Is circumcision the solution to the African HIV-AIDS epidemic?


Leading public health journal has doubts and seeks wider debate

Controversy surrounding the African circumcision programs has been reignited by a special issue of the journal Global Public Health, which subjects the current policies of UNAIDS and WHO to a searching critique. From the very start, the proposition that mass circumcision of African men was the best tactic against heterosexually transmitted HIV in sub-Saharan Africa attracted strong criticism on numerous grounds: that it ignored history, ethics and the functions of the foreskin; that it threatened human rights; that it was likely to be ineffective; that it was expensive; that it overlooked the needs of those at greater risk of HIV infection (women and homosexual men); and that it reflected a Western view of African sexuality, as well as a specifically American faith in the power of bio-medicine, to the exclusion of social, demographic, sexual and personal factors. Nonetheless, the critics were marginalised, and the circumcision lobby was able to attract massive funding for a series of supposedly voluntary circumcision programs that have continued with varying degrees of uptake.

What makes this special issue of Global Public Health remarkable is that it represents the first sustained critique of the “circumcision solution” from a major international journal at the heart of the public health policy community. Up until this time, critics of the circumcision programs have mostly been marginal and isolated figures whose views have been ridiculed by the biomedical experts and ignored by the media. This time it is different, and the circumcision lobby has reacted with some annoyance – not merely at the specific criticisms raised, but at the very idea that there was anything controversial about the “circumcision solution”. As far as they are concerned, the issue was settled by the three clinical trials and a subsequent “consultation” in Montreux, and they are furious at the suggestion that there is anything left to debate: the only issues they want to discuss are the most efficient circumcision instruments and the best ways to persuade men to submit.

But as the analysis by Giami et al shows, there never was any real debate about the implementation of the circumcision programs, which were forced upon the reluctant officials of the WHO by a well-organised United States faction, backed by abundant cash. As they write, “the time devoted to the presentations did not allow for a genuine, open debate, in particular about how to extrapolate from the findings in the narrow context of the RCTs to the general population. This question was thought to be settled, given the results from previous observational and epidemiological studies. There was no mention of the contradictory findings that had been published, nor of a scientific controversy. According to Dowsett during our interview, Hankins’ speech on the second day barely mentioned the recommendation’s social and cultural consequences.”

Catherine Hankins was the chief medical adviser to UNAIDS, and reportedly instrumental in having the papers based on the three clinical trials published in leading journals. The only firm sceptic of the circumcision solution at the Montreux meeting was Professor Gary Dowsett, an Australian sociologist with extensive experience in social science research on AIDS who had served as consultant for WHO and other international organisations. As Giami writes: “As one of a group of self-identified gay researchers, his activities in this field reached back to the mid-1980s. Nonetheless, the possibility for him to present his critique was limited by both the agenda and the perceived hostility towards him during discussions by, in particular, a major US epidemiologist, one of the recommendation’s principal advocates. During our interview, Dowsett cited this person’s name, which we have replaced with the pronoun HE in the transcripts: “I’m standing in the hotel, with a glass of champagne and HE … comes charging over to me, immediately … and just started to attack me, immediately, and … ‘How wrong I was! Why I was doing this? I got the argument wrong – Did I not understand how important all this was’ … and HE attacked me … every time I spoke in the meeting at Montreux. Every time!”

That should give you an idea of how consultative the Montreux consultations were. In this context, it is clear that the special issue of Global public Health is not asking for the debate to be reopened, but asking that a genuine debate take place. To that end, anthropologist Kirsten Bell criticises the narrow focus of the biomedical approach and seeks to expand the debate to include issues of culture and sexuality. Historian Robert Darby compares the response to HIV-AIDS in Africa with the response to syphilis in nineteenth century Britain, and notes that many of the same kneejerk responses and human rights violations are found in each. He also shows that in each case the circumcision solution was as much a product of culture as of “science”. Giami et al explore the limitations of the Montreux “consultation” and show how a well-organised pressure group was able to get the decision it wanted. Robert Van Howe performs a detailed statistical analysis which shows that there is no consistent relationship between circumcision status and susceptibility to HIV, concluding that circumcision is not an effective preventive tactic. Adams et al show that in Swaziland the ambitious program to circumcise 80 per cent of the male population failed because men learned from their friends that circumcision had an adverse impact on sexual experience and body image. Perez et al criticise the circumcision programs for paying insufficient attention to the needs of women and homosexual men and call for a gender-aware approach to HIV control. Finally, an article from an earlier issue of GPH shows that the “circumcision solution” is not a settled matter, as the circumcision lobby would like us to believe, but a controversial and unsettled question that requires far more genuine debate than it has received hitherto.

Abstracts of selected papers appear below.

Kirsten Bell. HIV prevention: Making male circumcision the ‘right’ tool for the job


In recent years, HIV/AIDS programming has been transformed by an ostensibly ‘new’ procedure: male circumcision. This article examines the rise of male circumcision as the ‘right’ HIV prevention tool. Treating this controversial topic as a ‘matter of concern’ rather than a ‘matter of fact’, I examine the reasons why male circumcision came to be seen as a partial solution to the problem of HIV transmission in the twenty-first century and to what effect. Grounded in a close reading of the primary literature, I suggest that the embrace of male circumcision in HIV prevention must be understood in relation to three factors: (1) the rise of evidence-based medicine as the dominant paradigm for conceptualising medical knowledge, (2) the fraught politics of HIV/AIDS research and funding, which made the possibility of a biomedical intervention attractive and (3) underlying assumptions about the nature of African ‘culture’ and ‘sexuality’. I conclude by stressing the need to expand the parameters of the debate beyond the current polarised landscape, which presents us with a problematic either/or scenario regarding the efficacy of male circumcision.

Robert Darby. Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms

In this paper, I discuss the parallels between responses to syphilis in nineteenth century Britain and HIV/AIDS in contemporary Africa. In each case, an incurable disease connected with sexual behaviour aroused fear, stigmatisation and moralistic responses, as well as a desperate scramble to find an effective means of control. In both cases, circumcision of adult males, and then of children or infants, was proposed as the key tactic. In the ensuing debates over the effectiveness and propriety of this approach, three questions occupied health authorities in both Victorian Britain and the contemporary world: (1) Were circumcised men at significantly lower risk of these diseases? (2) If there was evidence pointing to an affirmative answer, was it altered anatomy or different behaviour that explained the difference? (3) Given that circumcision was a surgical procedure with attendant risks of infection, was it possible that circumcision spread syphilis or HIV? I show that in both situations the answers to these questions were inconclusive, argue that circumcision played little or no role in the eventual control of syphilis and suggest that attention to nineteenth century debates may assist contemporary policy-makers to avoid the treatment dead-ends and ethical transgressions that marked the war on syphilis.

The full paper is available at

Alain Giami, Christophe Perrey, André Luiz de Oliveira Mendonça & Kenneth Rochel de Camargo. Hybrid forum or network? The social and political construction of an international ‘technical consultation’: Male circumcision and HIV prevention

The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a ‘hybrid forum’ and ‘network’, this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a ‘hybrid forum’, which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation.

Robert Van Howe. Circumcision as a primary HIV preventive: Extrapolating from the available data

Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56–1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection.

Alfred Adams and Eileen Moyer. Sex is never the same: Men’s perspectives on refusing circumcision

Faced with an HIV prevalence of 31% among 18- to 49-year-olds, Swaziland developed a male circumcision policy in 2009, following compelling scientific evidence from three randomised controlled trials. Utilising United States Agency for International Development funds, the state set out to circumcise 80% of adult men in 2011. Only 8667 of the targeted 150,000 men were circumcised during the campaign. This paper presents findings from a 2012 to 2013 in-depth qualitative study among Swazi men. Methods included 13 focus group discussions, 20 in-depth interviews, 16 informal interviews and participant observation. We argue that the campaign's failure can be partly explained by the fact that circumcision was perceived as a threat to Swazi masculinities, a factor hardly considered in the planning of the intervention. Results show that men believed circumcision resulted in reduced penis sensitivity, reduced sexual pleasure and adverse events such as possible mistakes during surgery and post-operative complications that could have negative effects on their sexual lives. Given the conflicting state of scientific data about the effects of circumcision on sexuality or sexual pleasure, this study addresses important lacunae, while also demonstrating the need for more research into the relationship between sexuality, masculinity and health interventions seeking to involve men.

Guillermo Martínez Pérez, Laura Triviño Durána, Angel Gasch. Towards a gender perspective in qualitative research on voluntary medical male circumcision in east and southern Africa

The World Health Organization endorsed voluntary medical male circumcision (VMMC) in 2007 as an effective method to provide partial protection against heterosexual female-to-male transmission of HIV in regions with high rates of such transmission, and where uptake of VMMC is low. Qualitative research conducted in east and southern Africa has focused on assessing acceptability, barriers to uptake of VMMC and the likelihood of VMMC increasing men's adoption of risky sexual behaviours. Less researched, however, have been the perceptions of women and sexual minorities towards VMMC, even though they are more vulnerable to HIV/AIDS transmission than are heterosexual men. The purpose of this paper is to identify core areas in which a gendered perspective in qualitative research might improve the understanding and framing of VMMC in east and southern Africa. Issues explored in this analysis are risk compensation, the post-circumcision appearance of the penis, inclusion of men who have sex with men as study respondents and the antagonistic relation between VMMC and female genital cutting. If biomedical and social science researchers explore these issues in future qualitative inquiry utilising a gendered perspective, a more thorough understanding of VMMC can be achieved, which could ultimately inform policy and implementation.

Global Public Health: An International Journal for Research, Policy and Practice. Volume 10, Issue 5-6, 2015: Special Issue: Circumcision and HIV prevention: Emerging debates in science, policies and programs

Kenneth Rochel de Camargo, Jr., Andre Luiz de Oliveira Mendonca, Christophe Perrey and Alain Giami. Male circumcision and HIV: A controversy study on facts and values

We present a controversy study on the association between male circumcision (MC) and HIV. Our general goal is to shed light on the issue, unravelling and comparing different conceptions of scientific evidence and their respective world views. We seek to reconstruct, based on an analysis of the literature on the topic, key moments in the history of the controversy about the association between MC and HIV prevention, analysing more closely three recent randomised studies, given their relevance to the argumentative strategy employed by those who defend circumcision as a prevention method. Following this, we present a synthesis of the main arguments against the three referred studies. In conclusion, it seems that reasonable arguments for a more cautious approach are not being adequately considered.

Global Public Health, Vol. 8 ( 7) 2013: 769-783

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