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INHERENCYGENERAL
INHERENCYAIDS
AIDS IMPACTS
SOLVENCYCIRCUMCISION
SOLVENCYINFRASTRUCTURE
SOLVENCYU.S. KEY

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CONTENTION ONE: INHERENCY


EVERY MEANS OF CONTROLLING THE SPREAD OF HIV IN
SUB-SAHARAN AFRICA HAS FAILEDMALE CIRCUMCISION
IS EFFECTIVE BUT THE DEMAND FOR THE PROCEDURE HAS
OUTSTRIPPED SUPPLY
NEW YORK TIMES 4-28-2006
JOHANNESBURG, April 27 For well over a decade, southern Africans have battled
the spread of H.I.V. with everything from condoms and abstinence campaigns to doses of
antiretroviral drugs for pregnant women and yet the epidemic continues unabated.
Now a growing number of clinicians and policy makers in the region are pointing to a
simple and possibly potent weapon against new infections: circumcision for men.
Armed with new studies suggesting that male circumcision can reduce the chance of
H.I.V. infection in men, and perhaps in women, health workers in two southern African
nations are pressing to make circumcisions broadly available to meet what they call a
burgeoning demand.
The validity of the approach is still being tested. But in Lusaka, the capital of Zambia,
surgeons at the University Teaching Hospital began offering circumcisions for about $3
some 18 months ago and are urging the government to expand the service nationwide. Dr.
Kasonde Bowa, a urologist at the hospital, says about 400 patients a month request the
procedure eight times as many as the surgeons can accommodate.
"One reason we decided to set up this service was the increasing evidence in the research
in relation to reducing H.I.V.," the virus that causes AIDS, he said. "The evidence is very
strong."
In Swaziland, the Health Ministry backed a workshop in January to train 60 doctors in
circumcision, responding to what it called a surge in demand. Studies indicate that
circumcision may protect against H.I.V., the ministry said, adding that the service should
be more available.

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USAID HAS SUCCESSFULLY SUPPORTED PROGRAMS FOR


MALE CIRCUMCISION IN AFRICA, BUT FUNDING HAS BEEN
WITHDRAWNRESTORING FINANCIAL SUPPORT IS
CRITICAL TO SUCCESS
WASHINGTON POST 10-13-2006
The Bush administration has decided to end its funding of a groundbreaking program that
has sought to curb the spread of HIV by offering subsidized circumcisions to men in
Swaziland.
A statement issued Thursday night by the U.S. Agency for International Development
said that it had only recently learned of the program and that it violated government
policy supporting study of circumcision but not services offering the procedure.
More than 300 men have been circumcised in the past 12 months at the Family Life
Association of Swaziland clinic in Mbabane, the capital of the southern African country.
A growing body of research has shown that circumcised men are less likely to contract
HIV, the virus that causes AIDS, which has infected an estimated one out of three Swazis
between ages 15 and 49.
USAID contributed $149,285 to the program last year but did not renew it for the coming
fiscal year, said Dudu P. Simelane, deputy executive director for the Family Life
Association. She added that the decision against renewing the funding, part of the Bush
administration's $15 billion anti-AIDS program, did not come as a surprise but that new
donors had not yet been found.
"It's best we try by all means to continue, but funding is the determinant," Simelane said,
speaking from Manzini, Swaziland, where the group is based. "We wouldn't like to stop,
really."
In its statement, USAID said the funding "should not have occurred, and there will be no
further circumcisions performed with U.S. Government funds until the PEPFAR
Scientific Steering Committee reviews data from ongoing clinical trials and considers any
recommendations on male circumcision from the normative international Agencies."
PEPFAR is the Bush anti-AIDS program.

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AIDS IS PREVALENT IN SUB-SAHARAN AFRICALACK OF


CIRCUMCISION IS A CRITICAL REASON
NEW YORK TIMES 4-28-2006
So far, southern Africa's H.I.V. infection rate, the world's highest, has resisted efforts to
lower it. Only three sub-Saharan countries Kenya, Uganda and Zimbabwe have
shown declines in the prevalence of the virus among adults, according to Unaids, the
United Nations agency devoted to curbing the epidemic.
Of the nearly 5 million people worldwide who became infected last year, 3.2 million live
in sub-Saharan Africa, the agency said.
Daniel Halperin, an epidemiologist and H.I.V. specialist in Africa for the United States
Agency for International Development, argues that low rates of circumcision and high
rates of multiple, concurrent sexual partners are the main reasons that the AIDS epidemic
has raged in southern Africa but left western Africa mostly unscathed.
According to a study Mr. Halperin published in 1999, seven southern African countries,
where fewer than one in five men were circumcised, had H.I.V. prevalence rates in adults
of 14 percent to 26 percent in 1998. In nine western African countries, where more than
four in five men were circumcised, H.I.V. prevalence rates were below 5 percent.
Researchers have suspected since the 1980's that such patterns are more than coincidence,
and while the topic has long been a controversial one, many experts say the bulk of
studies suggest that circumcision has at least some protective effect.
An analysis of data in 2002 cited by the Agency for International Development found that
38 studies, mostly in Africa, appeared to show that uncircumcised men were more than
twice as likely to be infected than circumcised men.

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CONTENTION TWO: HARMS


SUB-SAHARAN AFRICA IS THE EPICENTER OF THE GLOBAL
AIDS EPIDEMICMILLIONS DIE EVERY YEAR
OLUBOMEHIN AND BALOGUN 2005 (O. O. Olubomehin and W. A. Balogun The
United States of America and the War Against HIV/AIDS in Africa, West Africa
Review: Issue 8, 2005)
These comments of James Wolfensohn and Stephen Lewis echo and aptly capture the
concern of many about the AIDS situation generally in the world and particularly in subSaharan Africa. Twenty-three years after the first clinical evidence of Acquired
Immunodeficiency Syndrome popularly known as AIDS was reported in the U.S., it has
become the most devastating pandemic humankind has ever witnessed.3 AIDS has
killed almost 14 million people around the world, 11 million of who lived in SubSaharan Africa. In year 2000 alone, 2.4 million died from the effects of AIDS in SubSaharan Africa. This is 80 percent of the worlds total. Indeed, two-thirds of the 34
million people who are currently infected with AIDS live in Sub-Saharan African,
including 1million children.4 As noted by the World Watch Institute, the HIV epidemic
raging across Sub- Saharan Africa is a tragedy of epic proportion.5 It is not only a health
but also a development crisis; one that is altering the regions demographic future,
reducing life expectancy, raising mortality, lowering fertility, creating an excess of men
over women, and leaving millions of orphans in its wake.6
At the end of 2000, 36 million people were living with HIV/AIDS worldwide. Of these,
some 25 million (or 70percent) were living in sub-Saharan Africa, even though only a
tenth of the worlds population lives in the region. South Africa has the highest number
of infected people of any country in the World, estimated at 5.3 million. Here, no fewer
than 5,000 babies are born HIV positive every month.7

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THE IMPACT OUTWEIGHS ANY DISADVANTAGEAIDS KILLS


HUNDREDS OF MILLIONS OF PEOPLE, CAUSES GENOCIDE,
ETHNIC CLEANSING, AND ECONOMIC COLLAPSETHIS
BOTH MAKES WAR MORE LIKELY AND MAGNIFIES ITS
IMPACT
SINGER 2002 (Peter, John M. Olin Post-doctoral Fellow, Foreign Policy Studies at the
Brookings Institution, Survival, Spring. This is not the bioethicist/activist Peter Singer.)
A recurring themes at all of these meetings was the new danger presented by the epidemic, not just in terms
of direct victims of the disease itself, but also to international security. Speaking at the UN Security
Council session, James Wolfensohn, the head of the World Bank, stated, Many of us used to think of
AIDS as a health issue. We were wrongnothing we have seen is a greater challenge to the

peace and stability of African societies than the epidemic of aidswe face a major
development crisis, and more than that, a security crisis.2 Peter Piot, chairman of the
Joint UN Program on HIV/AIDS (UNAIDS), similarly noted that Conflicts and AIDS
are linked like evil twins.3
In fact, this connection made between the epidemic of AIDS and the danger of increased
instability and war was also one of the few continuities between the way the Clinton and
Bush administration foreign policy teams saw the world. Basing its assessment on a CIA
report that discussed an increased prospects of revolutionary wars, ethnic wars,
genocide, and disruptive regime transitions because of the disease, the Clinton
Administration declared it a national security threat in 2000.4 While it was originally accused of
pandering to certain activist groups, by the time of Secretary Powells confirmation hearings the next year,
the lead foreign policy voice of the new administration had also declared it a national security problem.
He later affirmed that it presented a clear and present danger to the world.5 Similarly, US

Under Secretary of State Paula Dobriansky stated that HIV/AIDS is a threat to security
and global
stability, plain and simple6
The looming security implications of AIDS, particularly within Africa, are thus now a baseline assumption
of the diseases danger. However, this threat has barely been fleshed out and the mechanisms by which
experts claim that AIDS has changed the landscape of war are barely understood. 7

This article seeks to fill this space. AIDS not only threatens to heighten the risks of war,
but also multiply its impact. The disease will hollow out military capabilities, as well as
state capacities in general, weakening both to the point of failure and collapse. Moreover,
at these times of increased vulnerability, the disease also creates new militant recruiting
pools, who portend even greater violence, as well putting in jeopardy certain pillars of
international stability. In isolation, this increased risk of war around the globe is bad
enough, but there are also certain types of cross-fertilization between the disease and
conflict, intensifying the threat. The ultimate dynamic of warfare and AIDS is that their
combination makes both more likely and more devastating.
It is no overstatement that AIDS is the greatest disease challenge that humanity has
faced in modern history.8 More people will die from the disease than any other disease
outbreaks in human history, including the global influenza epidemic of 1918-9 and the
Bubonic Plague in the 1300s. Over 22 million worldwide have already been killed and it
is projected that, at current rates, another 100 million more will be infected just by 2005.9

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WAR IN AFRICA COULD ESCALATE TO DRAW IN OUTSIDE


POWERSTHIS IS THE MOST LIKELY TRIGGER FOR A
GLOBAL NUCLEAR WAR
DEUTSCH 2002 (Jeffrey, Political Risk Consultant and Ph.D in Economics, The Rabid
Tiger Newsletter, Vol 2, No 9, Nov 18, http://list.webengr.com/pipermail/picoipo/2002November/000208.html)
The Rabid Tiger Project believes that a nuclear war is most likely to start in Africa. Civil
wars in the Congo (the country formerly known as Zaire), Rwanda, Somalia and Sierra
Leone, and domestic instability in Zimbabwe, Sudan and other countries, as well as
occasional brushfire and other wars (thanks in part to "national" borders that cut across
tribal ones) turn into a really nasty stew. We've got all too many rabid tigers and potential
rabid tigers, who are willing to push the button rather than risk being seen as wishywashy in the face of a mortal threat and overthrown.
Geopolitically speaking, Africa is open range. Very few countries in Africa are beholden
to any particular power. South Africa is a major exception in this respect - not to mention
in that she also probably already has the Bomb. Thus, outside powers can more easily
find client states there than, say, in Europe where the political lines have long since been
drawn, or Asia where many of the countries (China, India, Japan) are powers unto
themselves and don't need any "help," thank you.
Thus, an African war can attract outside involvement very quickly. Of course, a proxy
war alone may not induce the Great Powers to fight each other. But an African nuclear
strike can ignite a much broader conflagration, if the other powers are interested in a
fight. Certainly, such a strike would in the first place have been facilitated by outside help
- financial, scientific, engineering, etc. Africa is an ocean of troubled waters, and some
people love to go fishing.

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THE CYCLE OF AIDS TRANSMISSION AND WAR WILL ALLOW


THE VIRUS TO MUTATE, BECOME AIRBORNE, AND SPREAD
WORLD-WIDE
SINGER 2002 (Peter, John M. Olin Post-doctoral Fellow, Foreign Policy Studies at the
Brookings Institution, Survival, Spring. This is not the bioethicist/activist Peter Singer.)
Wars also lead to the uprooting and amalgamation of populations, bringing groups into
contact that otherwise would be less likely to mix. In the DRC war, for example, not only
were masses of civilians from rural provinces brought into urban centers, but soldiers
from all over Africa also arrived. Such mixing may potentially be the most dangerous
aspect of AIDSs heightening of the impact of war, as it facilitates the emergence of
mutations in the virus itself. Researchers have found that the conflict in the DRC has
created a veritable witchs brew of AIDS, bringing together various strains from around
the continent. The results are new strains being produced that researchers have called
strange recombinants. As one scientist noted, We are seeing variants [of HIV] never
seen before.54
In a sense, while AIDS can cause war, be used as a weapon of war, and make that war
more deadly, war is thus also a laboratory that can reverberate back on the disease itself,
making it even more deadly. The consequences of this aspect thus bode danger even for
those well outside the scope of the fighting. For those who can afford them, the recent
development of new multidrug therapies (cocktails) have cut the risk of death from
HIV/AIDS, leading many in the US to think that the disease is, in a sense, cured.
However, there always remains the possibility of far more dangerous HIV strains, such as
one resistant to these latest treatments or even one whose contagion is airborne. HIV has
always displayed a high rate of genetic mutation, so this may happen regardless of any
levels of violence. That said, if such deadly new strains show up one
day in the US or Europe, the many linkages of AIDS and warfare will likely find its
origin traced back to some ignored conflict elsewhere.

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AIRBORNE AIDS RESULTS IN EXTINCTION


POSNER 2005 (Richard, Author, Catastrophe: Risk and Response, excerpted in Skeptic,
Jan 1)
Another great twentieth-century pandemic, AIDS, which has already killed more than 20
million people, (4) illustrates the importance tothe spread of a disease of the length of the
infectious incubation period. The longer a person is infected and infectious---yet either
asymptomatic or insufficiently ill to be isolated from the healthy population--the farther
the disease will spread before effective measures, such as quarantining, are taken. What
has proved to be especially pernicious about AIDS is that its existence was not
discovered until millions of people had been infected by and were transmitting the MDS
virus (HIV), which has an average infectious incubation period of 10 years. Given the
length of that period, the only thing that may have prevented MDS from wiping out the
human race is that it is not highly infectious, as it would be if HIV were airborne rather
than being transmissible only by being introduced into a victim's bloodstream. Even by
unsafe sex it is "generally poorly transmitted. For example, theprobability of transmission
from a single anal receptive sexual contact with an infected partner is estimated at 1 in
100 to 1 in 500." (5) However, the length of HIV's infectious incubation period and the
difficulty of transmission may be related; for, given that difficulty, were the virus unable
to "hide" from its host's immune system for aconsiderable time, it would be detected and
destroyed before it had a chance to replicate itself in another host. (6)

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HENCE THE PLAN: THE UNITED STATES FEDERAL


GOVERNMENT SHOULD INCREASE ITS ASSISTANCE IN
TRAINING, FINANCING, AND BUILDING INFRASTRUCTURE
FOR MALE CIRCUMCISION IN SUB-SAHARAN AFRICA
CONTENTION THREE: SOLVENCY
INCREASED FOREIGN ASSISTANCE FOR CIRCUMCISION IS
NECESSARY TO OFFSET COSTS AND PROMOTE THE
PROCEDURE IN SUB-SAHARAN AFRICA
UNAIDS 2007 (World Health Organization/UNAIDS Technical Consultation, New
Data on Male Circumcision and HIV Prevention: Policy and Programme Implications,
March 28, http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf)
Health systems in developing countries are weak and there is a shortage of skilled health
professionals. The development and expansion of male circumcision services for HIV
prevention should not disrupt health systems and the implementation of other health
programmes.
The safety of male circumcision depends on the setting, equipment and expertise of the
provider. When circumcision is performed in clinical settings under aseptic conditions,
by well trained and adequately equipped health care personnel, complication rates are
low. High rates of complications have been found when male circumcision is provided by
untrained, poorly equipped providers and in some traditional settings. Male circumcision
should not be scaled up without assurance of quality and safety of services and
appropriate follow-up of clients.
Integrated approaches to deliver male circumcision services with other essential HIV and
sexual health services are most likely to be sustainable in the longer term. However,
vertical, stand-alone programmes that provide the recommended minimum package of
services may be useful in the short term to expand access to safe male circumcision
services and to train providers in standardized procedures, especially where demand is
high and health systems are weak.
Recommendations:
8.1 Needs assessments should be undertaken to describe and map out the anticipated
scope of male circumcision scale-up, human resource and training needs, infrastructure,
commodities and logistic requirements, costs and funding, and systems for monitoring,
evaluation and follow-up.
8.2 Training and certification of providers should be rapidly implemented to increase the
safety and quality of services in the public and private sectors.
8.3 Supervision systems for quality assurance should be established along with referral
systems for the management of adverse events and complications.
8.4 Information on traditional practices is required and ways should be found to engage
traditional practitioners to improve the safety of their services and counselling on sexual
and reproductive health.

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8.5 Appropriate service delivery models depend on the context and should be determined
locally.
8.6 If vertical programmes are established in order to rapidly expand access to safe male
circumcision services, there should be a clear strategy to ensure that these services are
integrated into strengthened health systems as soon as it is feasible.
Conclusion 9: Additional resources should be mobilized to finance the expansion of safe
male circumcision services
HIV prevention programmes are still under resourced and male circumcision requires
new and additional investment if it is to be expanded. The financial resources required to
rapidly and safely expand male circumcision services for HIV prevention are large and
will require efficiency in the use of existing resources and the commitment of additional
resources by countries and donors.
The cost of service at the point of delivery can be a barrier to men seeking safe male
circumcision services and needs to be addressed. Based on early studies, the costeffectiveness of male circumcision is comparable to other HIV prevention strategies.viii
Recommendations:
9.1 Countries should estimate the resources needed, develop costed national plans and
allocate resources for male circumcision services without taking away resources from
other essential health programmes.
9.2 In view of the large public health benefit of expanding male circumcision services in
countries with generalized HIV epidemics, such countries should consider providing
male circumcision services at no cost or at the lowest cost possible to the client, as for
other essential health services.
9.3 Bilateral and multilateral donors should consider male circumcision as an important,
evidence-based intervention for HIV prevention and allocate resources accordingly.

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CIRCUMCISION CAN REDUCE THE SPREAD OF AIDS BY


SEVENTY PERCENTIT IS EQUIVALENT TO DISCOVERING A
VACCINE
INTERNATIONAL HERALD TRIBUNE 12-14-2006
The announcement Wednesday about the results in two African studies of male
circumcision may be the most important development in AIDS research since the debut
of antiretroviral drugs more than a decade ago. The National Institutes of Health halted
studies in Uganda and Kenya when it became overwhelmingly clear that circumcision
significantly reduces men's chances of catching HIV.
The studies recruited men willing to be circumcised and randomly assigned them to
immediate surgery or to a control group. In both studies, the circumcised men acquired
half the number of HIV infections that their uncircumcised counterparts did. The studies
confirm the results of a trial that ended last year in South Africa, in which circumcision
prevented 60 to 70 percent of new AIDS infections.
Until now, efforts at AIDS prevention have largely failed. Little wonder. It requires
people to resolve every day either not to have sex or to use condoms. Circumcision,
by contrast, is a one-time procedure. It is familiar and widely accepted all over the world,
even by groups who do not practice it. And safe circumcision does not require a doctor.
Community workers and traditional healers can be trained to do the operation safely and
given the correct tools. Based on the South African results, groups like the United
Nations AIDS program and the World Health Organization were already discussing how
they might promote circumcision in countries around the world. They should now move
as quickly as possible.
Governments and international donors should also work urgently to provide new
financing to help high- risk countries train community workers to do safe circumcision.
News of the South African results has already led to a surge in demand for the procedure
across Africa, and clinics that now offer it have long waiting lists.
Any campaign will have to be coupled with warnings that circumcision offers only partial
protection against HIV and should not become a license for risky sex. Governments must
continue to promote condoms and partner reduction.
For years, the holy grail of AIDS prevention has been a vaccine, even one that is only 50
to 60 percent effective. A real vaccine is years away. But now we know its near
equivalent exists. International donors and governments should join together to spread the
good news about circumcision and make the procedure available everywhere.

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AMERICAN ASSISTANCE IS CRITICAL TO PREVENT THE


SPREAD OF AIDSTHE UNITED STATES HAS UNIQUE
HISTORICAL TIES, RESOURCES, EXPERIENCE, AND
STRATEGIC INTERESTS IN SUB-SAHARAN AFRICA
ALMQUIST 2007 (Katherine, Assistant Administrator of USAID, CQ Congressional
Testimony, March 13)
Mr. Chairman, as you are well aware, Africa is a region of extreme need and great
promise. I firmly believe that we have never known a more favorable time than the
present to build upon and consolidate the progress being made on the continent. Africa
offers rich development potential, along with huge challenges, including widespread
poverty, illiteracy, hunger, disease, environmental degradation, conflict, and poor
governance. Addressing the challenges facing Africa is critical to U.S. security and
regional stability. Africa is the world's second largest and most populous continent, after
Asia, and is a region of great strategic importance to the United States, both in terms of
emerging markets and as a front in our efforts to stem and reverse the threat of terrorism.
In addition, the United States shares a unique heritage and cultural bond with the people
of sub-Saharan Africa. For these reasons, the United States has assumed a leading role in
meeting the commitments to Africa the G-8 nations made in 2005 at Gleneagles,
Scotland. The United States is making meaningful progress in several areas critical to the
continent's development such as education, food security, trade promotion, environment,
and protection of women. In particular, the United States Government has committed
significant resources and support to fight two of the greatest challenges in Africa,
HIV/AIDS and malaria.
Mr. Chairman, as you know, under the leadership of Secretary Rice and Ambassador
Tobias, the State Department and USAID have undertaken a series of reforms designed to
improve the effectiveness of our foreign assistance programs and make it easier for us to
coordinate our assistance and track results. Our shared transformational development
goal is to "help build and sustain democratic, well-governed states that respond to the
needs of their people, reduce widespread poverty and conduct themselves responsibly in
the international system." Of course, the nations of sub-Saharan Africa vary widely in
terms of their relative state of development. Consequently, USAID's strategies begin by
taking country context into consideration in each of our strategic objectives, with the goal
of helping countries advance along the road of development in each crucial sector. If
confirmed, I will ensure that assistance strategies support United States Government
foreign policy objectives, are grounded in the context of the specific country in question,
and are developed collaboratively with those who have the most at stake in their success
or failure, our African counterparts. Most importantly, I will ensure that our programs
achieve results.

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THE UNITED STATES MUST USE CIRCUMCISION AS PART OF


ITS EFFORT TO SLOW THE SPREAD OF HIVAMERICAN
LEADERSHIP IS CRITICAL TO ERADICATE HIV
PRESIDENTIAL ADVISORY COUNCIL ON HIV/AIDS 2005 (Achieving an HIVFree Generation: Recommendations for a New American HIV Strategy December 1,
www.hivdent.org/publicp/PACHA/PACHA_INTERNATIONAL.htm)
Careful consideration should be given to the evidence that male circumcision reduces the
likelihood of HIV transmission. The latest data, although incomplete, on reduced
transmission rates from circumcision are so striking that they warrant careful review.
While more research must be done, and concerns about possible behavioral disinhibition,
sterile procedures and effective education to accompany the procedure are justified, the
recent data from 40 epidemiological studies as well as a randomized clinical trial (RCT)
in South Africa are compelling.8 If these findings are supported by ongoing work in
Kenya and Uganda, it is possible that transmission rates can be reduced dramatically, on
the scale of a partially effective vaccine. Much thought and discussion will be required to
consider the cultural and sociological implications of encouraging circumcision to reduce
HIV transmission.
HIV will continue to be a deadly enemy for the near future, but we cannot resign
ourselves to a world beset by HIV forever. We have seen poor nations develop successful
prevention campaigns with little outside assistance, which proves that prevention is
possible in the developing world. We have also seen the United States lead the world in
proving that HIV medicines can be deployed in areas with few resources. We have been
given hope that HIVs spread can be slowed, stopped, and in fact reversed. We cannot let
the gains we have made, and the hope we have been given, slip away. As we move into
the next phase of the Emergency Plan, and continue our extraordinary commitment to
fight HIV overseas, we must make our long-term HIV goal, the ultimate extinction of the
HIV virus. If we can imagine the birth of an HIV-free generation, and we commit to
achieving it, we can make it happen.

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INHERENCY--GENERAL

MEN WANT CIRCUMCISION, BUT CURRENT RESOURCES ARE


INSUFFICIENT TO MEET DEMAND AND TRADITIONAL
HEALERS WILL USE UNSAFE METHODS
NEW YORK TIMES 4-28-2006
Other H.I.V. specialists are concerned that the studies may encourage unsafe
circumcisions by traditional healers. Every year, the authorities in Eastern Cape Province
in South Africa report deaths and amputations from botched circumcisions of young
boys.
While many Western doctors routinely encourage circumcision of newborns, surgeons in
government hospitals and clinics in southern Africa typically schedule circumcisions only
if medically necessary. At Chris Hani Baragwanath Hospital in Soweto, South Africa, the
waiting list runs six to nine months.
To offer it more broadly, "you can imagine what kind of resources would have to be
made available," said Dr. Martin Smith, head of the hospital's surgery department.
Although circumcision is not a custom among most ethnic groups in the region, studies in
Botswana and elsewhere suggest that more than half of men would accept circumcision if
it were free and done safely. Most say they think circumcision improves hygiene and
sexual pleasure.
The few programs that offer free or low-cost circumcision have been swamped with
applicants. Officials of the Family Life Association, a nonprofit organization in
Swaziland, expected a few dozen volunteers when they offered free circumcisions in
January. But about 140 men and boys showed up at its clinic in the Swazi capital,
Mbabane. Doctors worked until 8 p.m. to circumcise 54 patients and told the rest to come
back later.

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INHERENCY--GENERAL

CIRCUMCISION IS EFFECTIVE BUT THERE IS NOT ENOUGH


MONEY--FOREIGN AID IS NECESSARY
AFRICA NEWS 6-14-2007
The agencies said the risks involved in male circumcision are generally low, but can be
serious if the operation is performed in unhygienic settings by poorly trained, illequipped health workers.
Priority should be given to providing circumcision to age groups at highest risk of
acquiring HIV because it will have the most immediate impact on the disease. But, it
said, circumcising younger males also will have a public health impact over the longer
term.
It gave no estimate how much providing the service would cost, but said more money
would be needed, but that donors should regard it as "an important, evidence-based
intervention."
During the 2007 G8 meeting German, donor countries agreed to release $60m to help in
the war against HIV/Aids especially in Sub Saharan African. The money will be used to
make ARVs more accessible to the poor; hopefully even the campaign for circumcision
will benefit from the donations.

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INHERENCY--AIDS

EVEN IF AIDS IS LEVELLING OFF, THE RATE IS STILL HIGH


AND THE NUMBER OF INFECTED PEOPLE IS GROWING DUE
TO POPULATION GROWTH
KANABUS 2007 (Originally written by Annabel Kanabus and Jenni Fredriksson-Bass,
updated and edited by Graham Pembrey, May 17, http://www.avert.org/aafrica.htm)
Overall, rates of new HIV infections in Sub-Saharan Africa appear to have peaked in the
late 1990s, and HIV prevalence seems to be levelling off, albeit at an extremely high
level. Stabilisation of HIV prevalence occurs when the rate of new HIV infections is
equalled by the AIDS death rate among the infected population. This means that a
country with a stable but very high prevalence must be suffering a very high number of
AIDS deaths each year. Although prevalence remains stable, the actual number of
Africans living with HIV is rising due to general population growth.

17

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AIDS IMPACTS

AIDS HOLLOWS OUT AFRICAN MILITARIES AND MAKES


DEPLOYMENT UNCERTAINTHIS CAUSES DOMESTIC
INSTABILITY, ALLIANCE COLLAPSE, AND INVITES
AGGRESSION FROM OTHER STATES
SINGER 2002 (Peter, John M. Olin Post-doctoral Fellow, Foreign Policy Studies at the
Brookings Institution, Survival, Spring. This is not the bioethicist/activist Peter Singer.)
The results are devastating for the military institution and can lead to a dangerous
weakening of military capabilities. Besides the effect on the regular line troops and the
general recruiting pool, the disease is particularly costly to military forces in its draining
effect on the skilled positions. In a way, the disease causes Adam Smith in reverse, by
taking away the specialists that allow an organization to succeed and grow. That is, AIDS
is not only killing regular conscripts but also the NCOs and officers that militaries are
least able to lose. Thus, leadership capacities and professional standards directly suffer
from the diseases scourge. Several armies, including Botswana, Uganda, and Zimbabwe,
are already facing serious gaps in their leadership cadres. In Malawi, at least half the
general staff is thought to be HIV positive, while the armys commander
stated that he believed a quarter of his overall force would be dead from the disease
within the next three years. 23
This hollowing out of militaries, particularly at the leadership level, has a number of
implications for security. As human capacity is lost, military organizations' efforts to
modernize are undercut. Also, as they lose their leadership to an unyielding, demoralizing
foe, the organizations themselves can unravel. The effects of the disease on the institution
is thus in a sense non-linear; its impact is not felt just in terms of lives lost, but overall
disruption.
Militaries, when under this type of pressure from disease, gradually lose their capabilities
and are less able to meet their commitments. As Colonel Kevin Beaton of the Royal
Army Medical Corps noted, "History is littered with examples of armies falling apart for
health reasons.24 Preparedness and combat readiness deteriorate. Even if a new
recruiting pool is used to replace sick troops, force cohesion is compromised.
The higher risk within the military, consequently, compounds the diseases impact,
transferring it to the political level. Commanders from certain high infection countries
already worry that they are now unable to field full contingents for deployment because
of the disease and most certainly are unable to assist their nations allies. AIDS-weakened
militaries also risk domestic instability and even invite foreign attack. Namibias defense
ministry, deeming AIDS to be a new type of strategic vulnerability, has treated military
infection rates as classified information.25

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AIDS IMPACTS

AIDS CREATES A HUGE NUMBER OF ORPHANS WHO BECOME


CHILD SOLDIERSTHIS CAUSES WAR, MAKES IT BLOODIER,
AND CAUSES PEACE EFFORTS TO FAIL
SINGER 2002 (Peter, John M. Olin Post-doctoral Fellow, Foreign Policy Studies at the
Brookings Institution, Survival, Spring. This is not the bioethicist/activist Peter Singer.)
A more direct mechanism by which the new demographics of AIDS can heighten security
risks is through its creation of a new pool of orphans, magnifying the child soldier
problem. By 2010, over 40 million children will lose one or both of their parents to
AIDS, including 1/3 of all children in the hardest hit countries. These include 2.7 million
in Nigeria, 2.5 million in Ethiopia, and 1.8 million in South Africa.40 India, alone,
already has 120,000 AIDS orphans.
Because of both the stigma of the disease, as well as the simple fact the sheer numbers of
victims will overwhelm the communities and extended families that would normally look
after them, this cohort represents a new lost orphan generation.41 Its prospects are
heartrending, as well as dangerous. Besides being malnourished, stigmatized, and
vulnerable to physical and sexual abuse, this mass of disconnected and disaffected
children is particularly at risk to being exploited as child soldiers. Children in such
straights are often targeted for recruitment, either through abduction or voluntary
enlistment driven by desperation.
The ramifications are quite dangerous to stability.42 With recent changes in weapons
technology that allow them to be effective fighters in low-intensity warfare, children
represent an inexpensive way for warlords, guerilla groups, and other violent non-state
actors to build up substantial forces irregardless of their own political agendas and local
support, or lack their of.
This new ease of force generation means a likely increase in the number of internal
rebellions and conflicts. Moreover, the unique features of the doctrine behind turning
children into soldiers means that those conflicts in which they are introduced will be
inherently messier. These wars prevalently feature atrocities and attacks on civilians.
At the same time, the lives of the child soldiers themselves are considered cheaper by
those that utilize them; they tend to be employed in a loose manner, making their own
losses much higher. Finally, childrens entrance into warfare is damaging to social fabric
as well as their individual psyches, creating future problems down the road, even after
initial conflict resolution.
Child soldiers have appeared on contemporary battlefields without AIDS being present.
The prevalence of a new, globalized mass of orphans, as well as a hollowing of local
states and militaries, will make them ever more widespread. The ultimate result is that
violent conflicts will be easier to start, greater in loss of life, harder to end, and lay the
groundwork for recurrence in the following generations.

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CIRCUMCISION SOLVENCY

THE BEST SCIENTIFIC STUDIES PROVE THAT CIRCUMCISION


SOLVES HIV
JHPIEGO 2006 (JHPIEGO is a health organization associated with Johns Hopkins
University, Male Circumcision Gaining Acceptance in the Fight Against HIV,
http://www.jhpiego.org/resources/pubs/infosheets/JHPinfo_MC.pdf. Last Mod Sept 26.
JHPIEGO is not an acronym; it is pronounced jay-pie-go)
There is very convincing observational, biological and now clinical trial evidence
suggesting that male circumcision has a strong protective effect against HIV transmission
and acquisition. Data from more than 40 studies show that men who are circumcised are
less than half as likely to get infected with HIV, and are also less likely to acquire or
transmit other sexually transmitted infections. There is also evidence that their partners
have lower rates of HIV, sexually transmitted infections and even cervical cancer.

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SOLVENCY--CIRCUMCISION

CIRCUMCISION PREVENTS THE SPREAD OF AIDSIT WOULD


SAVE AT LEAST THREE MILLION AFRICANS IN THE NEXT
TWENTY YEARS
HOME NEWS TRIBUTE 7-16-2006
Researchers with the World Health Organization said that, based on their study of male
circumcisions in Africa, widespread use of the medical procedure would prevent 3
millions deaths from AIDS over the next 20 years.
Africa has just 10 percent of the world's population but is home to 60 percent of people
infected with HIV, the virus that causes AIDS. Last year, 2.4 million people in Africa
— adults and children — died of AIDS.
AIDS in Africa has reached pandemic levels. In the United States, the problem is less
severe. But in this nation's black community, as in sub-Saharan Africa, AIDS is a much
more frightening presence than it is for other groups. And anything that holds out hope of
slowing its spread ought to be big news.
WHO researchers concluded that circumcisions help prevent HIV infections because the
foreskin removed in the procedure has cells the virus can easily penetrate. HIV also
seems to survive better beneath the foreskin.
So circumcisions deny the virus a breeding ground.
That's big news for a continent in which 40 million people are thought to be infected with
HIV and 25 million already have died of AIDS. The vast majority of Africans infected
with HIV have little hope of survival because they are too poor to afford expensive AIDS
treatments that have extended the lives of many infected people in this country.
Uganda has reduced its HIV/AIDS rate substantially, largely through the widespread use
of condoms. Circumcisions might prove another effective means of stemming the spread
of this deadly disease throughout Africa and elsewhere in the world.

21

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COMPREHENSIVE STUDIES SHOW THAT MALE


CIRCUMCISION PREVENTS HIV
USAID 2003 (Issue Brief: Male Circumcision and HIV Prevention, August,
http://www.usaid.gov/our_work/global_health/aids/TechAreas/research/issue_mc.pdf)
Researchers have noted links between MC and HIV prevalence rates since the 1980s. The
body of research now includes:
A systematic meta-analysis that analyzed the findings of 38 studies,
mostly in Africa, and found that circumcised men appear to be less than half as likely to
be infected by HIV as uncircumcised men. A sub-analysis of 16 of these studies found an
estimated 70 percent reduction in HIV infection among higher-risk men (see figure, page
2).
A two-year cohort study of male partners of HIV-positive women in Rakai, Uganda, in
which 40 of 137 uncircumcised men became infected, compared with 0 of 50 circumcised
men.
Mapping of the HIV epidemic that has demonstrated a strong correlation between
regions with higher levels of HIV infection and those with lower MC rates.
A Joint United Nations Programme on HIV/AIDS (UNAIDS) multisite study that found
MC to be a principal factor in the large and pervasive disparities in HIV prevalence
across different African regions. Similar patterns have been observed in South and
Southeast Asia (see table, page 3).

22

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MALE CIRCUMSION PREVENTS MEN FROM SPREADING HIV


TO WOMEN AND ALSO SOLVES CERVICAL CANCER
NEW YORK TIMES 12-14-2006
Male circumcision also benefits women. For example, a study of the medical records of
300 Ugandan couples last year estimated that circumcised men infected with H.I.V. were
about 30 percent less likely to transmit it to their female partners.
Earlier studies on Western men have shown that circumcision significantly reduces the
rate at which men infect women with the virus that causes cervical cancer. A study
published in 2002 in The New England Journal of Medicine found that uncircumcised
men were about three times as likely as circumcised ones with a similar number of sexual
partners to carry the human papillomavirus.
The suspected mechanism was the same cells on the inside of the foreskin were also
more susceptible to that virus, which is not closely related to H.I.V.

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STUDIES PROVE CIRCUMCISION SOLVES


NEW YORK TIMES 12-14-2006
The two trials, conducted by researchers from universities in Illinois, Maryland, Canada,
Uganda and Kenya, involved nearly 3,000 heterosexual men in Kisumu, Kenya, and
nearly 5,000 in Rakai, Uganda. None were infected with H.I.V. They were divided into
circumcised and uncircumcised groups, given safe sex advice (although many
presumably did not take it), and retested regularly.
The trials were stopped this week by the N.I.H. Data Safety and Monitoring Board after
data showed that the Kenyan men had a 53 percent reduction in new H.I.V. infection.
Twenty-two of the 1,393 circumcised men in that study caught the disease, compared
with 47 of the 1,391 uncircumcised men.
In Uganda, the reduction was 48 percent.
Those results echo the finding of a trial completed last year in Orange Farm, a township
in South Africa, financed by the French government, which demonstrated a reduction of
60 percent among circumcised men.

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CIRCUMCISION SOLVES AIDS


NEW YORK TIMES 12-14-2006
Circumcision appears to reduce a mans risk of contracting AIDS from heterosexual sex
by half, United States government health officials said yesterday, and the directors of the
two largest funds for fighting the disease said they would consider paying for
circumcisions in high-risk countries.
The announcement was made by officials of the National Institutes of Health as they
halted two clinical trials, in Kenya and Uganda, on the ground that not offering
circumcision to all the men taking part would be unethical. The success of the trials
confirmed a study done last year in South Africa.
AIDS experts immediately hailed the finding. This is very exciting news, said Daniel
Halperin, an H.I.V. specialist at the Harvard Center for Population and Development,
who has argued that circumcision slows the spread of AIDS in the parts of Africa where
it is common.
In an interview from Zimbabwe, he added, I have no doubt that as word of this gets
around, millions of African men will want to get circumcised, and that will save many
lives.

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MALE CIRCUMCISION SOLVES AIDS


MACLEANS JULY 10 2006
For five years, Dr. Stephen Moses from the University of Manitoba and Dr. Robert
Bailey from the University of Illinois have been circumcising young men of the Luo tribe
in western Kenya. They wanted to see if and how this would protect them from HIV
infection. On June 27, at a meeting in Washington, the two scientists will learn whether
their research, which seemed controversial or even peripheral when it was first
conceived, will be allowed to continue or be cut short a year early. A panel called a data
safety monitoring board (DSMB), made up of scientists from both North America and
Africa who meet annually to oversee all such clinical trials, will examine their
preliminary data (numbers Moses and Bailey have not seen) and decree the fate of the
project. If the project is stopped, in a bizarre -- or even ironic -- twist, it will simply be
because the news is just too good.
With $ 300,000 annually from the Canadian Institutes of Health Research and US$ 1.2
million from the U.S. National Institutes of Health, the researchers, together with their
Kenyan partner, the University of Nairobi, have been combing the markets and fishing
villages around the town of Kisumu to recruit 2,800 young men aged 18 to 24. On half of
them they performed surgery while requiring the rest to remain uncircumcised. Then they
asked both groups to stay in touch over a period of two years.
At the outset, the research was deemed a shot in the dark, yet plausible: in west Africa,
where cultural circumcision practices are more extensive, HIV/AIDS rates, they noted,
are lower. But quickly, the strategy of male circumcision has leapt onto centre stage as
the latest and potentially most effective tool of AIDS prevention. So effective, in fact,
some suggest it doesn't even require the full imprimatur of scientific certainty. A year
ago, a similar study conducted in South Africa's Soweto township by French scientists
was halted by its data safety monitoring board when preliminary data showed the
discrepancy in HIV infections between their two cohorts to be an astonishing 63 per cent.
The Catch-22 was that it seemed unethical to require the mandatory control group to
remain without the potentially life-saving operation even for the relatively short period of
the study. "It would not be moral," declared the DSMB, "in the light of such astounding
data, to continue with a group from whom you were withholding the possibility of
becoming circumcised."

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MALE CIRCUMCISION REDUCES HIV SPREAD TO WOMEN


NEW YORK TIMES 4-28-2006
One study in February of the medical records of more than 300 Ugandan couples
suggested that male circumcision also benefited women. In it, researchers estimated that
circumcised men infected with H.I.V. were about 30 percent less likely to transmit it to
their female partners.

27

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SOLVENCY--CIRCUMCISION

FRENCH STUDY PROVES CIRCUMCISION REDUCES THE SPREAD OF HIV


BY TWO-THIRDS
NEW YORK TIMES 4-28-2006
Perhaps the most compelling evidence came last year from a study financed by the
French government of 3,274 men outside Johannesburg. Half of them underwent
circumcision; the others were uncircumcised.
After 17 months, 49 of the uncircumcised men became infected with H.I.V., while only
20 of the circumcised men caught the virus. The study was called to a halt in March 2005
when a review board decided that it would be unethical to withhold circumcision from
the control group. Researchers estimated that the procedure reduced the risk of
contracting H.I.V. by roughly two-thirds.

28

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SOLVENCYINFRASTRUCTURE

TRAINING HEALTH CARE WORKERS AND PROVIDING


INFRASTRUCTURE IS CRITICALNO AMOUNT OF AID WILL
BE EFFECTIVE WITHOUT INCREASING HEALTH CARE
CAPACITY
AFRICA NEWS 8-3-2006
"With 11 percent of the world's population, 25 percent of the global disease burden and
nearly half of the world's deaths from infectious diseases, sub-Saharan Africa has only 3
percent of the world's health workers." Senator Durbin said. "Personnel shortages are a
global problem, but nowhere are these shortages more extreme, the infrastructure more
limited and the health challenges graver than in sub-Saharan Africa, the epicenter of the
HIV/AIDS pandemic. We will not win the war against AIDS or any other health
challenge without finding solutions to this crisis," Durbin said.
"I am very proud to join my colleagues in introducing this bill as it is critical for
bolstering our efforts to combat HIV/AIDS and other diseases in Africa," said Senator
Coleman. "The lack of health care capacity in Africa imposes major constraints on the
long term effectiveness of programs fighting HIV/AIDS and other diseases. For this
reason, any forward-looking, comprehensive strategy to fight these terrible diseases must
include elements that build African health care capacity."
"The massive shortage of healthcare workers may be the most critical issue facing health
care systems in Africa, contributing to millions of preventable deaths each year," Senator
Feingold said. "I am proud of the leadership role the United States has taken in
addressing HIV/AIDS, malaria, tuberculosis, and other global health crises. However,
the resources we have invested in Africa will ultimately be fruitless unless we establish
an infrastructure to ensure their effectiveness in the long-term."
"I am proud to join my colleagues in supporting this worthy bill that will help millions of
people in Africa get the basic health services they need. A coordinated strategy for
healthcare workers would ultimately help combat the HIV/AIDS epidemic by increasing
treatment and education about the disease. This, coordinated with infrastructure
improvements, will also give much needed doctors and nurses access to more patients,"
said Senator DeWine. "In addition, these measures will help these developing nations to
support economic growth and create jobs for their citizens."

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SOLVENCYU.S. KEY

AMERICAN SUPPORT FOR CIRCUMCISION IS CRUCIAL TO


OVERCOME LACK OF RESOURCES IN SUB-SAHARAN AFRICA
WASHINGTON POST 6-1-2007
There are also practical obstacles. Like any operation, circumcision presents a risk of
infection. Much of Africa lacks the equipment and personnel to perform the procedure on
a large scale. But similar arguments were made against the possibility of AIDS treatment.
A concerted American and international commitment proved that pessimism to be
unjustified.
The main problem with circumcision is that it is only partially protective. If a newly
circumcised male stops using condoms or increases his number of partners out of a false
sense of invulnerability, his risk of getting AIDS rises, along with the risk of giving it.
The Uganda and Kenya studies found no increase in risky sexual behavior after
circumcision. But clearly health education will be required. "People will still need to use
condoms consistently," Bailey says, "still need to reduce their partners, still need to
practice faithfulness."
As circumcision scales up, the reductions in overall infection rates will be gradual. But
the implications for the individual man in Africa are dramatic. A $40 or $50 procedure
can cut his risk of HIV infection in half. Giving him that option is a matter of moral
urgency.
That begins with African governments. Both routine infant circumcision and adult
circumcision must be considered, especially in the areas of highest infection.
International donors need to aggressively support African circumcision programs with
new resources. And European governments, which have refused to deal with this issue,
need to start respecting the data and lend their support.