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Male circumcision has been recommended by the World Health Organization as a pillar in HIV/AIDS prevention since 2007, when conclusive epidemiological evidence showed that circumcised males are significantly less likely to contract the virus than their uncircumcised brethren. And yet, despite the evidence of effectiveness, the recommendation that countries develop ethical, voluntary circumcision programs has met with controversy from unlikely corners. Typical arguments against major investment in widespread circumcision, summarized in an Op-Ed published by the South African web publication Health-e, are that the traditional healers who usually perform the procedure use unsterilized instruments, increasing the likelihood of many other types of infection; that they remove an insufficient portion of the foreskin to be effective for HIV transmission prevention; and that men who have undergone the procedure do not wait the requisite six weeks before having sex; all of which collectively make the individual more likely to contract the virus if they are exposed to it within a few weeks of being circumcised and even beyond. Perhaps the argument that carries the most concern for long-term risk, however, comes from HIV/AIDS prevention advocates, who argue that men who opt for circumcision may then be more likely to have unprotected sex in the belief that they are protected. That latter concern seems, at least in some contexts, to be unfounded. A study conducted by Research and Development Organization in Kenya showed that men who had recently undergone circumcision were no more likely to have unprotected sex in the year following the procedure than their uncircumcised peers. Counseling and other health services provided by the clinics that conduct the procedure seem to deserve partial credit for the positive outcomes.

Much more attention has been paid to recent comments by Pope Benedict XVI saying that condom distribution would not resolve the AIDS epidemic, but would instead aggravate it. The comment has generated the expected amount of outrage from the usual sources. More thoughtful commentators, like William Easterly, couch their criticism by pointing out that condom distribution campaigns have not in fact resulted in decreased infection rates for many countries in East and Southern Africa, where infection rates are at their highest. But using a condom while having sex with an infected partner has a very good track record of preventing infection and therefore the Pope’s comments are potentially a self-fulfilling prophecy—discouraging condom use makes condom distribution less effective.

But the Pope’s comment about condom distribution aggravating the epidemic is also correct, though not in the way he presumably intended. As Easterly, of all people, should recognize, condom distribution is one of those interventions that makes for easy counting of the wrong things, and therefore discourages the kind of “seeking” behavior in philanthropy that Easterly advocates. No one, regardless of their politics or ideology on HIV and sexual health, truly believes that the numbers of condoms distributed matters at all. The only metric that matters is the infection rate. Mass condom distribution tends to convince funders that the job has been done and the problem sufficiently addressed and they take their eye off the numbers that really matter. By ultimately distracting from issues like multiple concurrent partnerships and circumcision, condom distribution has aggravated the epidemic, in Africa at least.


 

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