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Is Male Circumcision the Key to Stopping the Aids Epidemic? [Rush Transcript; Federal News Service]

Speakers: Mark R. Dybul, U.S. Global Aids Coordinator, U.S. Department of State, and Thomas R. Frieden, New York City Department of Health and Mental Hygiene
Presider: Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations
May 7, 2007
Council on Foreign Relations

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LAURIE GARRETT: Good evening. Commissioner Frieden is stuck in traffic, but it is policy at the Council that we always start and end on time. We're off policy by six minutes, but we will therefore run over by six, and hopefully Commissioner Frieden will be here to join us.

And for those of you in webcastland, watching this on live webcast, we welcome you along with those here in the room. My name is Laurie Garrett and I am the Senior Fellow for Global Health here at the Council on Foreign Relations.

We are having a most unusual foreign policy discussion; I think in the history of the Council there has never been anything quite like what we're going to talk about here today.

Before we get into it, two reminders. Turn off your cell phones, please. If I hear your phone ringing I'm going to call out your name and embarrass you in webcastland. (Laughter.) And secondly, we are, unusually also for the Council, entirely on the record today, which includes your questions. So think before you babble.

Also, in the handout that you all hopefully grabbed off the table when you came in, there are some things in the back relevant to future events that we will be staging, so you'll want to hang on to that. I'll talk about it more later this evening.

Well, as I said, we're having a very unusual discussion, and with me on stage and hopefully in better than just spirit eventually, first Ambassador Mark Dybul. Dr. Dybul, is a U.S. ambassador in the State Department for U.S. Global Aids Coordinator. He was previously with the National Institute of Allergy and Infectious Diseases.

MARK R. DYBUL: Still am.

GARRETT: Still, technically.

DYBUL: Uh-huh.

GARRETT: You know, it's interesting in the federal government they way one can be seconded in more than two directions.

And Dr. Tom Frieden will, hopefully, shortly be joining us. He is our Commissioner of Health here in New York City; started in that position in 2002. For five years prior to that he was seconded by our CDC and World Health Organization to India, where he was the key adviser on India's tuberculosis programs.

And that was the result of his very successful performance here as an epidemic intelligence officer with the EIS of the CDC during our multidrug-resistant tuberculosis outbreak here in New York City. And he was really a key player in bringing that epidemic under control.

Well, as per our most unusual discussion today, most people think that MSF stands for Medecins Sans Frontieres, or Doctors Without Borders, but at the International AIDS Conference in Toronto last summer it was suggested that there's a new definition of that acronym. It is Mohels Sans Frontieres. (Laughter.) And that recommendation was actually made only half in jest by an Israeli speaker who said that he thought deploying mohels all over Africa would be the greatest piece of public diplomacy Israel could ever perform.

I want to actually, though, get quite serious about what we're going to talk about. And if the word "penis" makes you involuntarily snicker, just get it out of your system now, please.

Over the course of the AIDS epidemic -- pandemic -- we've noticed something very unusual geographically. The distribution of HIV has not been uniform by any means across Africa. In fact, in no country in West Africa and North Africa have we seen HIV rates exceed 10 percent. In actually only five countries in that region do HIV rates exceed 5 percent. And in contrast, in Eastern and Southern Africa we have very, very high rates of HIV, in several countries exceeding 25 percent.

And there have been a number of studies over the years to try and understand why this distribution was so deeply skewed. One of the interesting revelations that surfaced about five years ago was that there was a strong tradition of female entrepreneurship in Western Africa that was absent largely in both Eastern and Southern Africa, and that women in the West were more likely to have financial resources that allowed them to walk away from dangerous relationships, to, as we say, "Just say no."

And so there was a certain level of belief that that was, if not the key factor, a key factor. And it still is, obviously, an important factor, but with time and with more study, and particularly as a result of the Rakai Study Group in Uganda, a joint Ugandan and Johns Hopkins University Group, we can see that there are other issues at play, and in particular male circumcision or the lack thereof.

More than 80 percent of men in West Africa and North Africa are circumcised compared to less than 20 percent in most of the southern and eastern parts of the continent.

The biology is worth noting. The foreskin of the penis is heavily lined with what are called Langerhans cells. And it turns out that Langerhans cells are particularly adept at absorbing HIV and other viruses and that the highest concentration of Langerhans cells in the human body is actually beneath the foreskin, or in the foreskin, and that that region is exposed with an erect penis. So you have both an increased likelihood of getting infection and of storing infection. And in a sense you're looking at the gateway for male infection.

We don't really know -- we're waiting for data to tell us -- whether or not there is a significant difference in the likelihood to transmit to a woman through sexual intercourse whether a man is circumcised or uncircumcised but infected HIV-positive.

We do know that based on clinical trials comparing circumcised and uncircumcised men that there is a significant reduction in risk to men who get circumcised. We now have studies from Uganda, South Africa and Kenya all showing somewhere in the neighborhood between 50 and 60 percent reduction in risk. I should note that's a reduction studied for no more than two years, the longest study. So that is -- there is that caveat.

Clearly it is a less profound reduction, 50 to 60 percent, than would be absolutely consistent condom use or absolutely consistent sexual abstinence. But it is a greater reduction than we have seen with any other currently available prevention technology.

So the New York Times in mid-January ran an article in the Sunday Magazine likening male circumcision to vaccination and saying that mass male circumcision, particularly across Africa, would be akin to vaccination in that it would theoretically reduce the numbers of infected men, creating a sort of akin experience to herd immunity.

And that's led to several key decisions. First, on March 28th, WHO and UNAIDS jointly called for male circumcision as an effort to lower the risk of HIV transmission to men. Then the Global Fund to Fight AIDS, Tuberculosis and Malaria now say we're going to consider funding male circumcision procedures if countries requested that funding.

A joint U.S.-French study showed that male circumcision is cost effective if you assume that you're in a country where hospitalization for AIDS is an option, and therefore you're costing it against saved -- saved being saved from hospitalization.

Ambassador Dybul and PEPFAR, the President's Emergency Plan for AIDS Relief, on March 29th said that they would be willing to fund male circumcision if countries requested funding for that procedure. And on April 4th Commissioner Frieden said -- (chuckles) -- that he strongly supported male circumcision as a prevention tactic here in New York City.

So here we are: Should male circumcision be a component, directly or indirectly, of U.S. foreign policy?

I was going to open with questions to Commissioner Frieden, but in his absence, Mark, I want to ask you first of all -- there's a big difference between adult male circumcision and a bris. We're not talking here -- those in the room who have witnessed circumcisions have probably been to brises and seen an infant experience the procedure. Adult male circumcision, the procedures performed to date have involved physicians in hygienic facilities, but there's a considerable amount of blood transmission.

How do we ensure that we're not actually, number one, running the risk of blood-borne transmission to the health-care workers if they're performing the procedure on an HIV-positive male, or to future patients because the instruments involved are not properly sterilized in resource-scarce areas? And then further, that this doesn't spawn a sort of marketplace in circumcision, with ad hoc cutters in urban settings offering the procedure?

DYBUL: Well, as you know, this is actually one of our greatest fears, that people are going to rush to something and do it in an unsafe way and there are deaths from circumcision, whether it's infection or bleeding. I think the transmission from blood you manage the way you do any surgical procedure. And that is done across Africa.

There's still surgery happening in many locations. So I don't think that's a significant issue. You do that the way you do any surgical procedure. But we are concerned about those who are not expert at it, and there are some evaluations that show, or suggest, that you have to have done 200 of these to be good at it, or to know what you're doing. So it's going to take a certain level of medical expertise, and the WHO is dealing with this in their guidance and we are as well.

I think the critical question is what -- if we got to full -- the notion that this is like a vaccine I have to say is just patently wrong. It's not. The modeling doesn't show anything anywhere near that. We need a vaccine. And you'll see on the slide -- that's why I brought some of these -- why that's not the case.

This is done by Brian Williams from WHO -- I think it's published now, actually -- on the impact of male circumcision assuming you've reached everyone who is eligible. And the red line is what would happen with male circumcision, with incidence, prevalence and mortality. And the blue line is without.

We're not seeing these 50, 60, 70 percent reductions of vaccine impact. We're seeing a rather small one going out to 2025. And we're not seeing much for many years until you get -- you have to have a medical infrastructure, you have to scale it up. This is assuming 5 percent coverage in 2005, going forward from there.

So this a pretty aggressive, get to everyone you can, within the next eight years -- seven years, and that's not highly likely in the first place for a reason I'm going to talk about in a second, but even if you did, the impact wouldn't be the effect of a vaccine. It's a reduction and there's no question we need to include it, but it's not that substantial.

This actually -- it's substantial, but there are other effective mechanisms as well. This actually goes by region. But you'll see your best shot in South Africa because that's where we would have the greatest impact. There's a 20 percent reduction in prevalence and incidence. So not bad, not bad at all, from 2015 to 2025. So we're talking about 15 and 20 years from now but not what we're talking about in terms of a major impact.

And that's assuming everyone does it. Here's some data on acceptability of circumcision across countries in Sub-Saharan Africa. We're looking in the 50 to 60 percent range for the most part. That means educating people to even want to get circumcised.

And even in Swaziland, where there's a higher report, right now, while we're doing circumcisions actively they're having trouble getting people to come in for Circumcision Saturdays, which is what they're calling it. It's like TGIF, I guess, but Circumcision Saturdays are actually having trouble getting people in. They're doing 20 a Saturday now; they were expecting hundreds a Saturday.

So it's not as if everyone's, you know, pounding down the doors to get there. So we are going to have trouble getting everyone, and even if we did we wouldn't have this massive impact everyone's talking about.

Furthermore, and I think this is something we need to be very concerned about -- this is data from Ron Gray and Tom Quinn that was presented at NIS showing that if men actually increased their partnerships significantly, which may happen, you could actually overcome entirely the effect because it's not completely protective, which means we need to go back to the substantial behavior change of reducing your partners, abstaining or using condoms all the time. And unfortunately that doesn't happen all the time. And I'm going to show you some data as we get into it about why those pieces are so important in the context of circumcision.

So we are concerned about who does it, but I think we also need to be realistic: Circumcision needs to be a component of what we do, but it's hardly a silver bullet. There are no silver bullets in this disease. We need to do everything we can. We need to do behavior change so that people reduce their partners and abstain and use condoms, but we also need to do male circumcision but it's not this panacea, it's not this silver bullet that's going to dramatically shift things or have a vaccine impact. We shouldn't talk like that, because it's not going to happen.

THOMAS R. FRIEDEN: Hi, Mark.

DYBUL: How are you? Good to see you.

FRIEDEN: Good to see you.

GARRETT: Mr. Frieden, thank you for joining us. I already gave your introduction, so you don't know how I lied about you. (Laughter.) And I'm just going to throw you a question now that you're on the stage.

One of the greatest heroes of public health, Rene Dubos, was famous for coining the phrase, "Think global, but act local." And in a letter to The New York Times on April 12th, you sent a clarification because it was felt that The Times had misrepresented your position. And you said, "Because circumcision has the potential to decrease HIV transmission by more than half, we hope that men who choose the procedure will have access to it. A campaign to promote circumcision in this country would be premature without stronger evidence, but the time is right for a community-wide dialogue." What did you mean? Could you clarify that?

FRIEDEN: Well, I think, you know, the answer to the question that I saw in one of the flyers about this, "Is circumcision the answer?" is clearly, "No." Can we go home now?

But there are important aspects. It's obviously a very complicated and potentially conflictual discussion. There had been an earlier article in The New York Times that I felt had misrepresented an interview that I gave in response to reporters' questions. And actually the crux -- I listened to the transcript of that interview, and the crux of the misunderstanding was that I believe the reporter had sincerely misunderstood -- I'm often misrepresented intentionally by reporters, but this reporter I think had sincerely misunderstood what I had meant, in that I had said that -- worked out kind of an estimate in New York City of approximately how many men who have sex with men are there, approximately what proportion of them are circumcised or uncircumcised, and what might actually happen. What I said basically was that I very much doubted that even 1 percent of the uncircumcised highest-risk men would consent to and agree to and decide to undergo a circumcision.

And my exact words were, "If a thousand" -- which is about 1 percent of the uncircumcised MSM population -- "If a thousand men underwent circumcision that would be a lot." Meaning I'd very much doubt anything like that number would agree to it.

He interpreted that as meaning that would be a really big public health success. And that's the way he wrote his story. And then he made it as a big initiative, that we were promoting this and encouraging men to get circumcised in this country, and that's problematic because we really -- what I've said is we need to have a discussion, and we've already had one community forum, it was very interesting, in this area.

If men want to get circumcised I would hope the resources would be available. What about people who are insured? Will insurance cover it? What about the uninsured? What resources would be available?

We face situations in our STD clients where we have some men who come back repeatedly with STDs. Is that a population that it would be reasonable to think about in terms of their protection, in terms of also the protection of others?

So I think there's a lot that has to be thought through but there are very tough issues. I came in at the tail end of Mark's comments, but disinhibition is one, access to services is another. Clearly this is not going to make HIV go away.

One of the sad truths about HIV is that it's a terrible epidemic and the weapons that we have to combat it are all fairly weak. Promotion of abstinence doesn't work terribly well. Reduction in sexual partners doesn't work terribly well. Condom use is very hard get extensively used. Treatment of sexually transmitted infections has some potentially impact; however, it's relatively minor on a population basis. Treatment of HIV is a moral and ethical imperative, and terrific work has been done scaling that up. But even if we do so it's not very clear what the impact of that will be on the trajectory of the HIV epidemic.

So we have a situation where we're faced with a very challenging situation and we need to look at carefully every potential intervention that we might be able to use.

GARRETT: Well, let me ask you a sort of sensitivity question. We had a minister of health in South Africa who was very quick to scream and yell if any intervention was made available to Africans that was not considered the state of the art in America, and for that reason, for example, got very upset about a microbicide trial in South Africa.

Here in New York, one of the most prominent founders of Act Up, Peter Staley, recently said, in criticizing you, that promoting male circumcision, quote, "is going to sound like white guys telling black and Hispanic guys to do something that would affect their manhood." When you think about the sensitivity question --

FRIEDEN: Just to -- Peter was not criticizing me. He and I have discussed this issue and actually see fairly eye to eye on it. The challenge that Peter was bringing up is let's suppose that it is found to be protective in, for an example, an MSM context in the U.S. We don't know whether that will be the case or not. I'd be interested in Mark's thoughts about it. If it were, and you were trying to scale it up, which I haven't recommended, you would face really significant problems of distrust of the health-care system, of distrust of recommendations that come from public health.

The community forum that we convened was fascinating in the interests and concerns and objections that people had. And perhaps the most -- one of the most, one of the many interesting things that came out of that discussion was a question that was asked of someone who had been very much -- you know, this is a total wrong direction, it's medicalizing an epidemic; we need to focus behavioral issues. I tried to say, you know, those aren't either or; you can do both. But he was asked by a member of the audience, if male circumcision were found to be protective of gay men, what would you then say to the people that you're representing? And I didn't hear a clear answer to that question. But I think what Peter's highlighting is that it wouldn't be easy; you're dealing with obviously a very sensitive area.

GARRETT: Mark? That was not a (pundit ?).

DYBUL: Well, it is. And I think that's why we get to this, you know, 50 percent. In Uganda we're down to 30 percent say that they're interested in circumcision. I mean it's not something that people automatically think of, and where we're making it available people aren't rushing to it.

We are, however, going to -- we have actually gone to the countries and said, are you interested? And we're going to commit $15 million to expand male circumcision this year in our focus countries, and there are some places that are interested in doing it.

And I think what is hidden in these data is that if you -- it's like anything else. If you circumcise a bunch of people who aren't at risk, you're not going to have much of an impact. If you get to the people who are at high risk, you'll have a much greater impact. And so what we're trying to do is focus the intervention with limited resources on people where you'll have a high impact and in places you'll have a high impact. I think actually at the end I have a slide that might -- .

What this shows is the number of people you need to circumcise based on prevalence. If your prevalence is 0.1 percent, you need to circumcise 1,000 people to prevent an infection, whereas if you have a prevalence of 12 percent, it's eight. So what you're trying to do is get at the people even in those high prevalence areas who are at high risk; people with multiple partnerships and who are engaged. But you have to convince them to do it, and it's not always that easy.

More important is, if you're going to get circumcised, the most important thing to convince someone of is that they're not 100 percent protected. And that's the biggest concern. Tom's right, abstinence and fidelity and condom use haven't turned the epidemic around, but it's done an awful lot and it's done more than circumcision would predict to do with 30 to 40, 50 percent reductions in prevalence over a five-year period. The problem is that you could reverse all of that. We're seeing 50 percent reductions in men's partnerships.

If you look here in Zambia, in the middle, the B component, our B piece, you're seeing men dramatically reducing their partnerships in the past year. If you look in Kenya, with 30 percent reduction in prevalence you're seeing a marked reduction in male partnerships and even female partnerships, as well as increased at age of first sexual activity and some condom use.

So our concern is, if someone thinks they're completely protected, we could start losing those things. And they're important not only for HIV prevention, they're important for gender equality. You could reverse a lot of gains in gender equality we've made.

So you've got to ensure that your prevention messages don't go anywhere because again -- and these are, I think, some of the most important data from Ron Gray, that you could actually override the benefit of your male circumcision if behavior changes, if you reverse some of those important -- reduce partners, delay onset of sexual activity. So whether or not people accept it's an issue, but whether or not they accept that it's not 100 percent protective is a (the next ?) issue.

Most men want to do it because they think they can't get infected. When they start learning, well, it's actually only a 50 percent reduction, 40 percent reduction, then it's going to be even harder to convince them. But more importantly, they need to get that message or we may do more harm than good.

GARRETT: One of the other issues in here, of course, is religious. Tom, you used to work in India, and a good question would be, how would Hindus in India respond to an intervention that is really a demarcation between being a Moslem and a Hindu? And similarly in Western tradition, in Western history, during the Inquisition one of the ways you knew who wasn't a Christian was that they were circumcised.

We have long traditions all over Africa, all over the world of circumcision or non-circumcision having very distinct religious and cultural significance. Is that the kind of water that we want to walk into here? As a matter of foreign policy is this something that we should be messing with?

FRIEDEN: I think that's why we stick with the concept that you provide the information to the individual and then you give -- basically you provide information enough to provide informed consent, and if people choose it, you promote access. And that's basically where we're at it. Very interesting calculation; we've made similar calculations for New York City. We have populations in New York City where one in four males who have sex with males are HIV positive; and one in 10 or one in eight overall.

So you're seeing a relatively high rate, about a third uncircumcised. Then you need to think of, well, what could be the impact. I agree 100 percent with Mark that you have to, above all, do no harm. And you have to figure out how, if you do this, also you don't want to give the message if somebody is already circumcised that you don't have anything to worry about. There are plenty of circumcised men who have gotten HIV. So it's very, very important to get the message right. And it's not simple.

On the other hand, if you're talking about a situation where you could reduce by -- you know, if you look at the actually circumcised, it's a 60 percent reduction in three well designed, well followed up, randomized, controlled trials.

That's a pretty substantial effect. Now, we don't know, would that be the case for the MSM population? Would it be the case -- what's the situation with respect to infection of the woman? That's all female-to-male transmission. The data on male-to-female, as far as I know, and Mark may know more or may have said this -- sorry we were stuck in traffic for the last 45 --

GARRETT: We already went through that.

FRIEDEN: Is not known.

DYBUL: I think the way the question was phrased is an important one. The fact of the matter is if we don't engage with churches we can't do anything on HIV/AIDS in Africa. In Africa in particular, 50 percent of the health care is provided by faith-based organizations. Forty to 50 percent is provided by faith-based organizations.

Their leaders in their communities -- you can go to many communities where you won't find a government or anyone else but you'll find a church, you'll find a tribal leader, you'll find -- so if you don't engage in cultural issues, you can forget about tackling HIV/AIDS prevention, care or treatment.

And we have to do this anyway. We've had to go in and work with churches to teach them that this isn't a curse from God, that it's a medical disease. We've had to teach them that teaching the people in their community about how to protect themselves with abstinence and fidelity and condom use is evidence-based.

As long as you have evidence you can turn things around, so you've got to engage with the churches if you're going to tackle HIV/AIDS prevention in any format. And people have changed. There are polygamous churches that now teach monogamy. I go to conferences with bishops teaching priests and other bishops that this isn't a curse from God, that this is a medical disease just like diabetes.

I've seen bishops say, "II have diabetes, that's not a curse from God, this isn't a curse from God." This is how you engage. This is how you are involved. And the fact of the matter is you're not going to change anything regarding HIV/AIDS, in foreign policy or anything else, unless you wade into the waters of meeting people where they are. And in Africa, that is heavily involving the churches and the tribal leaders and others. So you've got to.

GARRETT: That almost underscores the whole dilemma. Particularly, you take a country like Nigeria. Its overall HIV rate is somewhere in the 7 percent ballpark, but that's heavily skewed to the south, which is Christian, and it's very, very low in the north, which is Islamic. If you walk into a -- the north is also circumcised, the south woefully not circumcised.

Now you walk in and start talking about let's do large-scale circumcision as an HIV intervention in the south of Nigeria, and you're walking right into a potent religious tension. Is that a place where we have any business?

DYBUL: Absolutely, because that's where the data are. So if we're going to do public health you have to follow the data. And you have to follow the evidence.

It's just like talking about refraining from sexual activity and being faithful and using condoms. That's evidence. You got to follow the evidence. And that's -- or you're not going to change anything. So you either walk away from it or you don't -- or you do get engaged. And we have to engage. So, yes, there are issues, but we've learned that this is why what we're doing in PEPFAR is so important.

You've got to get in the country and work shoulder to shoulder with the people who are there, build the trusting relationships, work with community organizations, work with the leaders there, and that's how things change. You can't do it from Washington, that's for sure, but you can do it in the country. And if you don't, you're not going to change anything. So yes, there are cultural and social issues.

You know Dar es Salaam is heavily Islamic and we're starting to see a lot of infection. So it's not as if being Muslim's going to protect you from this. And we're trying to get the faiths to work together. There are now some interfaith groups that come together and talk to each other.

You know, our approach is -- people like to talk about morality around our policies and -- we just follow the evidence. And if you follow the evidence you can go and you can change people's practices. And we've seen it over and over again. We've seen churches change from polygamy to monogamy when they see the data.

We've seen governments -- you have to do this with governments, too -- accept rapid tests and accept using opt-out testing. I mean if you show people data and you go through the public health reasons to do things, you can actually see these changes.

So yeah, it's difficult, but foreign policy is a difficult thing and public health's a difficult thing, and your choice is to either engage or let people get infected.

GARRETT: Bill Gates was taking note of the fact that about 70 percent of new infections in Africa are in women, and said, quote, "A woman should never need her partner's permission to save her life."

The whole male circumcision issue has raised a lot of hackles from women's health activists around the world because there is no demonstrated proof that there's any significant difference in heterosexual transmission with or without a foreskin. And also because if indeed male circumcision is going to be performed on a large scale by health practitioners -- skilled, qualified individuals -- then in places where the health personnel are so severely scarce and where the deficit is so severe, that would seem to imply other health services will pay a price.

Will we in countries that already have a lowered maternal mortality rate -- I mean a rising maternal mortality rate, will we see that even worsen more because the personnel that might have addressed it are busy doing male circumcisions?

And the way Joanne Csete, the prominent Canadian human rights activist, put it, her questions went like this: "Will resources found for scaling up male circumcision include major support for reducing women's vulnerability to HIV, including reducing violence against women, strengthening women's capacity to demand safer sex, and supporting greater economic autonomy for women; or will scaling up male circumcision reveal even further and perhaps exacerbate the gender inequalities that so effectively feed this destructive epidemic?"

DYBUL: I'm not sure that's much of an issue in New York, but --

FRIEDEN: Well, certainly women's empowerment is. And I think one of the concerning aspects of some of the objections is the perspective that there's an either/or between behavioral and medical interventions.

In Africa you've got an issue of too few surgeons and there are actually some very effective ways to scale up effective interventions, surgical interventions, that have been studied in several African countries, including Mozambique and Tanzania and a couple of others, where you can get excellent results on maternal mortality issues working with highly trained and well supervised and supported non-medical medical officers versus medical officers.

But the broader issue of female empowerment is crucial to reducing the risk of HIV in many communities, and New York City is no exception to that. But I think by in large the issues do relate to international issues.

DYBUL: And I think the biggest issue of those is will we change men's behavior? Will they think they're protected and not continue to reduce their partnerships? That impressive data from Kenya and Zimbabwe. Will they not reduce their partners by 50 percent? Will they not delay their sexual activity? And this is very important to me.

You know condom use has gone up in a lot of places, but in regular partnerships -- this data I'm showing you right now -- has never gone up. So men won't use condoms in regular partnerships; in fact, most women don't want them to use them. So if men think they're protected and they're having multiple concurrent partnerships, and they're circumcised and they won't use a condom, you're in tough shape. So I think we've got a very difficult situation.

I can't see how it would impact microfinance or other programs. I don't actually see much of an impact on child survival and health. You know, in the 15 focus countries we've seen gains in infant mortality despite all the deaths. The one exception was Botswana briefly, and it was all attributed to increased infant mortality from HIV/AIDS.

Now we're seeing a decrease in infant mortality because the mothers are staying alive. And, you know, when a kid's orphaned they have a three-fold risk of dying. So almost all those increases in infant mortality were directly related to HIV, and we're seeing them reverse as prevention and treatment is taking hold.

We're also seeing something fascinating. There's been this assumption that if you concentrate on AIDS you will actually draw from the health sector. Well, there was a study done in Rwanda, actually recently, looking in a section of Rwanda. And they looked at 22 non-HIV health indicators in a place where HIV was focused on and increased over a six- month period. Twenty-one of 22 went up significantly. With regression analysis actually five were directly -- because of AIDS they went up, including family planning and antenatal care. And this actually makes sense, which I'll explain. And another seven were indirectly related to the HIV increases.

What's happening is you're actually building an infrastructure where there was none. You're putting in complete blood counts; you're putting in x-ray machines. You're putting in and training health personnel and putting in established monitoring and evaluation systems. You're building an infrastructure that's spilling over. And we know this in research. We've seen for years that people participating in clinical trials have much better health even though they're not getting anything in a placebo. And the reason is they're in a health system that's growing and has a lot of care and monitoring and evaluation. And that's what we're building. So it's having a spillover effect and actually increasing.

So I don't know that dedicating resources to circumcision will have any affect on maternal child health itself. We're seeing actually maybe it could increase it. The more you train people, the more you get people engaged in the system. We don't have a lot of surgeons engaged now. If we got more surgeons engaged in an accountable system, maybe that would improve it.

I don't see it having an impact on microfinance, because it's a completely different funding stream and I don't think would have an impact.

But I do worry very much, and I think many people do, about will we change men's behavior. And that does have an impact not only on HIV/AIDS for women; it has an impact on gender equality. And that's the piece, I think, we're all very -- that's why you've got to continue to teach people basically that, you know, reduce your partners, don't have sex until later, or don't have sex if you can refrain from it, and use a condom.

So you've got to put all that stuff together or we will have a problem.

GARRETT: I want to give the audience a chance to get involved in this discussion, but let me just make one last comment, only because Dr. Allan Rosenfield very much wanted to be here today but unfortunately has had another health setback. And so he asked me if I would make this comment on his behalf.

Allan Rosenfield is the dean of the Mailman School of Public Health at Columbia. During the Korean War he was an Army physician, and apparently because of infections among the prostitutes in Korea during the war there were quite a lot of problems that involved penal infections that led to circumcision in adult soldiers. And he performed many of these procedures.

He said that he had cases where the men simply would not wait four to six weeks post-operation before engaging in sexual activity again, and that in one of these cases the tearing was so severe, and the infection, from an individual who went out and had sex two days after surgery that he thought the fellow might actually lose his penis.

So, thinking about this and imagining some of the health-care settings that we're talking about and the level of understanding, what's the take-home lesson for you? I'm thinking about, gee do we want to again get into funding these sorts of procedures.

DYBUL: Well, again it's a deep concern, and actually there are some troubling data that men will have sex earlier and they're actually more -- they could actually increase the transmission rate to young women because they're -- they have more openings to let the virus out. So we need to be very careful about that. Which gets back to you've got to teach the behavior change and ensure that places there the -- basically, you know, reduce your partners, abstain, or condom use, regardless. And that's what we're most worried about.

But there are certainly risks to this procedure, and that's why we're saying it's got to be done in a medical approach, it's got to be done carefully. But on the other hand, it's something that if we don't engage in -- yes, it doesn't have this massive impact but it has some impact. And the fact of the matter is that behavior change alone isn't going to get us to zero prevalence, and people will change. We need as much as we can get, which means we've got to push things where the evidence are. But do it carefully. Do it very carefully.

When there's pre-exposure prophylaxis we're going to have to do the same thing if that's proven to be effective. We've got to teach people the basics about what they are and aren't being protected by. That's just the trials of public health. But because there are problems doesn't mean not to do it, because some people will smoke even though you tell them not to or get --

FRIEDEN: Not in New York.

DYBUL: Not in New York, yeah. (Laughter.)

Public health is tough, whether it's -- behavior change is tough. These medical interventions are tough. So some people won't do it well but that's unfortunately going to be -- that's a part of public health. It's a messy business, but it doesn't mean we shouldn't do it. But you've got to do it carefully, you've got to do it in settings where it is culturally appropriate, you've go to -- but our concern is this is not a silver bullet. It is a piece of a puzzle to enhance prevention. It's not the thing that's going to change radically the world.

GARRETT: It's not the vaccine.

DYBUL: It's not a vaccine.

GARRETT: Okay, I'm going to open up for questions from the audience. I have a couple of quick rules of the game here.

One, wait for the microphone to get to you. I mean, raise your hand and don't start talking until you have the mike. Please identify yourself and, you know, let's not have speeches, let's actually ask some questions.

So do we have any questions? Over here.

DYBUL: We get to give the speeches.

QUESTIONER: I'm Adrienne Germain from the International Women's Health Coalition. And actually until your last sentence, Ambassador Dybul, you had done a pretty good job of dissuading, I thought, all of us from investing in male circumcision.

My question is the following. That why, when the prevention resources under PEPFAR are such a tiny amount, 20 percent of the total, and so many of those prevention resources are earmarked for particular interventions, would you chose to go down this road and at the same time withdraw funding for the female condom from Cameroon, where the demand for that commodity has risen so sharply that they can hardly keep up with the demand? And it's very clear that in the circumstances that girls and women face there, the condom is a real choice that helps a lot of them protect themselves and their partners.

DYBUL: Well, Cameroon isn't a focus country, so I don't know what's going on specifically with that but we do fund a lot of female condoms, and we wouldn't defund them unless there were a reason. Either there are budgetary constraints or someone else picked it up. Frequently there's rotation for who pays for condoms. So I don't know what the circumstance is there, but it wouldn't be -- we've provided 1.3 billion condoms.

As Peter Piot said recently, the United States government provides more condoms than the rest of the developed world combined. And that's what we're doing under the emergency plan. Specific circumstances where things change, I don't know. I'd have to look into it. And it's male and female and we do it in a demand-driven way supporting the local strategy. And there's usually groups that get together to decide who's going to pay for what and how it works out.

So I don't know the situation in Cameroon but we do support condoms in a huge way. But unfortunately, condoms alone aren't going to do it. There is some great data for you, actually.

This is Botswana. Botswana has one of the highest rates of condom use in the world, 80 percent. You see a spike in the yellow. At the same time the prevalence went up and increased to 40 percent. The reason is you need all three components across the board, so we do fund all three components, the ABC. We prevent mother son -- mother-to-child transmission. We fund male safe blood. We fund everything for prevention.

Now, it is 20 percent, but that's because treatment is more expensive, in general, it's about 23 percent. But if we -- if other things come up that are more expensive we'll just have to shift those percents and work with condoms to -- Congress to shift the percent.

So that's why we're leaving it in a country-driven way to determine what pieces they should and shouldn't pick up. But if you can reduce prevalence by 20 percent over a 20-year period that's not a bad thing, that's a pretty good thing. But we're leaving it up to the countries to decide. There are definitely pressures on the budget. We can't fund everything that we want everywhere in the world. It's not possible.

And I don't want to dissuade people from condoms -- I mean from condoms or circumcision for that matter. Circumcision is a piece of what we should be doing. It's $40 per circumcision. This is not a highly expensive thing; its $40 to $50, including all the behavior-change messaging that goes in.

That's a fairly cost effective means, particularly if you're targeting the highest risk people. So we need to do everything. You need to fund -- you absolutely need to continue to fund all those prevention programs. You may need to increase your percent of your work on prevention as more expensive technologies come in, but that's a decision we generally leave to the local environment.

But we do focus on what works and our dollars follow what works, which is reduce your partners, abstain as long as you can or abstain completely, or if you were active get out of it; use condoms when you have sex, do prevention mother and child during -- we find everything that works and so that's why our dollar amounts are distributed the way they are.

But there's no question, we can't do everything that needs to be done, particularly in non-focus countries. Right now the United States government is providing as many resources as the rest of the developed world combined. As long as that's the case anyone in this room can come up with a gap somewhere in prevention care, particularly when you get outside of the focus countries where our resources aren't high enough. And until the rest of the world responds the way we do, we're not going to tackle any of these problems for prevention, care or treatment.

GARRETT: I saw a raised hand here.

QUESTIONER: Thank you, Laurie. My name is Bunmi Makinwa. I work for UNAIDS in New York here. I'm not actually raising this question on behalf of UNAIDS at all. It's a personal question.

I just heard Ambassador Mark Dybul explaining, more perhaps in response to the question raised by Adrienne, that it would appear, as one hears on many occasions, that the argument against circumcision seems to override the arguments in favor of circumcision or the fact that circumcision actually has something to offer that we should do.

One sees that in many of the published literature to date, in many of the statements made by various organizations, and it is almost impossible to leave here so far tonight without having the same impression.

Is it the case that there's so much danger in circumcision that we don't want to exploit the possibilities? Or is it possible that in spite of these dangers there's something that it can offer and that we can combine the -- we can make the case for circumcision much stronger by allotting the organizations, policymakers and programs to making sure that whiles we are advocating for circumcision, we ensure that the dangers are reduced as much as possible? Is there a way to make that argument?

DYBUL: Yeah. I think there're absolutely -- that's the argument I'm trying to make. I'm not that fatalistic about people's ability to actually change their behaviors. If you teach people the facts, many of them will actually act in an appropriate way.

These are data from Thailand, the marked reduction in number of men who use prostitutes and the use of condoms within them, behaviors that many people thought were not possible. Is it possible for people to not use a prostitute? Absolutely! They did it because they were taught that that was the right thing to do to protect themselves.

Same thing again, in Kenya, where people are refraining from sex for longer periods of time, refraining from multiple partnerships, and using condoms.

Same thing from Zimbabwe. We see this in Zambia. We see it all over sub-Saharan. I'm not that fatalistic about people's ability to change once you give them information. Public health is based on that. Smoke -- anti-smoke -- all our campaigns are based on the educability of people, the intelligence of people to make decisions. And the fact that some of them won't do it isn't a reason to not act.

GARRETT: Let me follow up -- let me take what Bunmi was asking and go a step further. And this will go to both of you.

If you're talking about a voluntary procedure and I'm part of the wealthy class in my society and I'm a man, I can make that choice and I can afford to have it done properly and pay for it. So I have that option of seeing it as an additive level of protection for myself and maybe for my spouse, we don't know. Right?

DYBUL: Mm-hmm.

GARRETT: But if I'm from the underclass, if I don't have the financial resources, I don't have, in this country, health insurance, I can't get circumcision paid for. Then what -- in terms of thinking -- I think this is what you were trying to get at -- in terms of thinking of it as an additive level of prevention, making sure people understand it's not the answer, it's not the vaccine, we're in danger of creating a class-based level of access to this 50 or 60 percent additional protection.

FRIEDEN: I guess to start, if you look at what happened in the U.S. after 1999, when the American Academy of Pediatrics went from recommending circumcision to basically saying "No opinion," you saw a drastic reduction in the number of states that include circumcision in Medicaid benefits, and the most recent evidence suggests a pretty substantial reduction in circumcision in the U.S.

Now, there are clearly health benefits to circumcision. There are also people who are going to say, "No, it's not for me." And that's totally fine. But at least you should think that if someone wants to go through circumcision, whether it's infant circumcision or as a means of preventing HIV, you would hope there would be full access to that. And that's what I've been saying from early on in this.

Again, the numbers are not likely to be terribly high for adult circumcision in New York City, but if you think about the potential impact it's not nil. And in any one individual it may be significant, though clearly the avoiding the disinhibition is extremely important.

DYBUL: The class issue is an important one; it's a good thing to raise. And actually some countries are thinking long term and saying, why don't we do infant circumcision, because AIDS is going to be around for a long time and it's a lot easier and it might be a way to do it, get people used to it.

And some tribes actually did it 50 years ago, circumcised everyone. And then the Europeans came and taught them it was the wrong thing to do. So there's a history there too. So we might be able to go to infant circumcision.

But I think the class thing's a real issue. At least for us it's not an issue because that is just like treatment. We would expand it for everyone available, and certainly where it's been done so far, Swaziland, for example, and parts of Kenya and parts of South Africa, it wasn't based on class and people had access to it.

So it's important to get the education out so it's not just for some and not for others, and I think that's a very important point. It would have to be available in a similar way. It would have to be available -- we'd have to scale it to (sites ?), as we're doing with treatment, so that people have access to it across the board.

But you're absolutely right, it's got to be something that's equitable. And that would be something we would strive to do, to not just have it in the tertiary hospitals in the cities where only people who knew about it could get to it.

QUESTIONER: I'm Henry Greenberg, a cardiologist with an interest in global health issues. As I listened to this discussion, I'm really quite impressed with the complexities of adult circumcision. And every time anyone answers a question or asks one, the complexities increase. And Ambassador, you just touched on the issue of infant circumcision.

Where in all of this discussion is that? I mean isn't that in a sense the way to change behavior, by inculcating that concept? And since HIV is going to be here for decades, that would have a much better impact long term than a policy wrought with conflict and complications. And yet no one's discussed this; it was just sort of an afterthought you mentioned, you know, an hour into this discussion.

DYBUL: It actually is being discussed a lot in the countries about whether or not they ought to move towards infant circumcision as well. I mean, look at this graph. We're going to see an impact in 10 years if we try to scale up now in adults. Add to that infant circumcision, you're talking about 20 to 30 years.

Now, it doesn't mean we ought not to not do it. Maybe we should, because it's quite possible we're going to have this around. Unless we come up with a vaccine we're going to have this around. And even then we're going to have a lot of infected people walking around.

So I think you need to do -- again it's not either/or. And some countries are looking at both, some -- but those who want to dramatically reduce their prevalence now or have an impact now in an additive way are looking at adult circumcision as well.

And in a country like Swaziland, with 38 percent of the adult population infected, you need to do everything you can to reduce that prevalence now and to save peoples lives now. And so long term and short term comes into play. And people are talking about infant circumcision. There may be places where that actually begins first because people are more willing to accept it.

GARRETT: Over on this side. Over here.

QUESTIONER: Hi. My name's Amy Nunn. I'm from the Global Business Coalition on AIDS, TB and Malaria. And my question's for both panelists. I'm wondering what, if any, should the private sector role be in scaling up this intervention?

FRIEDEN: Well, in the U.S. it's pretty straight forward. We would like the insurance industry to cover circumcision among adults. I think if it's done it should be covered. In terms of private sector, as you would know well, and Mark can outline in much more detail than I, there are a lot of broader issues with HIV prevention. The private sector can be critically important.

DYBUL: Well, private sector has multiple parts. There are foundations, Gates and other foundations that can be active in this regard to help scale programs, to do monitoring and evaluation. We need as many partners as possible here.

And then corporations, I don't know, I haven't really thought about what corporations could do, that people make scalpels and gloves. You need -- as Laurie rightly points out, there is a lot of blood here, and so your normal precautions need to be in place and they aren't everywhere, so we could have groups that help with that. I hadn't really thought about it, but it's something to think about.

But certainly the private foundations piece we've thought about. We've already been talking with folks about how we could leverage each other and work together. And we've also talked with some of the other big bilateral contributors to talk about what we could do together.

GARRETT: Over here. Wait for the mike, please.

QUESTIONER: Phil Gates, lawyer. I want to know -- and perhaps everybody here knows more than I -- about what is the death rate. What is the cost to us of HIV in, say, Africa and America? Is it enormous? Are half our hospital beds full of it, or what?

FRIEDEN: Well, Africa's much more heavily affected than New York, but New York City remains the epicenter of the AIDS epidemic in the U.S. We continue to lose close to 1,500 people a year from AIDS, mostly young people in their 40s.

New York City has a rate of HIV that's many times the national average, and we're so far above where the national targets are. The cost economically is in the many billions of dollars, and the cost of human lives is enormous. And it's also the most disparate, the most unequal of all health conditions in New York City. So the risk of dying from AIDS is six times as high if you're black then if you're white, or if you're poor than if you're rich.

It's a terrible epidemic that we need to do whatever we can to reduce. And I really would reiterate or agree completely with what Mark says about we have to go where the data takes us. If things are proven to work, we have to figure out a way to scale them up.

DYBUL: The question about the cost of death, I think, is an important one because I think we're losing sight of it. You know, 25 million people have died -- 25 million people have died from this disease. Thirty-nine million people are living with it, 60 percent of them in sub-Saharan Africa.

When you talk about Africa there's something unique here. It's unique everywhere, but this disease disproportionately kills 15-to-40 year olds, disproportionately. You've got 38 percent of your adult population infected in some places. These are people in the most productive and reproductive years of their lives. That's different than any other infectious disease. It's different than most diseases like cancer and other things.

So when you talk the impact of that many lives, we're losing a generation of parents, and we know that kids have a three-fold greater chance of dying from all causes if their parent dies.

We're losing a generation of teachers. Teachers are disproportionately infected, two-fold. So even if the kids -- even if the orphan lives, we don't have anyone around to educate them.

We're losing the people who are producing an economy. UNAIDS estimates that the worst-hit countries are going to have a 20 percent decline in their gross domestic product. World Bank has said while the rest of the world is growing, Africa risks leaving left behind. So now you've got a generation without parents, teachers, and no one to create an economy.

And then you're going to need peacekeepers to keep the peace. Africa has 37 percent of all peacekeepers that the U.N. has. South Africa just tried to field a battalion for a peacekeeping; they couldn't field a battalion that wasn't impacted by HIV/AIDS. Forty percent of Malawi's military is dying from HIV/AIDS. Two-thirds of the new teachers in Zambia are dying from HIV/AIDS.

I mean how do you have a society when all of the -- it's rending the social fabric because it's killing those 15-to-40 year olds. So the cost of death is basically the destruction of a society. And if you don't stop that through prevention, care and treatment, all three, if you don't stop that, Africa can't pull itself out of destruction and despair. It's that simple.

And that's why the emergency plan is so important, to get in there and reverse that. And it's happening. It's happening. And it's extraordinarily hopeful. All that despair has been turning to hope. But that's the cost of death.

GARRETT: We'll have the last question. I saw a hand over here. One of you two, right there. You two decide. (Laughs.)

QUESTIONER: I'm John Bongaarts on the Population Council.

It seems to me -- I agree with Adrienne that you've given a fairly negative assessment of male circumcision. And perhaps you're right. But if that is the case, why is there two orders of magnitude difference in the epidemic in Africa? North Africa, a fraction of adults, 1 percent of adults is infected; in South Africa, 20 to 30 percent. If it's not male circumcision, then what is it?

And it seems to me that what's missing from your discussion and from the simulation is what Laurie referred to, the herd immunity effect. In epidemiological terms, if the reproductive rate of epidemic is above one, it explodes. If you can bring it down below one, it will die out. Maybe male circumcision can just move it from slightly above one to below one and the epidemic will die out.

DYBUL: Well, here are the mathematical predictions by the World Health Organization of what happens if everyone who's eligible for circumcision gets circumcised. This is their mathematical estimates. The same mathematical estimates have been done by others. It doesn't have the herd impact because you're not going to get the impact that you think you're going to get from the data that are available, and that's men only.

So I'm not trying to give a negative piece on this, what I'm trying to -- in fact I think -- we are doing it. We've got $(15/50?) million going to it this year, and we'll scale it up where people are willing to do it because you have to do everything you can. But it's not a silver bullet. It's not going to have a vaccine effect. It's something we need to do, but we need to do it carefully.

And there's a big difference between saying epidemiologically people who are circumcised have less of a risk than saying therefore if we can scale up male circumcision in 15-year olds to 40-year olds, that will have that same impact.

We found the same thing with acyclovir, right? People with herpes have epidemiologically a much higher risk of infection. The studies are showing that actually the acyclovir intervention isn't changing the transmission rate much at all, although the studies aren't done.

So there's a big difference from epidemiology to an intervention that will lead to the impact. And that has to do with human behavior, scaling up, all the things Laurie mentioned.

So I'm not trying to say we shouldn't do it. We're doing it. We're absolutely doing it. But it's not going to turn the epidemic around, it's going to be additive to everything else we're doing. It's something we need to do, and we need to keep all the work on vaccines and microbicides and everything else because this isn't going to solve our problem.

But it will help. It will help. And so we need to do it and we are going to do it. But we need to be eyes wide open about what you need to do around it and the real impact.

GARRETT: One of the things I want to draw to your attention. I hope you all got the handout. The last page of it is a list of more discussions along these lines that we have organized that will be coming up. You will have to RSVP for them if you're interested in attending.

Common thread, and something that came out of today's discussion repeatedly, is having a technological tool in and of itself is not good enough. You have to understand the social context of its use, the economics of its use, the actual clinical outcomes, the behavioral outcomes and try to understand why certain things that look like they would work very, very well have not received attention from our U.S. foreign aid budget. And that's one of the whole themes that we're going to be looking at with this entire series.

Bringing that series together involved a core group of outstanding members of the Council. I'd just like to thank them because they were also involved in helping to prepare tonight's event. Michael Darbello, Laura Efros, Sheri Fink, Michelle Forrest, Ella Gudwin, Jordan Kassalow, Puneet Sapra, Kirstin Tarcoon (sp), James Tunkey, Betsy Williams and Brett Zbar. Thanks to all of you.

This has been an absolutely marvelous discussion. I think we really did hit the full gamut of issues that are raised by this of potential intervention to slow the spread of HIV/AIDS. And I want to very much thank Commissioner Frieden and Ambassador Dybul for joining us tonight.

Thank you all. (Applause.)

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