Male circumcision for HIV prevention: what about protecting men’s partners?

Male circumcision for HIV prevention has been one of the “hot” topics at the International AIDS Conference in Mexico City this year. I think that’s great. Everywhere the subject has been raised, widely differing views have been expressed. It means we can confront all the issues openly in hopes of having a good effect on the practice, since male circumcision programmes are already being generously funded and moving full steam ahead to scale up male circumcision in as many countries as are keen to have it.

My expertise is women’s sexual and reproductive health and rights, including in relation to HIV. I was asked to put forward a gender perspective in this session. I’m not up here to condemn male circumcision. I understand the reasons why it is being promoted and sought after. But it is early days to know what it will contribute to reducing the HIV epidemic and we need to be mindful of comments such as these from a report by the UN news agency Irin in July 2008¹ regarding the very men who are intended to benefit from male circumcision:

“My husband did not believe he could be HIV-positive because he was circumcised.” (wife)

“Many of the men I speak with think circumcision is like an AIDS vaccine.” (doctor)

“I don’t want to give up sex, so I am getting circumcised.” When told that counsellors would advise him to carry on using condoms even after the operation, he said, “If I have to wear a condom anyway, what is the point?” (young men, age 25)

Here are some of the gender and sexuality issues I believe male circumcision for HIV prevention raises.

Partners of circumcised men have an equal right to protection

Male circumcision for HIV prevention is partially protective for HIV negative men but not for their partner(s), whether male or female, unless they also use condoms. It is the only HIV prevention intervention that does not protect both sexual partners, to some extent. This is highly problematic.

Male circumcision will reduce population-level HIV transmission only after a high proportion of the male population is circumcised, which was predicted to take up to 10 years to reach its full effects, even in a highly successful programme.^*

A public health perspective says that 50–60% protection for circumcised men is far better than nothing where there is sexual risk taking and unprotected sex.² Many women and men in high HIV prevalence countries welcome male circumcision because they do not wish to give up unprotected sex and are desperate for something.

I am acutely aware that I am not in their shoes. I approach male circumcision as a women’s health advocate, and my question is whether male circumcision is good enough for women, not in 5 or 10 years’ time if herd immunity is achieved, but right now.

I said in my conference presentation that I thought male circumcision was useless for HIV positive men, tested or untested. I was challenged and corrected on this from the floor, that circumcision still gives the man protection against some other sexually transmitted infections (STIs).³ Nevertheless, I did not accept the other point that was made – about the stigma for men of being “outed” as HIV positive if they are denied male circumcision when everyone else is doing it. I do not see that as a reason for circumcising someone.

But let’s stay with the issue of HIV status and circumcision for a minute longer. What does circumcision mean for the partners of positive men? If a man seeking circumcision doesn’t know he is positive and refuses an HIV test, and he is circumcised, and he thinks he is protected, and he continues depositing semen in his partner’s body unimpeded every time they have sex, then as I see it, his partner is in a worse position than before. There is currently a debate about whether male circumcision programmes should require men to have an HIV test. I think they should require it. Pregnant women are pretty much required to have a test for the sake of their babies. But whatever your views, you can be pretty sure that the need to protect partners is not being taken enough into account when policy on this is being set. These programmes are keen above all to get as many men in as possible.

Ironically, male circumcision does not require behaviour change in the man to achieve protection for himself, but for his partners to benefit, safer sex is still required. Equity for men’s partner(s) therefore needs to be created in other ways.

Can safer sex end the epidemic?

Safer sex is a way of thinking about and acting on sexuality, not just the activity of using condoms or having a bit of foreskin cut off. The promotion of safer sex has never received sufficient resources. The focus on male circumcision, antiretrovirals (ARVs) and other technical solutions is crucial in the face of that failure. But the question remains: could safer sex still succeed with a sufficiently renewed effort, or do we think – deep down – that it’s impossible in practice? Because if positive people are tired of protected sex and are giving it up, and if untested and negative people who are at risk are still engaging in risk-taking more often than not, then other prevention interventions are absolutely needed. But which ones should be prioritised, and for whom?

Many at the conference agreed that we have neglected prevention issues for a long time. But we need to get more sophisticated about what forms of prevention are most likely to be used and who they are most appropriate for, including male circumcision. Are we going to circumcise men just because they ask for it? Are we then going to drop them back into the street to continue having unprotected sex? Isn’t that a waste of resources?

Prevention options

A wheel depicting all the possible prevention modalities was presented in the prevention plenary at the Toronto AIDS conference in 2006. Several of the technical prevention options that looked promising in 2006 for reducing epidemic spread, i.e. vaccines, non-ARV microbicides, herpes simplex virus suppression therapy, and mass STI treatment, are still far off or have since been proven not to be effective. Thus, we are pretty much still left with voluntary counselling and testing, behaviour change, barrier methods and male circumcision – but, importantly, also the growing potential of antiretroviral solutions.

Male circumcision is 50–60% protective.² If I were to propose a contraceptive method to the world today that was only 50–60% effective, I would be laughed out of the room. But because there are so few solutions for preventing HIV transmission sexually, and because the most effective solutions to date are not accessible or are not being used nearly enough, less effective solutions are necessary.

Even so, if we were to compare male circumcision to a cheap condom that will break 40% of the time, it wouldn’t sound so attractive. But maybe a lot of men who think it is as good as an effective vaccine would understand it better in those terms and consider their behaviour more than many appear to be doing.

What about ARVs? All praise to the Swiss for their new policy, which has been expressed through the shorthand equation “treatment = prevention”, which was discussed in intelligent and thoughtful depth in a symposium in Mexico City (HIV transmission under ART at: <www.aids2008.org/Pag/PSession.aspx?s=485>). “Treatment = prevention” means protection exists for positive people with low viral loads who are on highly active antiretroviral therapy and have no other sexually transmitted infections. But it also means that in future antiretroviral prophylaxis in pill, barrier and microbicide form might be developed and be as revolutionary as the contraceptive pill was in its time. It was therefore quite surprising when one of the main proponents of male circumcision for HIV prevention at UNAIDS expressed concern during the symposium that ARVs might not be effective enough alone and so might increase infection rates. As if that didn’t also apply, and many times more so, to depending on male circumcision alone.

Prophylactic ARVs will need years to develop and disseminate widely, but circumcising 70% or more of men in high HIV prevalence countries to achieve herd immunity will take a long time too. When ARV options are available, what will happen to barrier methods, behaviour change and male circumcision? Look what happened to condoms for family planning when oral contraception arrived in 1960. Look how long it is taking to climb back up that Sisyphean hill now. There are short-term and long-term perspectives to be discerned here.

I was asked during the session: Have we given up on condoms? Well, I said, I certainly haven’t and from the response of the people in the room, they certainly hadn’t either. But this is a collective challenge that must be taken back to country level, to donors, and to the top of UNAIDS, and acted upon.

The value of male circumcision

Male circumcision has been practised for centuries by at least two of the world’s major religions and many others for hygienic, initiation and other reasons. So, yes, it is a public health measure and serious consideration should be given to universal circumcision of boy babies soon after birth. But that may be a bridge too far for many, especially in a world where distorted notions of “choice” are often trumping public health exigencies.

However, because I don’t think men have the right to tell me what to do with my body as a woman, I feel I don’t have the right to tell them what to do with their bodies either. This is, first and foremost, a men’s health and rights issue and men need to have views on it in the same way as women’s health advocates have views on women’s health. On the other hand, this is also about men as sexual partners and about social norms for sexual relations, so it isn’t only men who need to have views and be listened to.

How many men actually will line up and do it, as opposed to thinking it’s a good idea and not carrying through, remains to be seen. Again, family planning history shows that far more people say they don’t want more children than seek and then use contraception. Thus, it was suggested from the floor during the conference that male circumcision programmes have a lot to learn from vasectomy programmes worldwide, and I agree. But promoting vasectomy globally, like condoms, has been an uphill battle in most parts of the world. So putting all your cards on circumcision is a gamble – too large a gamble in the absence of promotion of other protection. In discussions of this issue, I am struck by the diversity of concerns expressed by women’s health advocates in this regard. Their biggest concern, however, which I share, is that male circumcision will let men off the hook and sideline women. This concern must be taken seriously.

Whose input was sought before programmes began?

Most of the interventions for fighting HIV were either invented by or widely advocated and supported by people living with HIV first. Have HIV/AIDS organisations and those representing key populations at risk, including men who have sex with men, sex workers, and organisations of people living with HIV, been approached to get their input and asked whether and how they might support this intervention? Why were women not consulted until long after the train had left the station?

Can we really be asked just to acquiesce in the imposition of a narrow, top-down, vertical prevention intervention 25 years into this epidemic? No. We deserve better.

Speaking of key populations, the assumption by male circumcision programmes that all men are heterosexual must be challenged. A review of the sparse literature to date looking at whether male circumcision protects either partner in anal intercourse between men, found that the data are inconclusive.⁴ Whether and in what ways this is being taken on board by male circumcision programmes remains to be seen. The protective value of circumcision for a man having anal intercourse with a positive woman is also, to my knowledge, mostly ignored. Yet anal intercourse is common, and if protection is low or non-existent, people need to know.

Monitoring male circumcision programmes

Here are some of the things we need to know about how male circumcision is playing out in real life:

•	how many men have been circumcised and where, and who are they (young, older, married, single, socioeconomic status);
•	why did they seek circumcision; what were their partners’ views;
•	how many circumcised men were tested for HIV before circumcision and found to be HIV positive;
•	how many were HIV negative, and what is their status several years down the line;
•	how many commenced sex before they healed;
•	how many had complications and what kind;
•	have they changed their sexual behaviour or practices, or reduced their number of partners, post-circumcision; if so how;
•	pre-and post-condom use;
•	how many had STIs that were treated at circumcision and how many have STIs now;
•	what was the HIV status of their partners at the time of circumcision and how many became HIV positive since;
•	what difference has circumcision made.

Monitoring and evaluation need to include far more than just how many men have been circumcised.

Meanwhile, here are some proposals for involving partners centrally in the roll-out of male circumcision programmes:

Involving partners

The partners of men seeking circumcision need to be involved in several ways:

•	Circumcision programmes should be for men and their partners – including information, couple counselling and testing, and promotion of safer sex to couples; with extra support for women in negotiating safer sex.
•	Programmes need to recognise and take into account the fact that the men who are at risk of HIV infection and other STIs are men who are connected into sexual networks involving multiple partnerships. This affects counselling before and after circumcision and in programmatic efforts to involve partners.
•	The sex of men’s partners must not be assumed to be exclusively female (or exclusively male either).
•	Women’s health advocates and organisations representing key populations in the HIV epidemic, including HIV positive people, sex workers and MSM, need to be involved in policy-making on including partners in service delivery.

As regards women as partners, some committed feminists are involved in male circumcision, hence, some women are being consulted. However, women organising themselves in order to influence programmes at national level is what is most required. No one is going to put out the red carpet for our participation. It is up to us to insist in our own countries, and to ensure that people at community level have the information they need to be able to take informed decisions and address unsafe sex.

Women have to stop being victims and allowing themselves to be described as victims in this epidemic. There are positive women in 50% of discordant couples in many sub-Saharan African countries.⁵ Many women also have more than one partner. Women are having unprotected sex and rejecting condoms, not just men. And like men, women have to confront reality and their options, and insist on safer sex.

Conclusions

•	Women’s health movement organisations need more resources for grassroots work in their countries on sexuality, gender and sexual relationships.
•	Prevention needs major investment, especially condoms and the development of antiretroviral prophylaxis, to make “treatment = prevention” a reality for millions of people.
•	Priority setting at country level may or may not include male circumcision. Where it is included, if it gets more people practising safer sex, then all those snips will have been worth it.
•	The snip alone won’t do it, however; there must be a link between the penis and the brain.
•	Partners of circumcised men have an equal right to immediate protection.

Safer sex promotion is needed now more than ever. So let’s see increased support for condom social marketing organisations like DKT Marketing and Population Services International to get more condoms out there, because they are the unsung heroes of condom promotion in this epidemic and doing a far better job of raising condom use levels than everyone else combined. Let’s advocate for a day on condoms at the next AIDS conference and an international day of the condom, for PEPFAR to drop its restrictions on condoms for adolescents, and for the Pleasure Project to open an office in every country (<www.thepleasureproject.org>). It’s only when safer sex and pleasure are addressed in the same breath that anyone will ever be interested in using condoms or making sex safe.

Note

This is a revised version of a paper presented at a panel on male circumcision, International AIDS Conference, Mexico City, 7 August 2008, and takes into account some of the discussion and questions during the session.

Notes

* Mathematical modelling found that in the conditions of two sub-Saharan African countries, with 80% male circumcision uptake, the reductions in HIV prevalence ranged from 45% to 67%, and with 50% uptake, from 25% to 41% over a decade.²