Male circumcision as foreign policy

The Council on Foreign Relations held its first of several rounds on the role of health technologies in US foreign policy. Laurie Garrett led the discussion with Ambassador Mark Dybul and New York Health Commissioner Tom Frieden. The full video is available on the CFR site. I’d be curious to hear what others think but I came away with the general sense that Dybul and by extension the PEPFAR program is overly cautious about male circumcision as HIV prevention. Several times Dybul pointed to slides (which hopefully the CFR video editor will post…) with WHO models that showed the HIV epidemic would not end with MC alone. Although Dybul did not mention the WHO authors, but he may have been referring to the Williams et al PLoS study published in July 2006. While not predicting the end of the epidemic, Williams et al did find that:

MC could avert 2.0 (1.1-3.8) million new HIV infections and 0.3 (0.1-0.5) million deaths over the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7 (1.9-7.5) million new HIV infections and 2.7 (1.5-5.3) million deaths, with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa.

Circumcision, like any STI control strategy, works when core spreaders at the nodes of the sexual networks are treated. There are no guarantees that high risk individuals will seek out the knife or that if they did, once cut, their new circumcised status would not affect decisions about high risk sex. But national policies to circumcise adolescents and infants, calling for safely deployed and closely monitored programs as with any public health intervention, promise to shift the epidemic curve over a few short years. New cohorts of young circumcised men, exposed to the same safe sex messages currently broadcast and presented with the same level of condom social marketing as now, will be at fundamental lower risk of HIV infection. That sounds like a worthy effort for US taxpayers to fund, certainly more than the $15 million currently available from an annual PEPFAR budget in the neighborhood of $3 billion.

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2 Responses to “Male circumcision as foreign policy”

  1. Comment function has been problematic. I got an email in response to the post and I’m sharing it here:

    Hi Ben,
    i couldn’t figure out how to create an account on the blog to comment on your post about Male circumcision as policy. There is one statement you make in the post, that i would caution – You say “Circumcision, like any STI control strategy, works when core spreaders at the nodes of the sexual networks are treated.” While this is accurate based on many of the assumptions driving a LOT of interventions, it doesn’t reflect the reality of sexual networks in SSA (and may not anywhere, but that’s beyond the scope of this particular point). The thing is, few, if any, sexual networks actually have any such “hubs”. Recent empirical evidence demonstrates this (see a forthcoming piece by Helleringer and Kohler in AIDS), and a handful of people have been
    suggesting it for a while (see especially Martina Morris’s work). This particular point doesn’t have much bearing on the “end-game” of the suggestion you make in this post, but is something that has been proliferated without much empirical backing for a while. Epidemics don’t need hubs, so interventions need to be broad based.

    Jimi Adams, PhD

  2. I worked on an gonorrhea outbreak investigation in California a few years ago in which the network was a clearly defined “spoke and hub” and in which treatment was targeted to the core spreaders and their contacts and out from there. That said, your comment raises an interesting point about concurrent partnerships and leads to questions about the nature of networks.

    It sounds like there are at least two archtypes for sexual networks, which for lack of better terms, I’d call vertical and horizontal. In non-hierarchical sexual networks of concurrent partnerships, it wouldn’t matter much where HIV entered as it would quickly burn through as everyone is in a sense a ‘node’ – there are fewer deadends in the tracing the contacts. In the gonorrhea network example, however, there were clear hierarchies of contacts, with ‘core spreaders’ at the primary hubs and sexual contacts branching off into fewer numbers of subsequent contacts.

    You raise an excellent point and I have to agree that under the conditions you imply with concurrent partnerships, male circumcision will be most effective when adopted broadly.