Thursday, January 8, 2009

Lawrence Gostin on Male Circumcision for HIV Prevention in Sub-Saharan Africa

Lawrence O. Gostin (Georgetown Law) has posted Male Circumcision as an HIV Prevention Strategy in Sub-Saharan Africa: Socio-Legal Barriers on SSRN.  Here is the abstract:

Lawrence_gostin UNAIDS and WHO recommend safe, voluntary male circumcision as an additional, important strategy for the prevention of heterosexually-acquired HIV in men in areas with high HIV prevalence and low levels of male circumcision. Comprehensive male circumcision services should include HIV testing and counseling, partner reduction, and male and female condom use. Yet, male circumcision can have deep symbolic meaning that could pose barriers to implementation. In some parts of the world, it is a traditional practice with religious or cultural significance, in others it is a common hygiene intervention, and in yet others it is unfamiliar or foreign. Consequently, the proportion of men who are circumcised varies from <5% to >80%, with an estimated 30-40% of adult men circumcised worldwide.

Confirming a number of observational studies, three randomized controlled trials in Africa have shown that circumcision reduces the likelihood of female-to-male HIV transmission by 50-60%, leading WHO/UNAIDS to conclude that the evidence is "compelling." Male circumcision is a relatively simple, inexpensive one-time surgical procedure that is cost-effective, but raises a host of ethical, legal, and human rights challenges.

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Even if we believed the validity of the three African randomized control studies and the integrity of the pro-circumcision researchers who conducted the research, condoms are 95-times more cost-effective than circumcision without the risks and lifelong consequences of the amputation. Condoms have effectively and successfully curbed the spread of AIDS in Thailand, Senegal, and Eastern Uganda, without the expense and risks of circumcision. When a male wears a condom, there is no need to be circumcised, but if he's circumcised, he still needs to wear a condom.

African countries are now being coerced into implementing circumcision programs in order to qualify for funding from PEPFAR, the Global Fund, the World Bank, and others. Let the buyer beware! Circumcision will not prevent HIV/AIDS, but it will make males believe they are safe from AIDS and that they do not need to use condoms. In addition, decreased sensitivity from the loss of 20,000 to 70,000 highly specialized, erogenous nerve endings that encircle the opening of the foreskin will make condom use less desirable because they exacerbate already decreased sensation. The "circumcision-to-prevent-HIV/AIDS" agenda will not work. How many males will suffer before people realize this is a dangerous agenda?

Lawrence Gostin is correct when he says, circumcision "raises a host of ethical, legal, and human rights challenges."

Posted by: Marilyn Fayre Milos, RN | Jan 9, 2009 8:47:33 AM

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