Circumcision programs have captured the attention and funding of governments in East and Southern Africa, global funders, and policymakers. Job postings for "male circumcision specialists" are circulating, and the Bill and Melinda Gates Foundation and the President's Plan for AIDS Relief (PEPFAR), two of the largest funders of global HIV/AIDS programs, have incorporated male circumcision work into their efforts.
First, the good news: Three recent trials have shown that circumcised men are about half as likely to contract HIV from unprotected vaginal intercourse as their uncircumcised counterparts. Circumcision also protects against some other sexually transmitted infections (STIs).
But the reality is that circumcision offers only partial protection. A circumcised man still has a significant risk of contracting HIV and other STIs if he engages in unprotected sex with an infected partner. Circumcision does not offer the man's current female partners any protection from contracting HIV.
On a larger scale, the predictive models that show a significant reduction in the number of new HIV infections assume that between that 80 to 100 percent of men are circumcised. Currently approximately 30 percent of men worldwide are circumcised, although this varies widely between different communities and countries.
Surveys have shown that many men are willing to be circumcised, and the promise of surgical prevention may bring throngs of men into local clinics that do not routinely use health services. It would be shortsighted not to couple circumcision services with education on HIV prevention and safe sex, provider-initiated HIV counseling and testing, and referrals to HIV/AIDS care and treatment.
But given the protection that circumcision provides, men may assume and assert that they are "safe" and insist on having sex without condoms. There are questions about whether newly circumcised men will be willing to abstain from sex for the six weeks necessary for the wound to heal so as to not possibly increase their or their partner(s) risk of contracting HIV or other STIs.
In the communities where the demand for circumcision is high and resources are scarce, unqualified circumcisers may begin offering the surgery to meet men's demands. It would take only a very few unqualified safe surgeons to taint the safety and acceptability of these programs. We cannot allow this to happen.
Clearly, circumcision is an imperfect solution to HIV prevention. Even so, it promises to be one of the most effective strategies we currently have to curb new HIV infections in men.
So, what about those of us who never had a foreskin?
By the most optimistic predictions, male circumcision will not translate into fewer HIV infections in women for decades. The reality of HIV and the epidemic is that women account for the majority of people living with HIV in the most affected region, Sub-Saharan Africa. For biological reasons, a woman is between two to eight times more likely than a man to contract HIV during vaginal intercourse with an HIV-positive partner.
On top of women's biologic predilection to infection, gender inequalities have sustained and feminized the epidemic by limiting women's abilities to negotiate safe sex, refuse unwanted sex, and ask their partners to be monogamous. We must be cautious about how male circumcision may change these realities.
Too often women are blamed for bringing HIV into the household. They are cast out of their homes, subjected to discrimination and violence, and shunned by their communities. Will circumcised men be more likely to blame their female partner(s) if either of them becomes HIV-positive? As fewer men contract HIV, will it increasingly be seen as a women's disease and become more stigmatized? Will women living with HIV become more vulnerable to violence and abandonment than they already are?
The Way Forward
Male circumcision offers new hope that more men can remain HIV-negative, and
this advance is good news for men and potentially good news for women. But it
would be inexcusable if we allow a potentially positive advance in HIV
prevention for men to harm women.
Women's health advocates, including those who met at the Expert Consultation on Male Circumcision and HIV Prevention: Implications for Women, are recommending that investments in male circumcision be matched by concurrent investments that directly benefit women. Among these investments is sexuality education, which teaches young women and men how to communicate with their partners about safe sex, to establish equality in relationships, and to respect the right to consent in sex and marriage. And, in this age of rising HIV infections, it teaches young people how to protect themselves and each other.
Sexuality education takes us part of the way by equipping women with the skills to negotiate safe sex, but we must also ensure women have access to male and, in particular, female condoms. As the only existing woman-initiated method of HIV prevention, female condoms offer women a way to protect themselves when faced with a circumcised partner who refuses to use a male condom. Current supplies of male and female condoms do not satisfy the global demand. But the female condom shortage is particularly dire: there are 700 male condoms for every female condom. Protecting women in a climate of male-focused prevention means we must make a meaningful commitment to promoting and widely distributing the female condom.
Although the main beneficiaries of male circumcision will be men in the near and medium term, we must not lose sight of the fact that women are stakeholders in these programs. Before these programs ramp up, women's health groups, including women living with HIV, should be involved in the analysis of how circumcision will affect women. Once the programs kick off, they should be closely monitored and evaluated in collaboration with these women's health groups. We must also initiate new research into what biomedical, structural, and behavioral interventions can best help women protect themselves from HIV infection such as microbicides.
Perhaps the most important thing we can do before the snipping begins is to communicate honestly about what male circumcision will, and won't, do for a man and his female partner(s). We should undertake public education campaigns and individual and couples counseling to ensure that women and men understand that:
Male circumcision is not a vaccine, and it is not a cure-all. It is simply one of the best ways to prevent HIV infections in men, right now. But we cannot overlook the fact that circumcised men, and their partners, are still vulnerable to HIV.
]]>Kate Bourne is IWHC's Vice President for International Policy and Regional Programs.
In the United States, we have long expected corporations to be accountable to their employees by providing health insurance for workers and their families. Recently, around the world, the framework of corporate responsibility has expanded to include not only a company's employees, but also surrounding communities.
Investing in women's health and rights is a key mechanism for promotion of corporate accountability, as well as one of the best investments that businesses can make.
More women are living with HIV/AIDS today than ever before - but HIV is only one factor in women's health. In total, sexual and reproductive ill health (which has been around for much longer than HIV/AIDS) accounts for an estimated one-third of the global burden of illness and early death borne by women of reproductive age, which basically corresponds with prime working age.
]]>Kate Bourne is IWHC's Vice President for International Policy and Regional Programs.
In the United States, we have long expected corporations to be accountable to their employees by providing health insurance for workers and their families. Recently, around the world, the framework of corporate responsibility has expanded to include not only a company's employees, but also surrounding communities.
Investing in women's health and rights is a key mechanism for promotion of corporate accountability, as well as one of the best investments that businesses can make.
More women are living with HIV/AIDS today than ever before - but HIV is only one factor in women's health. In total, sexual and reproductive ill health (which has been around for much longer than HIV/AIDS) accounts for an estimated one-third of the global burden of illness and early death borne by women of reproductive age, which basically corresponds with prime working age.
The aspects of girls' and women's lives that put them at serious risk of HIV/AIDS are the same ones that undermine their sexual and reproductive health in general: lack of quality health services and information; and basic and fundamental gender inequity and practices which violate the rights of women and girls, such as violence, sexual coercion and child marriage.
In order to improve women's health, businesses can increase their investments in three areas: Improved access to and quality of clinical services; factual information on reproductive health, including preventing pregnancy, sexually transmitted infections (STIs) and HIV/AIDS for women and men - young and old; and empowering women so they can control their own lives.
First, sexual and reproductive health services are the health services most women use. It's also where they take their children for early care. Addressing HIV - which is primarily a sexually transmitted disease - within these existing services is essential if we're going to make any real progress in combating the pandemic.
There is plenty of evidence about the cost effectiveness of reproductive health services, primarily because they have multiple benefits, including reducing poverty and hunger, ensuring educational opportunities and gender equality, higher productivity, and attaining environmental sustainability.
An investment of $66 billion per year for basic maternal and newborn care would lead to a savings of more than $360 billion per year by 2015. In the United States, when we think of maternal and newborn care, we typically visualize incubators, and other very high tech measures. But in much of the world, it is very basic interventions - prenatal and trained obstetric care - that are needed to be able to save millions of lives.
I was just visiting rural clinics in Udaipur, India where maternal mortality has been reduced by simple actions, including setting up reliable transportation links for emergency obstetric care - not buying ambulances - just making an arrangement with the local taxi service that ensures that women will be transported even if they don't have the cash on hand. There are many other reproductive health interventions that are similarly simple - but the will and the way have not yet made them happen.
Investments are also needed to make sure that women and men - young and old - have factual information on reproductive health, including preventing pregnancy, STIs and HIV/AIDS.
In many parts of the world, awareness of HIV/AIDS is still low. Even in regions where basic awareness is high, as in much of Africa, people still have many misconceptions about who is at risk, how to protect themselves, and where to go for help. Ironically, those who need information the most have it the least.
Women who are married or in stable partnerships in which they are monogamous tend to have a particularly low level of knowledge, and they are now among the groups with the most rapidly rising rates of infection. And young men and women tend to lack even basic information about pregnancy prevention. But we also need to go beyond basic biology to provide information about sexuality, rights, and responsibilities within relationships.
Employers can easily provide health education programs for employees, or ensure that counselors are available to answer questions. Even a small enterprise that doesn't have the capacity for clinical services can provide its workers with information and ensure that they know where to go for further help. Non-governmental organizations in virtually every country are available to work with businesses, vocational schools, and in communities of workers to provide information and shift normative behavior to healthier - and happier - models.
Finally, to fundamentally improve women's health, women need to have more control over their own lives and men need to be supported to take full responsibility for their own behavior. Business already affects these relationships. When women are employed and earning income, the power dynamics in a relationship or family shift. Some aspects of this are positive - women gain more say over what happens and how family resources are spent, and this benefits the health and well-being of the family. But it can also be disruptive when men don't know or respect it, or when men are the ones who are employed, often far from home.
One of the ugliest manifestations of gender inequality is violence against women. At first glance this may seem to be a social issue beyond what we can expect business to engage on. But, the health burden of violence against women of reproductive age is equal to that of HIV, TB, cancer and heart disease combined. Now, that has got to be expensive for business as well as for societies.
Business has an important role to play in helping employees and their families to adopt positive patterns of life. At a minimum, business leaders can decry violence against women and children, and provide role models for equitable, respectful relationships. They can sensitize on-site health services and provide counseling or legal assistance.
Violence, HIV, maternity care, contraception - all are crucial issues in women's health. The healthier women and girls are; the more ingenuity, creativity, and vitality will flourish; the more children will grow into healthy, productive citizens; and the more economies - and businesses - will thrive.
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