Male Circumcision as an HIV Prevention Strategy in Sub-Saharan Africa: Title and subTitle BreakSociolegal Barriers

The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) recommend safe, voluntary male circumcision as an additional, important strategy for the prevention of heterosexually acquired human immunodeficiency virus (HIV) infection in men in areas with high HIV prevalence and low levels of male circumcision.¹ Comprehensive male circumcision services should include HIV testing and counseling, partner reduction, and male and female condom use.² However, male circumcision can have deep symbolic meaning that could pose barriers to implementation. In some parts of the world, male circumcision 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 by country from less than 5% to more than 80%, with an estimated 30% to 40% of adult men circumcised worldwide.³

Confirming a number of observational studies, 3 randomized controlled trials in Africa have shown that circumcision reduces the likelihood of female-to-male HIV transmission by 50% to 60%, leading the WHO and UNAIDS to conclude that the evidence is “compelling.”¹ There is no comparable evidence demonstrating that male circumcision protects against male-to-female transmission or male-to-male HIV transmission.⁴ Male circumcision is a relatively simple, inexpensive 1-time surgical procedure that is cost-effective,⁵ but raises a host of ethical, legal, and human rights challenges.⁶

The international human right to health requires health services to be acceptable, available, and of good quality.⁷ Researchers report high rates of acceptability of male circumcision in populations in which circumcision is not traditionally practiced, but public acceptance depends on culturally sensitive scale-up adhering to medical ethics.⁸ Circumcision may be imbued with social meanings of manliness, sexuality, or religious observance. Because circumcision requires cutting the skin of the penis, the procedure may be viewed with suspicion, particularly if outsiders propose it. Consequently, country planning should involve all sectors of society, including government, health professionals, persons living with HIV, the media, nongovernmental organizations, traditional health practitioners, as well as men, women, and youth.

As an effective method of HIV prevention, male circumcision should be available and affordable to all who seek it without discrimination on the basis of race, age, income, or health status, unless medically contraindicated. Accessibility, however, is limited by weak health systems in countries with endemic HIV in sub-Saharan Africa. Furthermore, reaching disadvantaged or marginalized individuals is particularly difficult, especially rural residents, ethnic minorities, migrants and refugees, male sex workers, prisoners, drug users, and the poor. Making male circumcision accessible requires human resources, training, infrastructure, logistics, funding, quality assurance, monitoring, and evaluation. Under conditions of human resource scarcity, it may entail “task shifting” from surgeons and other physicians to trained clinical officers and nurses. Recognizing the importance of male circumcision, the President's Emergency Plan for AIDS Relief, the Global Fund, and the Gates Foundation are providing support for service scale-up or operational research, despite an overall emphasis on treatment over prevention.⁹

Ministries of Health and health professionals are responsible for ensuring that good-quality male circumcision services are provided under sanitary conditions. This requires trained and skilled personnel, sterile equipment, universal precautions, and monitoring adverse events. Traditional healers may provide beneficial complementary care and may play a role in service provision if neither safety nor quality is jeopardized.

The WHO and UNAIDS advise health professionals to recommend voluntary HIV testing to all individuals seeking male circumcision services.² Excluding men with HIV from male circumcision or diverting them to an alternative service provider, potentially breaching their confidentiality and stigmatizing them, constitutes discriminatory practices. Arguably, circumcising men who are HIV positive is a poor use of scarce resources because they already have the infection. However, human rights law cautions against compulsory testing or excluding individuals from services based solely on their HIV status.^{7 ,10} Furthermore, asymptomatic men who are HIV positive have low adverse event rates, similar to uninfected men,¹¹ and will benefit from reduced genital ulcer disease.¹²

All sectors of society should be able to access accurate information about the benefits and risks of male circumcision. Ministries of Health should initiate effective health education campaigns, whereas health professionals should communicate with patients and their sexual partners or parents in a culturally and linguistically appropriate and effective way. This entails, for example, counseling men and women about partial protection afforded against HIV and benefits of male circumcision in reducing other sexually acquired infections, such as genital ulcer disease and human papillomavirus infection which can lead to penile or cervical cancer.¹³ Similarly, men and women should be counseled to abstain from sex until complete wound healing occurs after circumcision and to engage in safer sexual practices, including correct male and female condom use thereafter.

Health professionals are responsible for providing full and accurate information necessary to secure informed consent for male circumcision, including risks, benefits, and the right to refuse the procedure without risk of reprisal or other adverse consequence. Clinical information should be communicated in a culturally appropriate manner, with due regard for the person's literacy, linguistic, and educational level. Boys and men, moreover, should have the right to make decisions about circumcision without undue influence from peers, sexual partners, or health professionals. National laws should allow mature minors the opportunity to make decisions for themselves or at least empower boys to participate in the decision-making process in an age-appropriate manner. For neonates or very young boys, parents or legal guardians should make decisions in the child's best interests. In some countries, fathers have primary or sole decision-making authority for their children, but justice requires that mothers have equal rights as parents.

Male circumcision can be imbued with social meaning that could stigmatize individuals or result in discrimination. Keeping a person's HIV and circumcision status confidential is therefore essential for the dignity of the person. Consequently, national laws should ensure privacy, health professionals should be trained to protect sensitive health information, and health records should be kept secure so that unauthorized persons cannot gain access.

Male circumcision does not appear to offer a direct benefit to women, although women would benefit over time if HIV prevalence among men were significantly reduced. It is therefore important that male circumcision services do not diminish the resources and attention devoted to prevention, treatment, and empowerment of women. Women are extremely vulnerable in many societies. Male condom use depends on men's willingness to use them, men can exert physical and economic power over women within and outside of marriage, and society sometimes tolerates age-disparate, intergenerational, and transactional sex, all of which may increase risk to women.

In some societies, laws and customary practices are deeply harmful to women (polygamy, sexual assault or rape within and outside of marriage, wife inheritance [a man claiming ownership of his brother's wife when his brother dies], and the legal preference for men in matters of property, divorce, child custody, and inheritance, resulting in destitution for women). Some misinformed and dangerous cultural beliefs persist in some parts of Africa (eg, having sex with a virgin cleanses the body of HIV).

Male circumcision without adequate counseling about wound healing and abstinence can enhance risk for both men and women. Early postoperative resumption of sex delays wound healing and increases the risk of HIV infection for men and their partners. Women would be more vulnerable if men, feeling safer because of circumcision, increased the number of sexual partners or unsafe sexual encounters. Although no evidence of such risk compensation was found in randomized controlled trials, in 1 trial,¹⁴ circumcised men reported a significantly higher frequency of sex than men in the control group reported.

It is critically important to defend women's human rights generally, and in particular to protect the sexual partners of men seeking circumcision. Sexual partners should be involved in the decision-making process, without compromising men's rights to consent and to privacy. Consequently, social change communication strategies should stress that male circumcision is only partially protective and encourage strong male involvement in reducing women's vulnerability with messages that reinforce the importance of postponing sexual debut, partner reduction, and consistent male and female condom use. Individual and joint counseling of men and women should emphasize mutual commitment to sexual abstinence during the postcircumcision healing period and to safer sexual practices thereafter.¹⁵ Moreover, and importantly, governments should take strong measures to ensure that male circumcision is not used as an excuse to tolerate female genital mutilation, which has no health benefits and is harmful to the health and well-being of girls and women.

Male circumcision, as part of comprehensive HIV prevention and treatment, can reduce the burden of HIV in sub-Saharan Africa and other parts of the world. It encourages men to access health care services, receive behavioral counseling, and take active responsibility for their health. To be fully effective, male circumcision services, whether for adults, adolescents, or infants, need to be scaled up to achieve coverage levels adequate for population effect. Male circumcision will have to be acceptable, available, and safe; sensitive to cultural and religious values; respectful of patients' rights to consent and confidentiality; and defend human rights of girls and women.