Tuesday, March 2, 2010

Mass Male Circumcision: Science or Politics?

Following the claim that a drive to test Kenyans for HIV resulted in 1.5 million people being tested in three weeks, another paper claims that 36,000 (male) circumcisions were performed in two months. I have serious doubts about the first claim and I have serious worries about the future health of the 36,000. In 2004, Kenya had 16 doctors for every 100,000 people and per capita spending on health was $9.10. There were 72 hospitals in Nyanza and 30.3 beds per 100,000 people.

Most of the circumcisions were performed in Nyanza because it's the only province with relatively low rates of male circumcision. In fact, it's only the part of Nyanza where the Luo tribe predominates that circumcision rates are low, standing at about 48%. HIV prevalence is high in Nyanza and especially high among the Luo. It's around double the national rate of over 7%. While this is said to be because of low rates of circumcision, it is not clear whether there are other factors that may result in high HIV prevalence among this tribe.

The scientific papers claiming that mass male circumcision can significantly reduce HIV transmission are notable for the frequency with which they are cited rather than for their great number. And perhaps the evidence is overwhelming, from a scientific point of view. Perhaps this is the one big breakthrough that the world has been waiting for. But some of the areas where circumcision rates already stand at almost 100% in Kenya also have high and increasing rates of HIV transmission. For example, prevalence is rising in Coast province and it is higher than the national average, even though circumcision rates are nearly 100%.

So what awaits Luos who have been circumcised? Some people I have met who are already circumcised believe that they don't need to use condoms and that seems to be a common view. Some even believe that condoms 'don't work' if you are circumcised. Apparently people who are queuing up to be circumcised now are also being given advice about using condoms once they are able to have sex again. I suspect people are getting circumcised because they think they will no longer need condoms. They may well be getting advice that says they still need to practice safe sex, but if they are heeding this advice then they could just skip the circumcision.

The scientific evidence claims that being circumcised reduces the risk of HIV transmission by 60%, regardless of sexual practices, for example, whether a condom was used, whether one has multiple partners, etc. Still, I just don't see what people think they can gain from being circumcised unless they think they can dispense with the need to use a condom. And maybe a 60% reduction in transmission will make some think the risks of unsafe sex to be small enough to be worthwhile.

Kenya's intention to spend $56 million on a small percentage of the population to prevent a handful of sexually transmitted diseases, given how little is spent on health per capita, seems strange. But spending this kind of money on an intervention that may not have anywhere near the effect it is expected to have is rash. Why, in a country that has so many health priorities, is so much being spent on this handful of diseases and targeting this small demographic (adult male Luos)? Yet the main funding sources, PEPFAR, the Gates Foundation and the Global Fund are all behind the initiative.

I hope this mass male circumcision campaign is worth it and HIV transmission rates drop significantly in the Luo population. But I just wonder if people who have swallowed the hype know that they will only be well protected from sexual transmission of HIV (and some other sexually transmitted infections) if they always use a condom, properly. Because if there are any other factors behind high rates of HIV among the Luo, aside from those relating to sexual transmission, it could be some time before they are given any consideration.


No comments: