Position paper
Voluntary Medical Male Circumcision (VMMC) as a biomedical approach to HIV prevention has recently become the focus of controversy within the HIV and AIDS advocacy and policy community. The question of VMMC and its effectiveness is the subject of a double Special Issue of Global Public Health, edited by Richard Parker, Peter Aggleton and Kenneth Rochel de Camargo (all members of GAPW Advisory Council). Some scientists argue that VMMC represents a prevention milestone that can have significant impact in the fight against HIV, while others have expressed caution and cast doubt on the effectiveness of VMMC as prevention and the scientific process that led to the recommendation (Parker, Aggleton and Camergo, 2015).
In 2007, representatives from the World Health Organization and UNAIDS publically announced their intention to use male circumcision as a priority prevention method for HIV transmission (Giami, Perrey, Mendonça & Camargo, 2015). In a Fact Sheet published in 2012, the World Health Organization states that VMMC can reduce female to male transmission of HIV by upwards of 60% and called for its use in 14 Eastern and Southern African countries (http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/). It is one of PEPFAR’s currently promoted Priority Interventions and USAID has been at the forefront in launching the initiative in a number of the focus countries in Africa ( Many of the infant and adult circumcision initiatives that UNAIDS, USAID, and PEPFAR support financially and technically are framed as offering “substantial” and “lifelong” partial protection against HIV and other sexually transmitted infections as well as offering “direct protection” against cervical cancer in women (http://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/accelerating-scale-voluntary-medical-male).
Despite the scientific claims that have been made as the justification for recent policies promoting circumcision as a key HIV prevention strategy, a growing body of critique has begun to highlight significant flaws in the scientific inquiry that led to this recommendation. This is especially salient in the absence of cultural and social considerations of the implementation of VMMC in target countries and the politics behind the Global North’s support of it. In the Special Issue of Global Public Health, a detailed article by Alain Giami et al. discusses the circumstances of the technical consultation on circumcision that the World Health Organization and UNAIDS conducted in Montreux, Switzerland in 2007. This technical consultation championed VMMC as a significant biomedical procedure for curbing female to male HIV transmission in certain regions of Africa. The authors describe how the consultation presented several randomized controlled trials (RCTs) as the main justification for VMMC with little discussion or regard for the cultural and social context of circumcision within the targeted countries (nor were these countries represented at the consultation). Despite the research-driven justification, they describe how the entire conference struck a moral tone that called for urgent adoption of VMMC. Further, the article describes how the focus of discussion was the implementation of the trial’s findings rather than a debate of their validity. The ‘hybrid forum’ brought together actors from all different sectors, but involved few opponents to circumcision or “NGO’s opposed to body or genital mutilation” and even less space for their opposition to be heard (Giami et al., 2015).
Additional articles in Global Public Health point out the difficulty of implementation of VMMC in some of the targeted countries. Implementation in countries like Swaziland, Botswana and Zimbabwe, with heavy financial backing by international organizations and foundations from the Global North, encountered resistance for a myriad of social and cultural reasons. As articles in the Special Issue document, resistance to circumcision in these settings has been associated with a range of issues, including the perceived loss of manhood/sexual pleasure, fear of failed surgeries, the continued necessity of condom use after circumcision, interference with traditional circumcision ceremonies, and distrust of Western medical interventions (Adams & Moyer, 2015; Katisi & Daniel, 2015; Moyo et al., 2015). Such research has called attention to the need for greater attention to cultural beliefs and practices that affect attempts to implement VMMC programs for HIV prevention purposes (Rennie et al., 2015).
The increasing promotion of VMMC on the part of global health organizations is particularly alarming in light of the fundamental flaws in its scientific inquiry and implementation and, perhaps most poignantly, because it seems to be the only HIV prevention measure given priority in the post-2015 development agenda. The Copenhagen Consensus Center, a non-profit organization that strives to find the most cost-effective solutions to problems, asked a group of economists to assess the UN’s Sustainable Development Goals (SDGs) and determine which would offer the best rate of return. The SDG regarding HIV and AIDS is under Goal 3.3, which aims to eradicate the AIDS, tuberculosis, and malaria epidemics, among other communicable diseases, by 2030 (https://sustainabledevelopment.un.org/sdgsproposal). Considering that this goal is extremely broad, the economists concluded that the most cost effective goal for AIDS eradication would be to avoid 1.1 million new HIV infections by 2030 through circumcision. While the initiative would cost approximately $35 million and would purportedly pay back at least $15 for every $1 spent, it is remarkably narrow, especially considering the social and structural efforts still desperately needed to combat this epidemic (http://www.economist.com/news/international/21647316-which-mdgs-did-some-good-and-which-sdgs-might-work-good-bad-and-hideous). Despite what these cost estimates suggest, if male circumcision continues to be heavily prioritized in post-2015 agendas, it is equally possible that tremendous costs to healthcare systems will indeed be felt as a result of the infections that could have been prevented through more comprehensive interventions.
While the United Nations has placed VMMC as a priority in its post-2015 development agenda, this does not mean that further investigation and study of VMMC is no longer needed. On the contrary, given the limitations of randomized controlled trials, which by their very nature seek to control against the unpredictable circumstances of the real world, what is perhaps most urgently needed is research that will offer insight into social, cultural, economic, and political factors that will necessarily impact policies and programs aimed at promoting circumcision as an HIV prevention strategy in public health practice. Failure to conduct such research before adopting policies promoting VMMC suggests a serious lack of attention to the scientific evidence base that should have been a necessary foundation for informing policy. In light of the questions raised in the Special Issue of Global Public Health, the policies surrounding the global response to HIV prevention appear to rely on the perspectives of supposed experts from large global actors rather than incorporating the voices of populations impacted by HIV. Lack of transparency and significant participation from the populations that these policies are intended to impact will not allow for public health decisions that truly represent the broad perspectives and needs of all those involved.
References
Adams, A., & Moyer, E. (2015). Sex is never the same: Men’s perspectives on refusing circumcision from an in-depth qualitative study in Kwaluseni, Swaziland. Global Public Health, 10:5-6, 728-738. DOI: 10.1080/17441692.2015.1004356. (http://www.tandfonline.com/doi/full/10.1080/17441692.2015.1004356)
Giami, A., Perrey, C., de Oliveira Mendonça, A. L., & de Camargo Jr., K. R. (2015). Hybrid forum or network? The social and political construction of an international ‘technical consultation’: Male circumcision and HIV prevention. Global Public Health,10:5-6, 589-606. DOI: 10.1080/17441692.2014.998697. (http://www.tandfonline.com/doi/full/10.1080/17441692.2014.998697)
Katisi, M., & Daniel, M. (2015). Safe male circumcision in Botswana: Tension between traditional practices and biomedical marketing. Global Public Health, 10:5-6, 739-756. DOI: 10.1080/17441692.2015.1028424. (http://www.tandfonline.com/doi/full/10.1080/17441692.2015.1028424)
Moyo, S., Mhloyi, M., Chevo, T., & Rusinga, O. (2015). Men’s attitudes: A hindrance to the demand for voluntary medical male circumcision – A qualitative study in rural Mhondoro-Ngezi, Zimbabwe. Global Public Health, 10:5-6, 708-720. DOI:10.1080/17441692.2015.1006241. (http://www.tandfonline.com/doi/full/10.1080/17441692.2015.1006241)
Parker, R., Aggleton, P., & de Camargo Jr., K.R. (2015). Circumcision and HIV prevention: Emerging debates in science, policies and programmes. Global Public Health, 10:5-6, 549-551.
DOI: 10.1080/17441692.2015.1015705. (http://www.tandfonline.com/doi/full/10.1080/17441692.2015.1015705)
Rennie, S., Perry, B., Cornell, A., Chilungo, A., & Umar, E. (2015). Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malavi. Global Public Health, 10:5-6, 679-691. DOI:10.1080/17441692.2015.1004737
(http://www.tandfonline.com/doi/full/10.1080/17441692.2015.1004737)
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