Circumcision - Prevention Technology Or Social Act?

At the Toronto World AIDS Conference there was a question-and-answer session at the end of the ‘Circumcision – Time to Act?’ session. Social scientist Gary Dowsett from La Trobe University in Australia, who himself presented sessions on how men who have sex with men define themselves in different cultures, questioned the way circumcision had suddenly become the latest ‘white hope’ in prevention technology.
He said that social scientists at the conference were becoming concerned about how the social and political consequences of potential mass circumcision programmes were being ignored by its proponents.
He said: “Circumcision isn’t a ‘prevention technology’, it’s a deeply meaningful social and political act. And even if some kind of effectiveness is demonstrated there are many public health tools we don’t use in this epidemic because of their moral and political consequences, such as quarantine.”
Dowsett earned both applause and mutterings for his intervention. But even if, as reports of Swazi men queuing at clinics suggest, fear of AIDS will overcome doubts about circumcision for men in high-prevalence countries, his general point is well-made: no prevention intervention can be divorced from its context, because HIV prevention always involves questions of culture, behaviour and identity. After all, condoms are a biomechanical prevention method with 90% efficacy, but we’ve spent 20 years trying to persuade people to use them, to supply them, and to sanction their use.
There were a huge number of posters and presentations about new ways of getting people to reduce risk presented at the conference, but few interventions were actually evaluated in terms of their effect on risk behaviour. One that was evaluated was the ‘popular opinion leader’ trial among young black gay men in North Carolina, reported here. This produced really quite significant changes in risk behaviour among its target community – a target community with among the highest HIV incidence – in one study, a record-breaking 15% a year – of any group of people on earth.
Yet trials of this approach in the UK have failed. Why? Culture again: when a similar approach was tried in London among gay gym users, the researchers had difficulty in recruiting opinion leaders, and they in turn had huge difficulty “in talking to complete strangers about sex,” to quote the researchers. This is less likely to be a US/UK cultural difference than a small town/big city one. All the trials of this approach that have been successful have taken place in small, tightly-knit gay communities. People come to big cities precisely in order to seek anonymity and change their identity and where there is no unitary ‘peer group’.
from AIDSMap