1. Religion and Male Circumcision for HIV Prevention R. Frank Gillum, MD Howard University College of Medicine Stefan Livingston, MPH M. Haider, PhD University of Maryland School of Public Health

2. The ABC approach to HIV/AIDS prevention  Abstinence  Be faithful (partner number reduction)  Condoms

3. Is a new C needed in ABC  Circumcision of males –Newborn –Adolescent –Adult

4. Evidence for adult circumcision  In observational studies, circumcised men have lower prevalence of HIV infection than uncircumcised men  In randomized clinical trials in Africa, HIV seroconversion rate over 2 years was reduced by 60% by adult circumcision

5. Results of a meta-analysis of African randomized trials of circumcision (adapted from Mills et al. HIV Medicine 2008)

6. Barriers to widespread adult male circumcision in Africa  Cost  Lack of trained operators/equipment  Pain and discomfort  Cultural factors  Complications  Possible increased risk taking afterwards

7. Should newborn circumicision be promoted in African American high-risk communities?  Cost for ininsured  Infant pain and suffering  Infant human rights  Complications  Other health benefits controversial

8. Religious issues  “Circumcision is a procedure inextricably bound with religion.” Chatterjee  Islam, Judaism, and many traditional/tribal religions mandate male circumcision

9. Religious issues  In Africa, male circumcision is the norm in Islamic populations  Usually performed in adolescents because of indigenous customs  May be performed in infancy or childhood, but must be performed before marriage  HIV prevalence rates are low in Islamic populations

10. Religious issues  Male circumcision as a rite of passage to adulthood is practiced in many African ethnic groups (e.g.W. Dinka, Kikuyu, Maasai, Yoruba, Igbo)  But not in others (e.g. E. Dinka, Lesotho)

11. Religious issues  Among African Christians, only Coptics mandate male circumcision  About 40% of health services are provided by Christian organizations in subsaharan- Africa (higher in rural/lower income areas)  Are faith-based organizations promoting male circumision for HIV prevention?

12. Religious issues  We conducted a preliminary study of a random 20 CCIH member organizations. Websites were reviewed  16 had websites  10 had ministries in Africa and 2 in Haiti  1 made any mention of male circumcision for HIV prevention (Presbyterian USA)

13. Religious issues  Brown and Michemi described church- related male circumcision programs in Kenya in a 2003 ICASA presentation.

14. Church and MC in Kenya Presb yterin 300/yMeru Nov - Jan Surg tech Gosp el VarKalenjinVarTrad Presb ytern 300KikuyuVarBoth Evang1700 Luhyia/K alenjin Aug Nov Trad

15. Religious issues  Three of the four programs included instruction of boys on HIV prevention  Two did large numbers during a boys’ rite of passage retreat during school holidays following primary school completion using physicians or medically trained circumcizers

16. Religious issues  Consultations among FBO’s should address the following questions:  Should FBO’s promote voluntary adult circumcision, rites of passage circumcision, both or neither in Africa or elsewhere?  Are there model programs that can be adapted/replicated?  Should programs have a faith component?

17. Religious issues  Can these barriers be overcome?  Cost  Lack of trained operators/equipment  Pain and discomfort  Cultural factors  Complications  Possible increased risk taking afterwards

18. Religious issues  Unwillingness of churches to be associated with rites associated with indigenous religions and Islam  Preference for Abstinence/Be faithful programs only

19. Religious issues  Conclusions  Involvement of FBOs with male circumcision to prevent HIV transmission is not widespread  FBOs should discern what role male circumcision will play in their response to the HIV/AIDS pandemic in Africa and elsewhere

20. Thank you

21. Number (x 10 4 ) and percent of male newborn infants circumcised in the US, 1980-2005