Circumcision and Other Interventions: Is the Real Enemy HIV or Sex?

Much of the HIV related work that has taken place in African countries over the last couple of decades has concentrated almost entirely on sexually transmitted HIV. There were probably measures taken in the 80s and perhaps even in the 90s to reduce transmission through unsafe healthcare and other routes of infection. But these have been discussed less and less, to the point where it is now generally stated that almost all HIV transmission in African countries (but not elsewhere) is a result of unsafe heterosexual sex.

You may think that this bias towards sexual transmission has resulted in significant falls in incidence (yearly rate of new infections) in countries that have received the bulk of HIV funding. But you'd be disappointed. Uganda has always had a special place in the HIV literature because, whatever happened there in the 80s, HIV prevalence dropped and stayed relatively low since some time in the 90s. But in the last six years (specifically, from 2004-05 to 2011) the percent of Ugandan adults with HIV increased from 6.4% to 7.3%. But the increase in the number of infections is much more, because Uganda’s population increased by 24% over that period. Taking into account more people, of which a higher percent are infected, the number of HIV infections in Uganda increased 40% over those 6 years. Uganda is no longer a success story.

In contrast, Burkina Faso is a country where HIV interventions have not been nearly so well reported and celebrated in the international press. Yet the percent of adults with HIV in Burkina Faso fell by almost half over the last 7 years, from 1.8% to 1%. During this period, taking into account population growth, the number of HIV infections dropped by 37%. Another country where prevalence (the percent of adults infected) has dropped in the last 5 years is Zimbabwe, during which time many aid agencies and donors suspended their work in the country. Prevalence has remained stable but very high in Lesotho and Zambia, but it has increased in Ethiopia. Although the percent of adults infected remained stable in Rwanda, the number infected increased with population growth. [The last two paragraphs have been amended as an earlier version contained several errors.]

So could there possibly be something wrong with the behavioral paradigm, the view that almost all HIV is sexually transmitted? This is not to suggest that HIV is never transmitted sexually, but just to raise the question of how much is transmitted sexually and how much is transmitted in other ways, such as through unsafe healthcare and cosmetic practices. These are not popular questions to raise, but they should be raised now that the orthodox view seems to have such little impact on the epidemics on which so much effort and money have been spent.

People I spoke to in Western and Nyanza provinces in Kenya, and most other people I've spoken to, have assured me that HIV is almost always transmitted sexually. They do, when pushed a bit, mention other modes of transmission, but they don't believe these are particularly important. Some will even tell you about how most people have lots of sex with different people all the time, not usually the person you ask, but other people, naturally. Sex is said to be generally unprotected, involving multiple partnerships, and even concurrent partners. There is also said to be a lot of alcohol abuse, which is seen as inevitably leading to sex and HIV transmission.

It is hard to get people off the subject of sex, the sex lives or others, of course. Even some people working for HIV NGOs realize that not all HIV is sexually transmitted, but they haven't time to research the issue and they will not do so unless there is funding available. There is good money in just accepting the behavioral paradigm. Others dismiss non-sexual transmission and say that it has been shown to be insignificant. I met one person who asked how UNAIDS and the HIV industry could believe that most people had the time, opportunity or inclination to have lots of sex with lots of different people and concluded that they had not actually checked, but such insights are rare.

When persuaded to name modes of transmission other than sex and related activities, some people mentioned unsafe healthcare. Some, independently of the issue of unsafe healthcare, said it was not possible to question anything in healthcare facilities, that the people working in them were secretive. But most people referred to such phenomena as if they didn't think they occurred much. One referred to 'negligent' doctors or quacks reusing sterile needles and others talked of 'village' or 'community' doctors (who are often not doctors at all). A traditional birth attendant said that they often don't have enough sterile supplies themselves, and also that some hospitals, such as village hospitals and dispensaries, are not safe.

Few people mentioned that HIV can be transmitted through unsafe cosmetic practices, such as hairdressers, where razors and other skin piercing instruments may be reused without adequate sterilization. One person had even been warned about such a risk at the voluntary counselling and testing clinic (VCT) where he was tested for HIV. However, he lived on the street, neither unsafe healthcare nor unsafe cosmetic practices are likely to the the biggest risks he faces on a day to day basis.

One difference between sexual and non-sexual risks is that the latter are ones that most people would not wish to take, if they knew about them. If sex is risky, that may not be such a disincentive to some people. If they prefer unprotected sex to using a condom they are unlikely to take much notice of advice to use condoms. But it doesn't seem believable that anyone would prefer to receive an injection from a reused, unsterilized needle. It is unlikely that parents would happily see their children having their heads shaved with a razor that had been used on several others, without any sterilization afterwards.

So what about the current Voluntary Medical Male Circumcision program (VMMC)? Is it safe? Healthcare facilities in Kenya are not safe, research has shown this, without any resulting action to improve safety. Research carried out before the VMMC program started made it quite clear that circumcision in health facilities was very unsafe and circumcision carried out in traditional settings was even worse. But rather than improve conditions in health facilities, a parallel health structure was set up with the sole aim of performing circumcisions. The tens of millions of dollars so long denied to health services was made available to a program that does nothing but circumcise men.

Like many parallel or vertical health programs, a lot of effort went into producing publicity materials claiming that VMMC was not just about HIV, and that it was not only beneficial to men. But this was similar to the research produced to show that such a multibillion program is worthwhile: very unconvincing. Of course, not so much convincing is needed now they have their money. VMMC clinics are probably safe. It's just that other types of health facility are at least as unsafe as they were before. Some probably have fewer trained healthcare workers and some are spending a lot more time on circumcisions, which are never urgent, but are very lucrative.

HIV continues to be treated as if it is in some way different from other diseases, with the result that people can continue to suffer from other diseases, often easily prevented or treated, as long as they are subjected to the popular HIV interventions, that almost always target sexual behavior and now include male circumcision. But targeting HIV as if it is exceptional among diseases has, by and large, failed. If that is because HIV is not always sexually transmitted, male circumcision programs will also fail to have much long term impact on transmission rates. It's almost as if reducing HIV transmission is not really a priority of the VMMC and broader HIV industry.

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