New Op-ed on male circumcision and HIV Prevention

Over at the CSIS Africa Policy Forum, I have a new op-ed on male circumcision and HIV prevention. Here are some excerpts:

In the past few years, clinical trials in Kenya, Uganda, and South Africa confirmed that male circumcision (MC) reduces the risk of transmission of HIV infection by approximately 60%.

In its Fourth Annual Report, the program [PEPFAR] announced that it had allocated $16 million in fiscal year 2007 for MC activities, up from $600,000 the year before. In FY 2008, funding may rise to $30 million.

The average cost to circumcise an individual has been estimated to be about $50. Thus, the $16 million for FY 2007 could be providing services to large numbers of people. Even assuming high start-up costs for training and administration, if only a quarter of these resources were dedicated to actual service delivery, that would still mean that more than 80,000 men could have received MC services by now. Unfortunately, while PEPFAR does a good job counting the number of individuals on anti-retroviral treatment, analogous data for circumcision services are not available. However, there is concern among experts and observers in the field that the number of people who have received MC services to date through PEPFAR is very, very low – probably fewer than 2,000.

A large part of the problem is that there are simply not a sufficient number of trained professionals nor properly equipped facilities to safely carry out the circumcision surgery for the large numbers of people who might request it. More worrisome still is the concern that MC funds are not being dedicated to organizations with the most experience and/or capacity to train people to carry out the procedure. In some cases, funds may be targeted to social marketing of the procedure and to encouraging local populations to support MC, without sufficient investment in the actual capacity and infrastructure necessary to meet that demand.

Male circumcision offers the same sort of compounded benefit that most effective vaccines offer to populations – herd immunity. As more men are circumcised, not only is their own risk of acquiring HIV reduced, but their current and future partners and their partners’ partners also are at lower risk.

While concerns about cultural acceptance should inform where and when MC services are provided, the main problem holding back the wider availability of such services appears to be supply, not demand. If training and infrastructure are the primary barriers to more expansive rollout of MC services, then it is incumbent on PEPFAR, now undergoing reauthorization before Congress, as well as on other donors, to respond. They need to do a better job channeling funding to those purposes and to implementing organizations that can translate support into effective service provision. To miss the potential of MC through squandered resources, oversensitivity to cultural concerns , and ineffective programming will only prolong the tragedy of HIV/AIDS in Africa.

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