Picking up on SFAF's Statement on Circumcision and HIV

The San Francisco AIDS Foundation, an organization for whom I have raised money, came out with a policy statement on male circumcision and HIV in March of last year. This escaped my attention even though I knew they were formulating a policy. Better addressed late than never ...

Here are the important points made.

• Being circumcised is not HIV protection. Circumcision may reduce, but does not eliminate risk of HIV infection. Sexually active men, whether or not they are circumcised, should use condoms to protect against acquiring and transmitting HIV and other sexually transmitted infections.

• There is a potential for men who have been circumcised to believe they are fully protected and to lapse in condom use and other modes of risk reduction, which could have the effect of increasing HIV transmission rather than decreasing it.

• The studies in sub-Saharan Africa took place in highly controlled medical settings and were conducted by medical experts on previously uncircumcised men who have vaginal sex with women. These men were given counseling about sexual risk and were provided with condoms. Their health was regularly monitored for any adverse outcomes from the circumcision, which were treated upon detection. [Statements that would seem to validate the lack of similar real world outcomes.]

• There  is no comparable evidence about the effect of male circumcision for gay and other men who have sex with men. [In fact, the evidence is in, and it is that circumcision provides NO protection for gay men.]

• There is no comparable evidence about the effect of male circumcision for anal intercourse.

• There is insufficient evidence about whether circumcision in HIV-positive men protects their male or female sexual partners. [In fact, there is some evidence that male and female partners of circumcised men are at greater risk.]

• There is no evidence about the effect of male circumcision on reducing acquisition of HIV among women. Another study in Rakai, Uganda is currently looking at this, but it is not yet completed. [Preliminary data from this last trial suggested women were at greater risk; see last bullet point above.]

• The evidence from the trials in sub-Saharan Africa applies to adult men. It cannot tell us specifically about the potential HIV risk reduction benefits of circumcision conducted on newborns or children. [Good as far as it goes. However, any reference to informed consent and voluntariness must recognize that these principles extend to all human life. Decision-making shifting due to age on care not intended to address an immediate health need, like say a polio vaccine shot, leads to lack of consent and involunatary procedures.]

• Male circumcision has cultural and religious significance in many settings, which may affect its acceptability among different communities.

With the foregoing in mind, the Foundation goes on to state:

• Circumcision is an invasive medical procedure that must be conducted by trained individuals under sterile conditions with appropriate monitoring and an adequate healing period to eliminate the risk of bacterial infection. Community and health care provider education will be essential for the implementation of male circumcision as an HIV prevention strategy.

• Payment for the procedure should not be an obstacle to any man who chooses to undergo it; public and private health care programs and insurers should cover male circumcision as part of preventive medicine.

• Adult male circumcision should always be voluntary, with appropriate informed consent. ["Should" is too weak. It must always be voluntary and with complete informed consent. No overreaching or undue persuasion should be permitted. The loss of sexual function must also be addressed.]

• The public health community should understand and respect religious and cultural meanings of male circumcision in formulating implementation strategies. [Statements like these require clarification. What about cultural aversion to the procedure? Wouldn't such aversion require the same level or a greater level of respect? The Luo seem to have lost out on this particular principle.]

• Circumcision is a personal decision that should be made in consultation with providers, pediatricians and others. The Foundation does not make recommendations about individual health choices. [Reference to pediatricians is telling as to where the Foundation lies in its conventionality viz. infant circumcision.]

The SF AIDS Foundation is a non-governmental political body trying to maximize its fundraising potential. It has some obligation to kowtow to have its greatest success. And so in this particular case, it has gone along to a certain extent while trying to make obviously valid points. It fails in the end by pointing to sources, such as the AIDS Vaccine Clearinghouse, which is an egregious choice for information on this issue. Which brings me to a point that needs to be made.

I think it is a stunning success for the proponents of circumcision that they have sold the lie that circumcision prevents HIV with such alacrity. Today whole nations are purportly willing to force their populations under the knife with scant proof that it will do anything in their fight against HIV/AIDS. This is just stunning.

I think anyone with an interest in public health policy would do well to learn from this development. One important message to be drawn (I write here somewhat sarcastically) is that one should start with a plausible proposition that is essentially unverifiable, do your experimenting in and make your weightiest pitches to the most desperate nations far, far away, and publish, publish, publish. It also helps to have an acquiescent media and be employed by prestigious medical and educational institutions who are familiar with and favorable to circumcision as a cultural artifact.

I would recommend everyone who wishes to weigh in on SFAF's policy to write to them. Put the "public" back in health policy.

Contact SFAF:

policy@sfaf.org
415/487-3080

Public Policy Dept.
San Francisco AIDS Foundation
995 Market St, Ste 200
San Francisco CA 94103

Comments

[Concerned Mom]

I am really disappointed with the "suggestion" that circumcision may reduce the insertive partner's risk of getting HIV infection. The USA studies of gay men do not show this, of course. The infection risk to the receptive partner, whether male or female, is an order of magnitude higher than that of the insertive partner. It is highly misogynistic to suggest circumcision as a fix for the HIV-crisis in Africa. (or as a fix for HIV-infection in the USA)

So is it now OK for women to have unprotected sex, because the male may have statistically insignificant reduction in the male's risk of HIV infection? The woman, and her future offspring, receive no protection. Where anti-retroviral therapy is not available, this is a death sentence to the woman.

Any intervention that is being sold as an alternative to or adjunct to condom usage needs to protect BOTH PARTNERS as well as condoms. Circumcision can never measure up to this test.