Circumcision to the Rescue?

The Atlantic’s Shaun Raviv has a long article on the scale-up of male circumcision for HIV prevention in Swaziland online here. According to the article (and other sources I’ve read) circumcision is in demand in Swaziland, but that demand isn’t necessarily driven by accurate information:

Many Swazi men want to get circumcised, “but most of them for the wrong reason,” says Bheki Vilane, the national director of Marie Stopes Swazi­land, a non-governmental organization performing circumcisions. He’s voicing the main concern about circumcision as an HIV-prevention strategy: will it make Swazi men even more sexually reckless than they are already? “Some of the men have the misconception that they’ll be 100 percent safe.” To dispel this myth, NGOs are ensuring that every patient goes through counseling before and after the procedure. Each man is told to use condoms, and also given the option to be tested for HIV, which about 85 percent agree to do.

This massive scale-up is of course based on three randomized controlled trials:

[In 2005] a randomized controlled trial in South Africa (later confirmed by studies in Uganda and Kenya) found that circumcised men are as much as 60 percent less likely to contract HIV through heterosexual sex.

What is often not mentioned is the difference between the intervention that was tested in those trials and the intervention that’s being scaled up. I would summarize what the randomized trials intervention as “male circumcision with very intensive counseling on the risk of MC (many visits) in an environment where fewer of the participants had the expectation of it completely eliminating risk” vs. the counseling alone. They showed a strong and surprisingly consistent effect across the three studies.

But I would describe the intervention that’s being scaled up as “male circumcision with much less intensive counseling (one visit) in an environment where many of the participants have unrealistically high expectations of risk reduction.”

I’m worried that the behavioral dis-inhibition from circumcision will more than make up for the risk reduction from the procedure itself. Thus, I’m interested in seeing more data from evaluations of these programs, as well as population-level data that includes the less-well-supervised circumcision operations that are likely to spring up in response to demand.

The article quotes Dr. Vusi Magaula, chair of Swaziland’s male circumcision task force, as saying, “With the highest prevalence of HIV in a population ever recorded, we have got to do something to intervene.” But does the urge to do something justify the programs being implemented, especially if there’s a very real risk of harm?Unfortunately I don’t think we really know the answer to that question, and only the data will tell.

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01 2011

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