Scale-up of Male Circumcision Programs for HIV Prevention Will Require ‘Strong Political Backing,’ Funding, NEJM Perspective Piece Says
"In a radical departure from earlier strategies, public health officials are now arguing that circumcision of men should be a key weapon in the fight against" HIV in Africa, Ingrid Katz of the Beth Israel Deaconess Medical Center and Brigham and Women's Hospital and Alexi Wright of the Dana-Farber Cancer Institute write in a New England Journal of Medicine perspective piece. They add that some "skeptics argue that efforts to 'scale-up' circumcision programs on the continent that has the fewest physicians per capita may draw funds away from other necessary public health programs, ultimately threatening already tenuous health care systems."
According to the authors, "Key distinctions between penile surgery and less-invasive methods of HIV prevention" might "hinder momentum." They add that some African "officials remain wary of circumcision because of concerns about cost and safety." In addition, physicians currently are performing most circumcisions, but "many countries are hoping to decrease costs by training a cadre of lower-level health care workers ... to fill the provider gap that many countries face," the authors write, adding, "Adequate training is essential" to avoid complications associated with the procedure.
According to Katz and Wright, some policymakers also are "struggling with complex cultural barriers in societies where circumcision is not part of mainstream practice." They add that several "public health researchers fear that there are deeper reasons for some African governments' skepticism" about circumcision. For example, some researchers "speculate that Africa's colonialist history has left these leaders with lingering suspicions about possible oppression," according to the authors.
However, all involved "agree that implementation of circumcision on a national level will require in-country champions and strong political will to succeed," according to Katz and Wright. In addition, several international donors -- including the Bill & Melinda Gates Foundation and the President's Emergency Plan for AIDS Relief -- "agree that ramped-up circumcision efforts must be funded as add-on services to guarantee that they will not detract from other programs," the authors write, adding that officials from UNAIDS and the World Health Organization "are advising that countries offer a minimum package of services in addition to circumcision, including HIV testing, screening for sexually transmitted infections, promotion of condom use and counseling on safer sex."
According to the authors, reaching out to "women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women." They add that although "circumcision has increasing support from researchers, donors and politicians, its status as a nonbehavior-based intervention may ultimately be its biggest obstacle." As programs "move forward, the scale-up of circumcision will require strong political backing, adequate funding and leaders to champion the cause to ensure that it is a safe, low-cost option available throughout Africa," the authors conclude (Katz/Wright, NEJM, 12/4).