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Hesitations and reservations: an analysis comparing past concerns regarding antiretroviral therapy (ART) roll-out with current apprehension over the scale-up of medical male circumcision (MC) for HIV prevention
M. Marco, W. El-Sadr
International Center for AIDS Care and Treatment Programs (ICAP), Columbia University Mailman School of Public Health, New York, United States
Background: While current wide-spread roll-out of ART in resource-limited countries has demonstrated early successes in markedly decreasing HIV morbidity and mortality, it was only a few years ago when there were numerous concerns raised about embarking on providing ART in these settings. Twenty years of ecologic and observational study data revealed strong protective effects of MC against HIV infection, and three randomized controlled MC trials-the first published in 2005-demonstrated a 50-60% reduction in HIV acquisition in circumcised men. And yet, scale-up of MC has been limited to date. An analysis of ART roll-out could inform current concerns and reservations in the scale-up of MC.
Methods: A systematic review of peer-reviewed literature was conducted analyzing editorials and commentaries regarding ART roll-out and MC scale-up from 2000-2008. Arguments for and against swift implementation of ART and MC were then categorized according to shared thematic areas.
Results: Our analysis established that similar arguments were voiced regarding ART roll-out and MC scale-up. Concerns comprised 8 main domains critical to the contemplation of scale-up and roll-out: 1) weak health care infrastructure, 2) cost of programmatic implementation; 3) cultural constraints; 4) perception as alien or “western medicine;” 5) lack of trained healthcare workers; 7) adherence with instructions; and 8) behavioral disinhibition post ART initiation or MC.
Conclusions: Current concerns against MC implementation programs mirror those raised with ART roll-out. Largely, past reservations regarding ART roll-out have not materialized. Mobilization similar to that which made possible the success of ART scale-up will be necessary to enable and garner the benefits of MC in the global battle against HIV.
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