To circumcise or not to circumcise?

A heated debate at South Africa's third AIDS conference had delegates grappling with the question: should the country introduce a mass circumcision programme?

The question was posed on Wednesday by Dr Francois Venter, president of the Southern African HIV Clinicians Society, and taken up by a panel of researchers, doctors and social scientists with enthusiastic input from an audience of conference delegates.

Neil Martinson, deputy director of the Perinatal HIV Research Unit at the University of Witwatersrand in Johannesburg, described the evidence confirming the protective effects of male circumcision against HIV, as overwhelming.

"It's almost like a vaccine," he said.

Noting the "deafening silence" on the issue from policy makers in South Africa, he conceded that it was not an intervention everyone was comfortable with. "It's not warm and fuzzy," he said. "It's all about cold steel."

But Martinson argued that the next step would be to look at operational issues, such as how to drive up demand for the procedure.

Prof Alan Whiteside, director of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal, called for the procedure to be routine for all male babies born at public health facilities - unless parents objected.

For adult men who wanted to be circumcised, he said, the procedure should be covered by medical aid schemes.

A more skeptical stance was taken by Timothy Quinlan, research director at HEARD, who was not convinced the evidence for male circumcision warranted promoting it for HIV prevention.

"Fifty to 60 percent effectiveness is not the standard scientists look for," he said. "It's okay if there's nothing else, but there are a whole host of other ways to prevent HIV."

He added that male circumcision ignores women and does nothing to change behaviours that are driving the epidemic such as multiple, concurrent partners.

"Of course it's a personal choice," he concluded, "but is it worth investing the time and money?"

Most audience members felt it was, but had a number of concerns. Several emphasised the need to take into account the cultural issues surrounding male circumcision and to involve traditional leaders as the custodians of culture. In a country where 30 percent of men are already circumcised as part of traditional rites of passage, "circumcision is very close to African men's hearts," said one audience member.

Others wondered whether the male-centred intervention would have a disempowering effect on women and increase their HIV risk by giving men an excuse not to use condoms.

"Let's get ready," was Whiteside's response, "because it's going to happen and we need clear, informed advocacy and communication."

ks/kn