Challenges Around Implementation

The positive news from clinical trials that showed male circumcision reduces men's risk of acquiring HIV from female partners has paved the way for pilot programmes and scale-up. This implementation phase can be more time- and labour-intensive than the research process itself. The programmes must be well-designed and sufficiently-resourced to ensure that the benefit seen in clinical trials is approximated in the "real world."

Success in this endeavour depends on input from a broad range of stakeholders, from community members to policy makers to medical professionals. Civil society advocates have identified a range of concerns and challenges around implementation of male circumcision, and are working with other stakeholders to identify solutions. These include:

Communications and messaging

There are multiple messages related to male circumcision that will need to be communicated clearly, consistently and in context-specific formats. These include core messages around:

• Integration of male circumcision into comprehensive approaches to HIV prevention.
• Partial efficacy — male circumcision is neither 100 percent protective nor a substitute for other methods of HIV risk-reduction.
• The multiple meanings of the procedure (rite of passage, marker of religious identity, personal health and hygiene, HIV risk-reduction strategy).
• What is known and not known — the data on safety, risks and benefits for partners of circumcised, HIV-positive men are indeterminate but suggest women may be at increased risk of HIV infection if sex is resumed prior to wound healing.
• There are no clinical trial data on protection during anal intercourse.

Financing

Civil society groups have played key roles in mobilising resources for prevention programmes in many countries. Non-governmental organisations (NGOs) have worked to develop proposals for the Global Fund to Fight AIDS, Tuberculosis and Malaria, and have advocated for priority spending on various strategies. As male circumcision scales up, operations research will help refine estimates of programme costs, identify strategies for lowering them, and further improve cost-effectiveness through negotiation for affordable supplies and techniques such as "task-shifting" of surgical procedures to nurses and medical officers. Advocates have a role to play in many of these efforts.

Impact on uptake of and funding for other prevention strategies

As the WHO/UNAIDS March 2007 document (PDF, 128 KB) emphasises, it is important to develop programmes that situate male circumcision in the context of other biomedical and behavioural prevention options. There is a critical need for country governments, donors, and programme implementers to support creation of such comprehensive offerings. In every instance, community groups working on HIV/AIDS prevention, treatment and care, and/or on sexual and reproductive health have a role to play in shaping these programmes, advocating for sufficient resources, and following up on their long-term outcomes.

Impact on women

Due to the high incidence of HIV infection among women, particularly young women, it is important that HIV research and programmes continually examine the potential effects, risks, and benefits for women.

Some specific critical issues related to women include:

• Messages around male circumcision, its risks and benefits; its place in the spectrum of proven prevention options; and its impact on women's ability to negotiate safer sex with spouses, stable, and casual partners.
• Impact of male circumcision on women's risk of acquiring HIV from circumcised, HIV-positive partners (who may or may not know their status and may or may not wait for full wound healing before resuming sexual activity).
• Impact on men's behaviour — rates of risk behaviour, coercive sex, condom use, et cetera.
• Development and analysis of research on men's and women's sexual satisfaction and pleasure pre- and post male circumcision (what questions are asked, how, by whom, how are the data used to make cases for/against male circumcision?).
• Impact of new male circumcision programmes on national- and community-level priority-setting around HIV prevention, and on staff at health facilities that may be asked to add male circumcision to existing services.
• Impact on cultural rituals that may include traditional circumcision as a rite of passage.
• How to make decisions about circumcising infants and young children.

Impact on health care workers and infrastructure

Implementing a surgical procedure such as male circumcision requires specific supplies, training, and human resources. Civil society groups have already voiced concerns about the need to adequately resource male circumcision scale-up such that there are additional trained personnel available to perform the procedure, including counselling and testing as well as the surgery itself. Given the ongoing human resources crisis in health care sectors throughout sub-Saharan Africa, this is a critical issue that advocates are addressing on many fronts. Sustainable solutions will require broad health systems strengthening, and not intervention-specific responses.