Why Circumcision? Because it Gets Funded, Stupid!

The received view of HIV in African countries is that almost all transmission is a result of unsafe sex between heterosexuals. But HIV transmission through penile-vaginal sex is not particularly efficient. Only extremely high levels of unsafe sexual behavior among most adults in a population, most of the time, could possibly explain some of the worst epidemics, even some of the medium level epidemics found in East African countries.

By extremely high levels, I mean a large proportion of the population would have to have sex many times a week, some perhaps many times a day, with several different partners a year, and much of that sexual activity would need to be quite unsafe, for example, engaging in sexual intercourse without condoms with people whose HIV status is unknown. Evidence that large numbers of people engage in such high levels of sexual activity, unsuprisingly, is in short supply.

Therefore, models of sexual transmission that purport to explain high rates of transmission need to latch on to the few studies that appear to have found the right sort of evidence. But, while incredible levels of unsafe sexual behavior have been reported, it doesn't seem credible that most people in a population could have the inclination, the time or the strength to do so for a lengthy period of time. But without ridiculously high levels of unsafe sex between most people in a population, the various models of HIV transmission would not explain either high or medium prevalence epidemics.

Some people have wondered about how the received view could become so pervasive. Do most people believe that HIV transmission in African countries is mostly a result of heterosexual sex? If they know that heterosexual sex is a relatively inefficient means of transmitting HIV, they must believe some version of the 'behavioral paradigm', the belief that HIV in Africa (but not in most other countries) is a sexually transmitted virus. So, who is having all this sex, where, with whom, and what is it about this sexual activity that results in very high rates of HIV transmission?

I've asked some people, but they usually trot out the tried and tested reflexes about not using condoms, concurrent relationships, lack of circumcision, bits on the side, migration, intergenerational relationships, lack of empowerment, gender inequality, etc. But I can't find the people who are having lots of sex. I'm sometimes told that it is 'idle people' who spread HIV. But I wonder if this is not a kind of moralistic reaction. After all, many people are 'idle', in the sense that there is very little employment in some areas. And HIV prevalence tends to be higher, often a lot higher, among people who are employed, rather than people who are unemployed.

Other explanations say that employed people have more money and so they can have more sex, paying for it, of course. Where they find the time, I don't know. But who are these people, and is all unsafe sex paid for? Thankfully some people here say they also wonder how people could find time to have sex so frequently, perhaps every day, perhaps even several times a day. But they are surprised to find that there is this received view about HIV transmission, and that it applies to Africa only, that Africans are seen as somehow different.

Disturbingly though, many people accept the explanation. Which makes it easier to argue that 'voluntary' medical male circumcision (VMMC), and various other HIV 'interventions' seem to be so easy to sell to people. It is claimed that as many as 450,000 men have been circumcised in the last four years under the current program. They must believe that circumcision will protect them, at least to some extent, and also that the main risk for HIV infection is sex.

I spoke to a man who is the head of a clinic that does this operation, among other procedures. He is from a non-circumcising tribe, he has been circumcised under the program and he is happy; he says it is 'easier' in bed, that it is easier to put on a condom. I had no idea lack of circumcision made putting on a condom so difficult to some people, but he insists it can be a problem. We discussed the program at length, with me asking questions and even objecting to some of the answers I got, and him laying out all the usual reasons for VMMC. He seemed entirely convinced and nothing I said appeared to shake his faith.

But he and others involved in the program make a potentially very worrying point: the program in Kenya is, in reality, a very big experiment. The randomised controlled trials (RCT) that are often trumpeted as proof that VMMC reduces HIV transmission enough to make the billions to be spent on circumcising tens of millions of men worthwhile, did not really provide strong evidence. The current program is due to last 10 years, which means it has another six years to go. It is expected that the evidence from this 10 year exercise will support the decision to circumcise between 22 and 38 million African adults and possibly tens of millions of infants and children. In other words, it is hoped to be shown that the intervention works after it has been carried out, because there's isn't yet enough evidence for its effectiveness at the community level!

That could mean that Kenyans who are consenting to be circumcised may not be consenting to take part in a trial to demonstrate that VMMC actually works. In other words, an experiment is being carried out on enormous numbers of people without their consent. Even though the Kenyan, Ugandan and South African RCTs suggested that circumcision may provide some protection against HIV, if people also take other precautions, it is even clear to the researchers involved that the results from a trial will generally be better than the results from a program that is not so closely monitored, than the effects of the intervention at the community level.

But it seems the VMMC program is another trial, even though it's not an RCT. It is not known whether the results will be better or worse, or whether there will be other consequences, good or bad. Will VMMC also achieve the sort of changes in sexual behavior it hopes to achieve? Or will the program adversely affect sexual behavior? By the time the program has run for 10 years, around one million more Kenyans will have been newly infected, if current transmission rates continue. If transmission rates decline, will that be attributed to VMMC, just as a decline in transmission rates in the early 1990s was attributed to ABC and other programs that never actually took place?

The man running this clinic asked me what I thought they should be doing, and that's a good question. For a start, I think we should be tracing contacts. For every person found to be infected, identify their risks, identify the people with whom they have had contact, sexual or otherwise. This exercise needs to go beyond sexual contacts because some people, believe it or not, either don't have sex, don't have unsafe sex, or only have sex with their long term partner, who is very often HIV negative. We don't yet know that all or most HIV transmission is sexual, therefore we need to find out first, before implementing programs that assume we already know.

Despite being convinced that VMMC is the way to go, several arguing for it have told me that it requires that people also use condoms, yet they argue that just running programs to increase condom use will not work, because most people don't use condoms. But they can't really say what it is about being circumcised that will increase condom use if most people don't already use them. Behavior change programs that included condoms have been going on for years without having much impact on behavior, the VMMC proponents agree with that. But according to them, VMMC won't work unless behavior change also occurs. It sometimes sounds as if even proponents of VMMC don't really believe it will work, but that it may have some slight benefit. Some even admit that if there is any benefit, it will be slight.

There is also the issue of this program being donor driven. Even the clinic director with the cogent arguments in favor of VMMC, when asked about other health and development priorities, said: 'it is you donors who decide what money is spent on'. And this is no secret. But it makes one wonder what else would be done in the name of HIV transmission reduction if donors were willing to pay. Another health worker was even clearer, saying that people apply for grants to do whatever the grant is offered for. If it is offered for reducing sexual transmission of HIV, it will not be paid to those working with non-sexual transmission.

Several people have told me that Kenyans (presumably they were referring mainly to Luos, amongst whom HIV prevalence is highest) have sex before everything, before going fishing, when they return with their catch, before ploughing, planting, harvesting, etc. I don't know what this means or how it differs from other populations all over the world. But when carrying out research into what it could possibly mean, researchers may need to spend less time concentrating on bars, hotels and other places reputed to host inordinate levels of sexual activity.

Because even people who are not employed need to work. Research should also take in people in fields, down by the river, in markets, workshops, on the sides of roads where work is done and things bought and sold, places where evidence of great sexual prowess may be harder to find. The oversexed Kenyan or African may exist, but is unlikely to be in the majority. And high levels of sexual activity has not been shown to be high enough to result in major HIV epidemics. If VMMC programs are being implemented, ultimately, because there is funding for them, and because they may reduce HIV transmission slightly, this does not justify carrying out an invasive operation on millions of people who seem unaware they are an insignificant guinea pig in a massive human experiment.

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