While there is compelling research indicating that circumcision prevents HIV, several issues remain.
First, several questions emerge about the randomized controlled studies that were conducted. First, could the Hawthorne effect be at play—that the participants are making better health choices simply because they are being observed? Second, in the Orange Farm study, at baseline both the control and intervention groups had high (over 80%) condom use (Auvert et al., 2005), indicating that participants may have already been healthier people. This is a common problem with research studies—typically those that volunteer to be in research studies are healthier than the general population. However, the study did offer a cash reward to participants, which may have motivated healthy and unhealthy individuals to participate. Third, while the studies were performed with attention to proper research methods, a randomized controlled trial that measures whether or not individuals contract a disease is difficult to use to show causality. In essence, individuals’ behaviors highly influence their contraction of the disease; if an individual never participates in any risky behaviors, then they are unlikely to contract HIV and would therefore not be a good measure of the efficacy of this intervention—something that statistics and confounding can only control for so much.
Image 1- Circumcision Marketing
There are huge concerns over educational and behavioral damage that mass circumcision to prevent HIV may cause. The WHO, UNAIDS, PEPFAR, the World Bank, and the George and Melinda Gates Foundation say that 80% of men of reproductive age in Eastern and Southern Africa need to be circumcised by 2015—which is more than 20 million circumcisions. In order to spread their message and encourage men to be circumcised, these organizations spread the message that circumcision is the best defense against HIV (see image 1) (de Lange, 2013).
Image 2- Education Materials Suggesting that Circumcised Men May Not Need Condoms
However, this may have undesired negative consequences. Some scientists remain skeptical that circumcision will be the solution that the WHO and others claim is it. For instance, they worry about the mixed messages that men are receiving—that condoms will protect them from HIV and should be used 100% of the time, but that if they didn’t want to wear condoms they could get circumcised instead. This leads individuals to prioritize circumcision while continuing to participate in risky behaviors, such as low condom use (see image 2). Further, health workers are overemphasizing the benefits of circumcision—some educational materials say “You are preventing your partner from cervical cancer” (de Lange, 2013). Some critics also say that the fact that circumcision is so popular shows that men are still participating in risky behaviors—in other words, why should an individual bother with circumcision if they have to continue to use condoms (de Lange, 2013)?
Critics also worry about the effect on women. Condoms are already not an incredibly attractive preventive measure due to how they decrease sensitivity during sex, and men may want to forgo condoms altogether if they believe that circumcision protects them. However, this disregards the fact that circumcision does not protect females from HIV (de Lange, 2013). Further, when surveyed, women said that they preferred circumcised men because they thought they were cleaner and that they were less likely to transmit HIV (Layer et al., 2013).
There are also concerns over how circumcision campaigns are being carried out. During the trials, participants received counseling before and after circumcision, and at regular intervals afterward, on HIV prevention and the benefits and limitations of circumcision. During mass campaigns, however, individuals only receive one counseling session, given before their procedure (de Lange, 2013). This leaves some confused and unclear on whether circumcision really does provide better protection than condoms.
Lastly, some concerns arise over the ethics of these studies and campaigns. Most are being conducted in sub-Saharan Africa, an area notorious for extremely high HIV rates as well as low education and low incomes. Because of the vulnerability of individuals in parts of Africa, extreme sensitivity must be given to compensation for participating in a study as well as the educational materials presented to the public. For instance, individuals who are desperate for income may join the study only to receive compensation, or individuals with little education may be susceptible to problematic health education messages.