Ambitious plans to curtail the spread of AIDS by promoting male circumcision have fallen far short of organizers' hopes, particularly in Africa.
As activists prepare to mark World AIDS Day on Saturday, researchers are touting new technological methods to raise circumcision rates in grown men, but face growing scientific questions and popular resistance.
Global leaders in the fight against AIDS are pushing for an accelerated drive to meet the goal of circumcising 20 million African men by 2015.
But results so far are sobering: Only around 2 million African men have had the procedure, even though it is viewed as an "exceptional" HIV-prevention method. And there are strong voices who say the entire effort to promote circumcision in adult males is misguided.
Circumcision backers are closely watching the practical results of two new techniques that aim to help the 14 targeted African countries meet their circumcision goals.
"We're here for one reason: to help Africa reach 20 million men by 2015 – full stop," said Tzameret Fuerst, chief executive officer of Circ MedTech. The private, Israel-based company developed PrePex, a plastic-and-elastic device that results in a "bloodless" circumcision in a week's time, without surgery, stitches, sterile settings or shots of painkillers.
PrePex is now being tested in pilot studies – the final steps needed to get World Health Organization (WHO) approval. If approved in 2013, PrePex would be available for countries to use in their "voluntary medical male circumcision" or VMMC, campaigns.
Another "sutureless" product, the Shang Ring, is also moving through the process to receive WHO approval. "We are optimistic it will receive prequalification status," said Dr. Mark Barone, senior clinical adviser at Engender Health, which is researching the Chinese-developed device with Weill Cornell Medical College.
Opponents of circumcision, who cite both health and efficacy concerns, are warily watching the arrival of these devices, which are intended to dramatically increase the number of circumcisions that could be done in a day compared with conventional surgery.
"Whether men will sign up in droves for a procedure that slowly strangles their foreskins to necrosis rather than cuts it off in a single transaction is a good question," said John Geisheker, executive director of Doctors Opposing Circumcision.
The push for the 'cut'
Voluntary male circumcision is a key part of a "blueprint" outlined by Secretary of State Hillary Rodham Clinton on Thursday. U.S. funds have already supported the some 2 million circumcisions worldwide, and there are plans to reach 4.7 million men by the end of fiscal 2013.
Other groups, such as AVAC, Global Advocacy for HIV Prevention, are urging a significant "scale-up" of VMMC. It is "one of the untapped potential success factors" to end the spread of AIDS, said Mitchell Warren, executive director of AVAC.
The mass circumcision campaign for African men resulted from years of observations that "uncut" men seemed to get infected with AIDS more often than their circumcised counterparts.
Scientists tested this theory in three studies that involved more than 10,000 African heterosexual men and found that those who got circumcised had a 50 percent to 60 percent lower relative risk of getting HIV than those who weren't circumcised.
"This is not iffy data, this is serious data," Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at National Institutes of Health, said when findings from the Uganda and Kenya studies were released in December 2006. Mrs. Clinton announced at the AIDS 2012 conference held in Washington in July that the United States was dedicating $40 million to circumcise 500,000 men in South Africa.
In many African countries, political leaders have gotten circumcised and promoted VMMC through advertising. One Uganda poster, for instance, shows a young woman clasping her surprised face as she looks downward, presumably at a man's crotch. "You mean you're not circumcised!" says the caption, adding, "Stand Proud. Get Circumcised."
The campaigns led to about 1.5 million circumcisions, as of March 2012, according to AVAC.
But compared with the 2015 goals, progress to date has been unimpressive: Uganda, for instance, wants to circumcise 4.2 million men by 2015, but was less than 10 percent of the way to its goal by mid-2012.
Mr. Geisheker and his allies in the anti-circumcision or "intactavist" movement oppose both infant circumcision and misinformed adult circumcision, saying that male foreskin is normal, healthy and important for male sexual satisfaction.
VMMC "is a gigantic experiment," said Mr. Geisheker. Even if it were to work, the African circumcision studies only looked at men getting HIV from women, he noted. When researchers looked in the opposite direction – women getting HIV from men – being circumcised didn't stop AIDS transmission.
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