Male circumcision for HIV prevention: perspectives on gender and sexuality/Circoncision masculine pour la prevention du VIH: perspectives sur le genre et la sexualite.

• Author: Berer, Marge
• Position: Reprint

For more than a decade, those working in the field of sexual and reproductive health have been calling for "male involvement" of various kinds. When men are actually expected to do something specific, however, the success rates have been very uneven. Very few men have had vasectomies, for example, except in a handful of countries, as compared to the number of women who have been sterilised when they no Longer wish to have more children. On the other hand, although millions of men in countries such as Turkey still practise withdrawal for contraceptive purposes and gay men began to use withdrawal for risk reduction against HIV transmission early on as well, that practice has received no publicity or promotion, let alone randomised trials to determine its use--effectiveness, so as to promote it if it is proven effective for risk reduction.

Condom use and promotion too have a checkered history. Men have been slow to take up condom use to prevent pregnancy or HIV/STI transmission between themselves and their partners in both vaginal and anal sex. And neither the family planning world nor the HIV world have championed the condom or promoted it to men or women in anything Like the way they should have been doing for the past 25 years-and should stilt be doing--to bring about the defeat of the HIV epidemic.

Now, men are about to be asked to take a different kind of action to protect themselves against HIV, this time by being circumcised. Inevitably (this being about sex), as with the use of condoms and withdrawal, male circumcision affects men's penises. Unlike with condoms and withdrawal, however, this intervention involves more than just covering the penis temporarily with a condom or pulling out before ejaculation. Male circumcision is more comparable to vasectomy, because it involves an irreversible surgical procedure. Unlike with vasectomy, however, it is more than "just a snip", as it involves the removal of the whole foreskin. After the procedure, as with vasectomy, protection is delayed.

With vasectomy, men have to wait until their sperm count has gone down to zero. With circumcision, before they have sex at all, men have to wait until the surgical wound has fully healed. Unlike with vasectomy, however, protection against HIV for a circumcised man will always only be partial. From a man's point of view, some protection is obviously better than nothing. But to be really protected--and in order for a man to protect his partner(s)--he will need to start or continue to use condoms or to practise safer sex in some other proven way.

Male circumcision is the only intervention intended to prevent sexual transmission of HIV that is beneficial and (partially) protective only against female-to-male transmission and only through vaginal intercourse. Whether male circumcision will ever become an effective means of preventing sexual transmission of HIV to women at a population level is highly uncertain, because it will require a majority of men to be circumcised in any given population where HIV is prevalent before women can benefit as a group from the reduced HIV prevalence.

Given limited resources, is it ethical to suggest that certain countries prioritise an intervention that will (partially) protect only men in the next 10-20 years? The answer is far from clear, and the question deserves serious consideration. Others will ask whether it is ethical to withhold it, which is also a cogent and relevant question, but that is precisely what priority setting and discussion of the pros and cons of different forms of HIV prevention have to be about, as more modes of prevention come on the...