A blog about the 16th International AIDS Conference, Toronto, Canada, August 13-18, 2006.
On Tuesday morning, while President Clinton was speaking about the promise of circumcision (thanks Bryan, for your summary), I was attending a session entitled, "Male Circumcision: Is It Time to Act?". The moderator of the discussion was none other than Bertran Auvert, a French researcher who led the first randomized control trial (RCT) to determine whether circumcision truly has a protective effect against HIV. (Observational data and some basic biological research have suggested it does.)
In 2005, Auvert's team demonstrated that men who were circumcised were 61% less likely to be infected by HIV than a non-circumcised control group. The trial was immediately ended on ethical grounds, and these promising results soon caught the attention of activists, public health workers and governments around the world--all of whom had been waiting for a major advancement on the prevention front.
WHO and UNAIDS immediately reacted, releasing a statement calling for prudence in interpreting the results, as well as more research. "Although the trial shows promising protective effects of adult male circumcision in reducing HIV acquisition, UNAIDS emphasizes that more research is needed to confirm the reproducibility of the findings of this trial and whether or not the results have more general application."
Currently, there are two other RCTs underway on the efficacy of adult male circumcision in HIV prevention--one in Uganda and one in Kenya. At Tuesday's session, Dr. Robert Bailey gave an overview and update on the trial in Kisumu, Kenya, which will conclude in September 2007. Other researchers presented promising results from non-randomized trials in Africa, and still others outlined mathematical models and analyses of the numbers of lives saved and cost savings associated with male circumcision, should its reported benefits be confirmed and realized.
As interesting as the science itself was the audience's response to the work. There was a strong undercurrent of resistance to the approach throughout the session. It finally erupted during the question period. One man asked the panelists whether they considered circumcision a form of mutilation, and what kind of counseling or support services they would put in place to offset the traumatic effects of the surgery? When Auvert pointed out that all the studies are looking at voluntary, adult male circumcision, the man retorted, "It's not because you're an adult that you might not be traumatized by the loss of your foreskin." This is an extreme example, but several social scientists chastised the panelists for "decontextualizing" the debate about circumcision, and rallied against the label "biological technology," as some of the panelists had referred to it.
As Clinton suggested in his speech on Tuesday, there's a long road ahead to acceptance of male circumcision as a preventative tool in the fight against AIDS. Based on what I witnessed yesterday, I'd say the road ahead is indeed very long--and winding. The social, cultural and religious parameters of this debate need to be played out before widespread acceptance will occur. And the scientists exploring the promise of circumcision would be unwise to shutter themselves to these forces, hoping their results will speak for themselves. The history of the AIDS pandemic is rife with examples of how social norms, as well as cultural and religious beliefs can thwart even the best evidence-based approaches to prevention and treatment. The global AIDS community needs to begin addressing these factors now.
Comments
There needs to be a lot more work done on correlation of causality here. While we can be proximally certain that condom usage prevents HIV infection, there could be other things that correlate circumcision with infection rates. There are several options in behavior alone that could well affect results.
While I'm circumcised (it was not by choice), I don't believe it's a practice that should be undertaken -- it is the deliberate mutilation of a human being in the name of either social convention or alignment with the edicts of some phantom being. Neither is a valid rationale.
Particularly since we're talking about deliberate mutilation being done on someone who is likely either unwilling to have it done or incapable even of voicing a decision either way, the idea that any global health organization might even nominally speak out in support of the act is extremely unsettling.
Posted by: Warren | August 18, 2006 2:34 PM
If there is concrete medical evidence in support of circumcision (which the WHO and UNAIDS seem to appropriately doubt) as a mode of prophylaxis/therapy for HIV infection, it should be introduced as such. The tremendous threat that HIV represents, in terms of medical, social and economic contexts, should alone be able to nullify all pertinent objections to yet another therapeutic modality. However, it seems to me that because of the multifactorial nature of HIV infection and AIDS, before these results can be generally applied, there should be further studies showing causal relationships, such as carriage of the virus in the foreskin.
Even accepting that it indeed may be immensely useful in prevention of HIV infection, it may be very difficult to implement in certain parts of the world that are bound by social and religious mores. For example, I happen to know for sure, that in the Indian subcontinent, absence (because of removal) of the foreskin is considered to be a characteristic of Muslims (whose religion decrees circumcision), and not of the Hindus (whose religion does not speak of it), and the idea of having the foreskin surgically removed may be abhorrent to the adult Hindu male, despite the perceived health benefits.
Posted by: suirauqa | August 20, 2006 1:18 PM