs have the potential to partially protect men from HIV, and it’s an intervention that will be particularly important in communities with little access to the information, education, and healthcare needed to prevent HIV infections. It is also true that if these programs are well crafted, they present an unprecedented opportunity to reach men with male and female condoms, information on safer sex, and HIV counseling and testing, treatment and care. Although I am cautiously optimistic about the promise of adult male circumcision programs, it’s 60:40, caution: optimism. Although the surgery offers one of the best HIV prevention options for heterosexual men, it is not 100 percent protective. It is not a magic bullet or a cure-all. This point bears repeating again, and again, and again.
By most estimates, adult male circumcision is 60 percent effective at protecting men from being infected by a HIV-positive, female partner in a clinical trial setting. 1,2,3 There is no hard evidence yet to show that it protects women. What we have is mathematical modeling, 3, 4 which suggests that if a very high proportion of men are circumcised, decades from now we may see some decline in new HIV infections in women. There is no definitive evidence that circumcision protects men who have sex with men.
As these programs move full-steam ahead, it is crucial that we exercise caution and a critical eye when talking about and reviewing them. Are we asking enough questions? Do these programs adequately inform men of the risks and benefits? Are we evaluating how well the men who participate in these programs understand the partially protective nature of the surgery? Do the programs engage women from the community, particularly women living with HIV/AIDS, in program development and monitoring and evaluation? Do these programs encourage men to be tested for HIV before undergoing surgery as outlined in the WHO/UNAIDS guidelines (PDF)?
In Kenya, for example, the national guidelines (PDF) do not even mention HIV testing much less suggest every man who seeks circumcision should be encouraged to get an HIV test.
In many ways male circumcision programs present a tremendous, albeit complicated opportunity to reach men and engage them in comprehensive sexual and reproductive health programs and HIV prevention. But if the programs are implemented recklessly or to the detriment of women, it will be a wasted opportunity. Nearly a year ago, my colleague Kate Bourne wrote on RH Reality Check, “Perhaps the most important thing we can do before the snipping begins is to communicate honestly about what male circumcision will, and won’t, do for a man and his female [and male] partner(s).” Now the snipping is well-funded and underway, the most important thing we can do is to stress the inconvenient reality that circumcision is protective but it isn’t enough. All people in communities where circumcision is being promoted need to understand that:
•Circumcision does not completely protect men from HIV. Circumcised men should continue using condoms to protect themselves and their partner(s) from infection.
•Having sex with a circumcised man does not protect his female or male partners from HIV. Partners of circumcised men should continue to insist on safe sex.
•Men must abstain from sex for a full six weeks after circumcision to protect themselves and their partners.
•A man who is already circumcised is not necessarily HIV-negative, and if he is, there is no guarantee he will remain so.
Susanna Smith is the Program Officer for Communications at the International Women’s Health Coalition. Read her bio here.