Benefits and Challenges to circumcision as a public health intervention

Circumcision Is Found to Curb Two S.T.D.’s - NYTimes.com

A major study came out in NEJM further strengthening the biomedical argument that circumcision can help curb STD spread - HPV2 and HIV. However as always, proving the biomedical science is only the first step - next is the implementation - here are some of my thoughts on male circumcision as a public health intervention. I will try to get around to commenting on the EMR papers in NEJM this week - which are also very important - but back to our subject, here's my thoughts:

Male Circumcision shows tremendous potential:

• The data published to date suggest that male circumcision has greater benefit than any potential vaccine investigated to date.

• An additional benefit is that male circumcision is that it is similar to a vaccine - it's a one time intervention, that does not require "routine use" such as a prophylactic pill

• Male circumcision is not encumbered by the burdens of intellectual property or patents, thus making it suitable for rapid scale-up

However, barriers exist to scale-up

• Scaling up a surgical procedure will be difficult in health economies facing health infrastructure challenges. In addition to ensuring that there are appropriate health physical infrastructure, programs will need to ensure appropriate human infrastructure o ensure the quality of the procedures is adequate

• There are tremendous obstacles that public health officials will face in attempting to overcome cultural and social barriers and stigmas

• Avoiding risk compensation is critical and complex

•There are relatively few studies that understand the "demand" for the procedure, so it is hard to develop marketing strategies for male circumcision

•Implementation funds will likely be slow to reach prevention programs due to funding cycles, lack of proven models, and limited demand

•There is a catch up cohort that will need infusion of funds upfront for service delivery, monitoring, and training until providers are trained, social norms are changed, and neonatal male circumcision prevalence increases