Monday, December 22, 2008

Circumcision for All. Then What?

Male circumcision (MC) as a protection against HIV has been a controversial subject for some time. It is believed to protect against male-to-female transmission of HIV. I shall leave much of the controversy to the experts and consider two questions that the literature, as far as I know, doesn't address:

1) To what extent can Kenya benefit from a mass MC campaign?
2) How feasible is a mass MC campaign in Kenya, under present conditions?

I raise the question of the extent to which Kenya can benefit because rates of MC are already very high in most provinces. The only province with relatively low rates of MC is Nyanza. Just over 50% of men are uncircumcised and HIV prevalence is 15.3%, the highest in the country. Around 20% of men in Nairobi are uncircumcised and HIV prevalence is 9%, the second highest in the country.

That sounds like a strong case for mass MC for those two provinces. However, one would also need to look at other factors in the transmission of HIV, such as population density and demographic balance (between males and females) in Nairobi, say.

One could also look at cross-generational marriages and rates of other sexually transmitted infections, such as herpes simplex virus, in Nyanza. (Cross-generational marriages referring to those where the man is considerably older than the woman.) No doubt, additional factors would also be relevant.

But the other six provinces have high rates of circumcision, standing at over 90% in four of them. Of course, they all have lower HIV prevalence than Nairobi and Nyanza. But in two of them, Rift Valley and Coast, HIV is increasing faster than in any of the other provinces. The absolute numbers involved here are worrying as well, the population of Rift Valley alone exceeding that of Nairobi and Nyanza together.

If a mass MC campaign is beneficial and feasible, quite a substantial number of people could benefit. A liberal estimate would suggest that four million men could benefit directly by being circumcised and another six million could benefit indirectly (these figures being VERY rough estimates). That would be almost one quarter of the population of Kenya.

It would be hard to argue against a campaign that could benefit so many people. Even if I have overestimated the number who could benefit, the numbers would still run into millions.

The second question is more difficult and I would compare it to the question of how feasible it would be to test every sexually active Kenyan, perhaps once a year, and put all those who are HIV positive on ART (antiretroviral therapy).
Similar questions arise: what sort of health service capacity does Kenya have, how many trained health service employees are there and how much capacity will be left for HIV prevention and care for the 75% or so of Kenyans who will neither directly nor indirectly benefit from mass MC?

It may well be the case that mass MC, universal testing and ART are desirable, but their feasibility is still in question once the experts have discussed all the other issues. Preventive medicine is desirable, so is health surveillance and so is treatment. They should all help to reduce HIV transmission.

But general health is also desirable, so are adequate nutrition and food security, water and sanitation, education, environmental protection and many other things. Why spend so much time and effort on something that may protect a minority of people, albeit a substantial minority, and ignore all these things that will benefit everyone?

Ok, I have listed some intractable problems and I agree, let's do something we know how to do rather than despairing about the things we may not know how to do. But I would seriously question the feasibility of safe mass MC in Kenya. Health services, education and other social services have been run down over several decades, the ratio of health personnel to patient is low and even though more health personnel are being trained, this is not keeping up with population growth.

The desirability of reducing transmission of HIV is not in question, but how will it be achieved? Will the Kenyan government build up the health service, develop educational programmes that will support this mass MC campaign and address all the other social conditions that contribute to the transmission of HIV? If so, then we should support such a campaign.

But I suspect these measures are not on the agenda and that mass MC will be rolled out as if HIV were a short term emergency. HIV is not a short term issue, it's been a long time building up and the conditions that allowed it to build up go back many decades. Allow those conditions to persist and HIV will not be eradicated.

Those conditions include structural problems that would make a mass MC campaign very unlikely to succeed without many adverse effects and complications. Circumcision carried out in modern, well equipped, well funded health institutions may suffer few adverse effects and complications but how many hospitals and health institutions meet those criteria in Kenya, and how many will do so in the next five or ten years?

MC is sometimes compared to a vaccine. Indeed, so is education. In fact, neither of them is particularly like a vaccine. People who are circumcised and people who are educated are still vulnerable to HIV, especially in a country with high prevalence. MC is just one more way of reducing HIV transmission, education is another. Combined with all the others, they may even reduce transmission considerably.

Unfortunately MC can be like a vaccine in the sense that those who are vaccinated may think they don't need to be careful. A circumcised man may assume he will not be infected, even if he doesn't use a condom. I have heard this belief many times and I am also aware of how much men dislike condoms and would avail of any argument to avoid using them.

Even if this so called 'risk compensation' behaviour has not been has not been detected yet, it does exist. People soon forget the safety messages or start to ignore them, especially if the death rate from HIV is seen to be dropping substantially.

So I'm not against mass MC if the experts can settle their differences, and there are many differences to settle. I also realise that those arguing for mass MC are not talking of circumcision on its own, that they would include counselling, testing, behaviour change messages, condom provision, STI treatment, etc.

In answer to my first question, I believe that Kenya would only benefit to a certain extent from a mass MC campaign and needs also to avail of all known types of prevention programming.

In answer to my second question, I don’t think a mass MC campaign is particularly feasible in Kenya at the moment. But if the conditions that make such a campaign unfeasible are addressed, the benefits will go far beyond those of a mass MC campaign alone. In fact, the benefits will go far beyond HIV prevention.



Claire said...

Interesting that HIV is increasing fastest in Rift Valley and coast. Do you mean proportionate to their prevalence or absolutely? If actual incidence is highest there, that's a really useful point/finding.

SJOH1013 said...

Where is your liberal estimate of people benefiting from MC in Kenya from? Did you make it? Cool!

Claire said...

Don't mean to sound like your fan club, but I like the way you always try to keep in perspective. The aim of everything we're doing is to improve people's lives - when you work in a small area it's hard not to get carried away championing that. I really appriecaite the way you have a broader perspective on the way to address any particular question, too.

Claire said...

Is there much talk within Kenya of circumcision being protective against HIV? Have you heard men say they believe they will be safe if they are circumcised? It would be interesting to go back to the papers demonstrating the efectiveness of MC and look at their methodology, and discuss how behaviourally disinhibited the trial participants were compared to the population in Kenya.

Simon said...

Hi Claire, thanks for the questions, I'll try to answer them in turn.

Prevalence has increased between the last Demographic and Health Survey in 2003 and the Kenya Aids Indicator Survey in six provinces. The two provinces that showed the biggest increase in prevalence were Rift Valley and Coast.

Their prevalence is not about the same as that for the whole country but it does sound as if there has been an increase in incidence, too.

Also, the male/female ratio is changing. Still more females than males but the gap is narrowing. Can't give you the figures off the top of my head, I'm afraid and KAIS is supposed to publish the full findings in January. But I'll believe that when I see it.

Second question, the latest census is 1999, so estimating numbers of uncircumcised men is not so easy. Nyanza has a relatively small population, Rift Valley relatively large, nearly 10 million. Half of them are male (roughly) and about half will be sexually active. Throw in quite a few more because population has grown a lot since 1999 and you get a generous four million.

It is a pretty notional figure, it's just that uncircumcised men only make up a sizeable proportion of some provinces. Nationally, they make up a big enough group to be targetted, but the task of safely circumcising that many people will be a big one and there's a danger of deflecting funds and efforts from things that benefit everyone, such as education, health and other social services.

Of course, some would argue that that's just what HIV has done all along, but as I've said, if health and other services are going to be built up preparatory to mass circumcision, great. I just don't see that happening.

As for people's attitude towards circumcision, I have talked to some people and those who do talk about it vary a lot. In Western Kenya there was one man who insisted that condoms don't work on him because he is circumcised. It is just one of the many myths that people enjoy because they just don't like condoms.

Others want to know if circumcision really has a protective effect and if so, why. And I don't think experts are completely clear about that yet, they are certainly not in agreement.

Other people ask about circumcision because they are circumcised and they suspect that they don't need to use a condom, but they won't ask straight out.

There has even been some confusion because the term 'circumcision' is sometimes used for Female Genital Mutilation. This is worrying because, though technically illegal, is still carried out here.

There has been research that showed that disinhibition is not a result of circumcision but that sounds like too convenient and dogmatic a finding. I think there are important empirical matters to be cleared up. But I think mass circumcision is far less risky than something like pre-exposure prophylaxis or the plan to test everyone once a year and put all those who test positive on ART.

I hope that answers them, and thank you for the compliment!

Claire said...

Thanks for your response.
The increases in prevalence by province are not in the KAIS ( where did you get them? This is an interesting result.

"There has even been some confusion because the term 'circumcision' is sometimes used for Female Genital Mutilation."

Eek! Oh God, not the continuation of FGM in the name of HIV prevention!

"I think mass circumcision is far less risky than something like pre-exposure prophylaxis or the plan to test everyone once a year and put all those who test positive on ART."

Do you? I suppose MC prevents infections, better that waiting until after infection before the intervention. But all those operations - so many could go wrong.

Claire said...

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Claire said...

Oh yeah- the highest increases are really seen in coast and rift valley!
these are the circumcision rates in 2003:

Nairobi 80.0
Central 89.4
Coast 95.6
Eastern 96.1
Nyanza 46.4
Rift Valley 86.7
Western 86.8
North Eastern 100.0

They seem to correlate well with prevalence, but not at all well with the prevalence change.

Simon said...

Thanks for those figures. I don't mean to diminish the significance of circumcision but I would seriously question the wisdom of giving a huge amount of attention to this at the expense of other things, especially considering the possible risks.

I would also question the commitment of donors. Would they give the minimum required for multiple operations and then step back or would they ensure that all the enabling conditions for such a programme would be in place and make sure that women and circumcised but vulnerable men are also taken care of?

I think they have the latter in mind.