UNAids is careful in its assessment: “Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’ — it does not provide total protection and it does not mean people can stop taking the safe sex precautions they were already using.”
The caution is a response to the excitement — and debate — triggered by results from three random trials in South Africa, Kenya and Uganda in 2005 and last year, which seemed to demonstrate that circumcision reduced the risk of HIV infection for men by between 50% and 60%.
After the slow slog of behaviour-change messaging, here was a simple medical procedure — already widely accepted by many African cultures — that could have a significant impact on HIV acquisition. A broad front of United Nations agencies, key United States-based donors and, recently, African health ministers are rallying around an endeavour to make the foreskin history.
But there are voices of dissent: some argue that there is not enough incontrovertible evidence to rush to scale up circumcision and why, for example in South Africa, there does not seem to be a significant difference in prevalence between communities that circumcise and those that do not.
Frustration over the slow headway made by orthodox Aids programmes has resulted in “a desperation to find something that works, with a growing lobby for biomedical intervention”, says researcher Peter Aggleton.
The danger that men will see circumcision as a quick fix — and ignore the public health exhortations to condomise — is acknowledged by both sides of the debate. But the dissidents question why any potential dilution of the latex message should be risked when condoms provide close to 90% protection and it has been such a struggle to persuade men to put them on.
For Richard Delate, communications director of the South African health and education programme of Johns Hopkins University, circumcision is just an additional prevention method. “We need to give men a choice … and circumcision provides an entry point where we can engage men to talk about their penises in relation to sexual and reproductive health.”
Circumcision, though, is not just a medical or cosmetic procedure — for many men it is loaded with meaning around identity and manhood. Social scientists, who feel they have been sidelined in the debate, argue that it is a deeply political act serving as a marker for status, power and social differentiation.
Can a mass roll-out work among men in ethnically mixed societies, where foreskins — or their absence — are shorthand for kinship, culture and, inevitably, chauvinism? Delate is clear that culture changes: Zulus were once traditionally circumcised, but obeyed a decree by King Shaka and simply stopped.
But it also boils down to money. Health services in Africa are already overburdened, under-resourced and unable to provide the most basic care. Should circumcision be added to that load?