Pay the Piper; Circumcise Him; Never Mind the Tune

When I ask people why they think 450,000 men have agreed to be circumcised under the voluntary medical male circumcision (VMMC) program currently being carried out in Kisumu, I am told that it's because they are convinced that it will work, that they will be '60% protected', that they will be less likely to be infected with HIV. (Some have even said that they will be less likely to transmit HIV if they become infected, but this has not supported by evidence.) That may sound reasonable enough, people choosing to benefit from a public health program with (allegedly) proven benefits.

But another person who promotes VMMC has suggested that the vast majority of the people who have been circumcised, he estimates about three quarters, are not sexually active men in long term relationships, those who are considered to be most at risk of being infected with HIV. Indeed, people in the areas with some of the highest prevalence rates in the country, areas such as Suba, Homa Bay and Asembo Bay, have been the most difficult to 'recruit'. The easiest to recruit are teenagers, the younger the better.

Another good source of stuffing for the 450,000 figure is people from tribes who already circumcise, but would like to avail of the free and safe operation, something they would otherwise have to pay for. I don't know if those providing circumcision are collecting information about tribes, whether the person would have been circumcised anyway or even if they are getting people who are young to confirm their exact age. Perhaps they are. But the original plan was to target people who are at risk of being infected and who would not normally be circumcised.

Young boys do not face a very high risk of being infected with HIV, especially when they are not sexually active. Any protective benefit that can be expected must wait for another five, ten or perhaps more years. But, apparently, it is easy to 'recruit' whole groups of people who are young, perhaps too young to have had any sexual experiences whatsoever. It seems their parents are willing to give their consent. Even that sounds quite remarkable, but I have yet to ask any parents who have given consent.

This man who was 'recruiting' said that the program has probably now circumcised the bulk of those they can expect to recruit in this way. Others running the program have also confirmed that numbers are slowing down now that they have got the 'low hanging fruit'. But there is another group that will not be protected from HIV through VMMC: people who are already HIV positive. People don't have to agree to be tested for HIV before being circumcised. About 8% refuse to be tested. But HIV prevalence is high even among men in this part of the country (it tends to be lower, sometimes a lot lower, among men in other parts of Kenya). In excess of 15% of men may be infected. This percentage should be lower in the 450,000 if the majority of them are teenagers, of course.

So what percentage of the figure we are given are even considered to be likely beneficiaries of circumcision? It's unlikely to be even half of all those circumcised. Earlier work has shown that the number needed to treat to prevent a single HIV transmission is about 76. But if half or more of those treated are not at risk, the number needed to treat to prevent a single infection must also be far higher. We don't know how high it is. If it is necessary to circumcise 76 people to prevent one infection in randomized controlled trials, that will probably cost around $9000. But if the number is twice that, or higher, then the cost is also much higher than we have previously been led to believe.

One of the people I spoke to was employed to collect data about circumcision for a specific communications/publicity/marketing related project. But the institution funding the research made it quite clear what sort of data to collect and what sort not to collect. It was made clear to this researcher that his job was to find out positive things about circumcision. He pointed out that it very easy to find people who will say that sex is better for them after they have been circumcised, that they are very happy and that their sexual partner also enjoys sex more. But it's also easy to find people to say the opposite. All the researcher needed to remember was which to report and which not to report.

Few people really know how to explain what '60% reduction' means, how to express it to people who actually ask, who are not content just to repeat the phrase whenever asked. Several who are involved in rolling out the program have wondered what the phrase means, not just how to express it or explain it. Clearly, they haven't answered these questions. Over and over again, I hear people saying '60% reduction', as if on cue. Even those speaking in Swahili or in the Luo language use the exact English phrase, which is the usual way with unfamilar terminology, such as 'abstinence', 'faithfulness' and other terms that people trot out with alarming regularity.

In addition to the evangelical fervor and the ready repetition of campaign mantras, the VMMC program approached Luo political leaders very early on. I have talked to Luo elders (who are cultural rather than political leaders) and they did not wish to say whether they thought Luo politicians agreed to be circumcised themselves to persuade their people it was a good intervention, or for political reasons. But the tribe as a whole does appear to have been persuaded. Even though adult men who are in long term relationships, those who are most likely to be infected, seem to be staying away in droves, there are a lot of parents who are giving their consent to their teenage sons being circumcised. One Luo elder felt the program was not well implemented and should be rethought. Another felt that he and his fellow Luos may not have been told the full story about circumcision or about HIV.

VMMC proponents are fond of pointing out that those who agree to be circumcised are also given various pieces of information about 'safe sex', abstaining, being faithful, using condoms, etc. This sort of behavior change communication (BCC) has been around for some time and it doesn't appear to have been very successful. Indeed, the lack of success of BCC is sometimes used as a reason for trying VMMC, even though VMMC itself may not have much impact. Why the two in combination should be worth all this effort and money when there are other priorities is not clear. But there is a clear get out clause here.

When something like pre-exposure prophylaxis (PrEP) or vaginal microbicides or treatment as prevention or anything else doesn't work very well, those pushing the programs blame the participants. They say that adherence wasn't very high or that people didn't use the drugs properly. This may, of course, be true. But in the case of VMMC, you either buy into it or you do not. So if it doesn't work, the proponents can simply say that participants did not adhere to the various pieces of BCC that were employed: they didn't abstain, they had more than one partner, they didn't use condoms, etc. We know in advance that many people will not take much notice of BCC if they haven't done so in the past. So any HIV infections among men circumcised during the program can easily be explained away. And, naturally, any reduction in infections, or anything that can be presented as a reduction in infection (many of those being circumcised are not at very high risk anyway) can be claimed as evidence that the program was brilliant.

HIV programs have been run by foreign donors since the beginning. Otherwise, we might know a lot more about why some people, especially Luos, are infected in such high numbers. We might not have depended on programs that sounded quite stupid when they were first mooted (BCC, for example). And we might never have seen a program that is doomed to failure, but has been dressed up to look like a success before it has even been completed by forms of false accounting that proponents have been developing, unchallenged, over the years. Driven by greed, ambition and a large amount of bigotry, it is a long shot to get Kenya to take another look at the HIV epidemic and question the emphasis on sexual transmission, and to question the VMMC before it goes any further. But it would be a good start if Kenyans themselves started to ask questions.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]