Male Circumcision
Male circumcision has now been shown in three randomized clinical trials to reduce the risk of HIV acquisition for men by 50–60% (Auvert et al., 2005; Bailey et al., 2007; and Gray et al., 2007). Male circumcision at birth as part of postnatal care could result, upon sexual initiation and for his lifetime, in a reduction in the risk of HIV acquisition and transmission. The evidence for rolling out male circumcision is incontrovertible. However, given evidence that male circumcision could potentially put women at an increased risk for HIV under certain circumstances in the short term, how best to roll out programming through gender-equitable approaches that do not increase short term HIV risks for women remains to be evaluated. “The roll out of male circumcision presents [an ideal opportunity] to …provide interventions to transform harmful gender attitudes and behavior as part of programming of the roll out of male circumcision… (Greig et al., 2008: S37-8). “Outside the clinical trial setting, the effect that the decreased perceived risk of HIV infection will have for circumcised men’s willingness (and women’s ability to negotiate) condoms requires close monitoring’ (Gruskin and Ferguson, 2008a). Women will benefit in the long run from male circumcision, as fewer of their male sexual partners will be HIV-positive. Clear and consistent messages must emphasize that male circumcision is an additional prevention method for men, but that it does not replace measures such as delay in the onset of sexual relations, avoidance of penetrative sex, reduction in the number of sexual partners, and correct and consistent use of male or female condoms.
With roll out of male circumcision, it is critical for men to wait until they are fully healed to engage in sex since sex for an HIV-positive man prior to the wound fully healing increases the risk of transmission to his female partner (Wawer et al., 2009). If a man refuses an HIV test, is circumcised and thinks he is protected, then “his partner is in a worse position than before” (Berer, 2008a: 172). “As sexual partners, women should not abandon negotiation of condom use with circumcised men, and this will be greatly facilitated if everyone understands that with circumcision alone, men are not fully protected and their partners are not directly protected from HIV infection” (Hankins, 2007: 65).
How can male circumcision be effectively introduced so that it complements and does not detract from other prevention strategies? Will male circumcision affect women’s ability to negotiate condom use? Will male circumcision confer any protection during anal sex? (AVAC, 2007) These questions will need to be addressed as male circumcision is rolled out. It is clear that male circumcision is an important component for HIV prevention strategies, but the extent to which it protects women is, while promising for the long term, unclear about women’s risk in the short term. “From the standpoint of public health, the risks of circumcision, such as procedure-related infection, must be weighed against the relative protection it offers against HIV infection. As with any HIV prophylaxis strategy, it is also important to consider that false security arising from use of a partially effective risk reduction strategy may, because of an increase in the frequency of unsafe sexual practices, result in a paradoxical increase in HIV transmission” (Cohen, 2007: S290).