Male Circumcision, HIV Prevention, and Support for Health Systems in Africa

In the past few years, clinical trials in Kenya, Uganda, and South Africa confirmed that male circumcision (MC) reduces the risk of transmission of HIV infection by approximately 60%. This news generated a flurry of activity in 2006 and 2007 by the international HIV/AIDS donor community, including WHO/UNAIDS and PEPFAR (the President’s Emergency Plan for AIDS Relief, a U.S. program), to support access to safe male circumcision (MC) services. However, despite this official change in policy, the large-scale rollout of male circumcision services remains a long way off. Meanwhile, Africa experienced an estimated 1.7 million new HIV infections in 2007. U.S. policymakers, including the Office of the U.S. Global AIDS Coordinator (OGAC), the State Department office which oversees PEPFAR, must give a much higher priority to MC services if PEPFAR is to make the maximum contribution to slowing the spread of HIV.

In a January 2008 article in a new journal, Future HIV Therapy, six scientists, including four prominent African health professionals, made a poignant case for large-scale provision of MC services. In light of the slow pace of implementation, they asked:

Why the continuing delays in the implementation of MC? Why do some prominent officials, nongovernmental organizations, Ministries of Health, and international organizations vacillate as thousands become infected every day, preferring to debate over cultural imperialism, the ‘rights’ of the foreskin, the ‘real world’ validity of randomized trials and so on?

UN and U.S. officials would likely respond in several ways, none of them wholly convincing.

Argument #1: We must be cautious and sensitive to local cultures.
Circumcision rituals, some have argued, are a practice that serves as a core rite of passage for young men among some ethnic groups and helps distinguish those groups from others. Blithely extending this practice without regard for its potential significance could end in tears. The use of circumcision as an identifier in targeting male victims for attack in the recent ethnic violence in Kenya, where Kikuyus generally practice circumcision and Luos do not, is a cautionary reminder.

Counter-Argument: Male circumcision could constitute an “African solution.”
While it is said - or feared - that MC is not culturally appropriate, this was a practice that was once more widespread throughout Africa until foreign missionaries and colonial governments condemned it , in some cases as a pagan ritual, in others as unhygienic, or, in the case of Botswana,simply because the British were worried about the political consequences of large-scale gatherings.


Re-valuing circumcision as a traditional African practice, as the authors of the Future HIV Therapy piece point out, could encourage the perception that MC isan “African solution to an African problem.” A dozen acceptability studies in different parts of Africa where circumcision is not traditionally practiced suggest that a majority of uncircumcised men want the procedure. Concerns about culture are not wrong, but if the acceptability surveys are an indication, culture may be more malleable than we think, particularly in the context of a crisis where millions have already died and millions more are at risk.

The Office of the Global AIDS Coordinator, in its just-released Fourth Annual Report to Congress, suggests that the U.S. Government is implementing MC programs only at the written request of governments. It is admirable that in this one area of development assistance western governments are suddenly heeding what developing countries want. Fortunately, African opinion is already shifting on circumcision, and PEPFAR officials need to continue being proactive in persuading African governments to encourage this trend.

It is perhaps understandable that African governments treat advocacy of trimming male foreskins with caution and that more local buy-in might be required for MC than for other policies. But lack of support by would-be African patients may not be the biggest barrier to delivery of MC services. The limiting factors appear to be an insufficient number of trained professionals and a lack of capacity in health facilities. As a recent article in the Journal of Epidemiology and Community Health noted: “The result is that men who can afford it are already protecting themselves, whereas the poor either cannot access MC or are going to unsafe and untrained providers.” There have already been waitlists for the procedure in Swaziland and Zambia, among other places.

Argument #2: We are doing the best we can and scaling up rapidly.
PEPFAR argues that services are being rolled out as fast as possible, with activities in eleven countries – including training facilities in Zambia and Kenya; assessments in South Africa, Malawi, and Lesotho; and, service delivery having started or about to start in Swaziland, Kenya, Zambia, and Uganda. In its Fourth Annual Report, the program announced that it had allocated $16 million in fiscal year 2007 for MC activities, up from $600,000 the year before. In FY 2008, funding may rise to $30 million.

Counter-argument: While spending is increasing, actual MC services and training are not yet being provided on a significant scale.The average cost to circumcise an individual has been estimated to be about $50. Thus, the $16 million for FY 2007 could be providing services to large numbers of people. Even assuming high start-up costs for training and administration, if only a quarter of these resources were dedicated to actual service delivery, that would still mean that more than 80,000 men could have received MC services by now. Unfortunately, while PEPFAR does a good job counting the number of individuals on anti-retroviral treatment, analogous data for circumcision services are not available. However, there is concern among experts and observers in the field that the number of people who have received MC services to date through PEPFAR is very, very low – probably fewer than 2,000.

A large part of the problem is that there are simply not a sufficient number of trained professionals nor properly equipped facilities to safely carry out the circumcision surgery for the large numbers of people who might request it. More worrisome still is the concern that MC funds are not being dedicated to organizations with the most experience and/or capacity to train people to carry out the procedure. In some cases, funds may be targeted to social marketing of the procedure and to encouraging local populations to support MC, without sufficient investment in the actual capacity and infrastructure necessary to meet that demand. As Robert Bailey, a professor of epidemiology and biostatistics at the University of Illinois at Chicago’s School of Public Health, and the lead investigator in one of the recent studies, explained:

Most places are not geared up to spend the funds they have been given already. It takes a lot to ramp up safeMC, especially if it is to be integrated with the other HIV prevention strategies, as it must be. There just aren't enough players (contractors) who are knowledgeable and have the staffing and expertise to start all the training and infrastructure building that is necessary.

Nomi Fuchs-Montgomery of the Office of U.S. Global AIDS Coordinator (OGAC) indicates that PEPFAR is in its early stages of rolling out its support of male circumcision services, and that much preparatory work by partner governments and organizations has to happen even before training and service delivery programs can begin. Ms. Fuchs-Montgomery suggests that “very few countries with PEPFAR funding have actually engaged in service delivery at this time.” She notes that Kenya, Zambia and Swaziland have begun to offer male circumcision services, but that Swaziland, for example, has a limited number of physicians and other trained technical staff in country.

Moreover, given timing of funding disbursement, much of the $16mn in funding for fiscal year 2007 has either just been received in country or will arrive shortly, with the result that much of the programming for last year is only now beginning to happen. However, OGAC anticipates that 13 countries will continue preparatory activities, including training, for large scale MC programs or will begin actual services in fiscal year 2008. At the same time, OGAC is reworking its approach to indicators for AIDS service delivery, including male circumcision services, as part of a broader harmonization effort with WHO, UNAIDS, partner governments and other stakeholders.

Given the resources already available, it would be a significant setback if considerable progress on indicators, training, and service delivery were not achieved in the current fiscal year.

Argument #3: Male circumcision does not offer women protection.
Recently, a widely reported study carried out by a team of researchers from Johns Hopkins and Uganda raised concern that women may not receive a benefit in reduced HIV risk if their partners are already infected with HIV prior to the time they are circumcised. If women aren’t benefiting in terms of HIV protection from their HIV-infected partners, then some have questioned the utility of male circumcision.

Counter-argument: If fewer men become infected by HIV because they are circumcised, fewer of their female partners will ultimately become infected.
Harvard’s Daniel Halperin has made a convincing argument for why this recent study does not undermine the case for MC. First, the study, given its small sample size, did not, in fact, find statistically significant results even for the reported lack of benefit to women. More importantly, Halperin argues, the critique missed the whole point of why MC could be significant:

It's important to understand that the main reason, by far, for the interest over the years in male circumcision has been from the directly protective effect for men, and the also important, but more indirect, protection that women would gain, at the population level, if uptake of MC is substantial.

Male circumcision offers the same sort of compounded benefit that most effective vaccines offer to populations – herd immunity. As more men are circumcised, not only is their own risk of acquiring HIV reduced, but their current and future partners and their partners’ partners also are at lower risk.

Conclusion
While concerns about cultural acceptance should inform where and when MC services are provided, the main problem holding back the wider availability of such services appears to be supply, not demand. If training and infrastructure are the primary barriers to more expansive rollout of MC services, then it is incumbent on PEPFAR, now undergoing reauthorization before Congress, as well as on other donors, to respond. They need to do a better job channeling funding to those purposes and to implementing organizations that can translate support into effective service provision. To miss the potential of MC through squandered resources, oversensitivity to cultural concerns , and ineffective programming will only prolong the tragedy of HIV/AIDS in Africa.

Josh Busby is an Assistant Professor at the LBJ School of Public Affairs at the University of Texas-Austin. He regularly contributes to a blog on HIV/AIDS policy at http://blogs.law.harvard.edu/politicshiv/

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