Circumcision is Great; (Almost) Everyone Says So

I have been writing up my findings about circumcision and HIV from my visit to Western and Nyanza provinces in Kenya so I haven’t had time to concentrate on blogging. But this post will be about a group of findings and subsequent posts will look at other groups. There are seven groups of findings, representing the seven major themes I could identify. Of course, anyone else looking at the same findings might divide things up completely differently, but that’s the way with qualitative findings. In fact, you could say the same about a lot of quantitative findings, but scientists tend not to draw attention to any of the more subjective aspects of their writings.

The most common finding was that most people believe what they have been told, that circumcision reduces HIV transmission. Most follow this by saying that it only gives partial protection and that other precautions need to be taken to reduce the risk of HIV transmission further. The ‘60%’ level of protection was cited far and wide, though no one attempted to redescribe it or explain what exactly it means. But despite at least 20 people expressing the above finding, only four Luos, the main target of the exercise, had been circumcised under the current Voluntary Medical Male Circumcision (VMMC) program; one of them worked for the program and another was a traditional Luo leader, who agreed to be circumcised to help promote the program. A boy who lives on the street and a third level student were the other two. Sexual risks are unlikely to be the worst threat to the health of the former and the latter didn’t seem to face any serious sexual risks.

Six were women, some were from tribes who already circumcise, some had been circumcised for other reasons, often as an infant, for religious reasons. Three were all in favor but were still considering having the operation. One said all the right things about VMMC, as he promotes the program and recruits people to be circumcised. But he then made it clear that he didn’t actually believe any of the rhetoric, he just said it because it was made clear that he would have lost his job otherwise. Another who worked for the program praised VMMC vigorously but when I pressed him about higher health priorities he agreed and said that donors decide what priorities donor money should be spent on.

Another man who worked on the program, an ex-pat, said that the evidence is not strong but it is sufficient, that it is getting stronger, that it could be worse, that some public health programs are supported by weaker evidence, that some vaccines offer a lower level of protection, that you don’t know until you try it, and that that is the way public health and science work. While he may be right, he is one of the most senior public health experts working on the program, this is not the ringing endorsement that VMMC receives in the press or in UNAIDS, WHO or other institutions’ colorful brochures.

There seems to be a belief that cleaning a circumcised penis is easier and more effective than cleaning an uncircumcised penis, though this is not one of the findings of the oft-cited randomized controlled trials used to promote circumcision as a means of reducing HIV transmission from females to males. The senior expert working for the program said he had never heard of the limited amount of research that had been carried out into penile hygiene but later said he remembered it, but also that it was inconclusive. In fact, what the research found was that washing directly after sex increased the risk of HIV infection, whether circumcised or uncircumcised. Waiting for at least 10 minutes and then cleaning with a dry cloth was said to be the most effective means of reducing risk.

The VMMC employee expressing such strong views about donor priorities said he thought it was easier to put on a condom after being circumcised. But the man engaged in promoting VMMC said that for everyone who expressed such subjective views, you could find people who expressed the opposite view. Several women said it was easier to wash a circumcised penis but they conceded that a circumcised man can still fail to wash himself. Surprisingly, with all the talk about hygiene, none of them pointed out that they live in slums, with no running water or proper sanitation. An extreme example was the boy who lived on the street, who was given a lift ‘home’ after the operation and left to look after the wound while living wherever he could find shelter.

A senior health worker working with the VMMC program was willing to concede that appropriate penile hygiene in conjunction with safe sex practices may obviate the need for circumcision but said, on balance, that people just don’t wear condoms. He was not able to suggest why circumcision should promote condom use if behavior change communication interventions had not done so in the past and he agreed that some of his claimed advantages of circumcision did not correspond to findings from randomized controlled trials.

While some said that circumcision can reduce other STIs, none said which ones, or what level of protection could be expected. Some had to be prompted to list other advantages of circumcision and none mentioned that using condoms reduces transmission of STIs, as well as HIV. Only one person mentioned the use of condoms to prevent pregnancy. After years of public health programs about ABC (Abstain, Be faithful, use Condoms), only two people mentioned abstinence and none mentioned being faithful as a means of reducing HIV transmission. ABC itself was not explicitly mentioned.

A couple of people working for NGOs said that they don’t apply for anything they won’t get funding for, and they know that they won’t get funding for HIV interventions that do not target sexual transmission. A senior public health worker said that he could apply for funding to address something like unsafe healthcare, but he knows it would be pointless, that he would not get any money for it. Some don’t believe VMMC will have much impact, others are indifferent to the question of impact, being more interested in funding, faith or politics than mere effectiveness.

Few people publicly question or oppose circumcision, although a few are opposed to infant circumcision and forcible circumcision. Several mention that VMMC received the ‘blessing’ of traditional and political Luo leaders. But even some of them believe that political support may have been a result of political motives, rather than the claimed public health benefits of circumcision. Luo politicians and the Luo electorate are tired of the discrimination against them that is said to stem from the belief held by members of circumcising tribes (the majority of Kenyans) that until one is circumcised, one is a boy, and that an uncircumcised man can not be president.

Several religious leaders from a sect that practices circumcision spoke of the benefits of the operation. But their pronouncements on the subject were mixed with exhortations to ‘preach the gospel’ and it became clear that they did not distinguish carefully between information about circumcision and more spiritual forms of guidance. Their Sherriffs, who perform the operation, are said to be very experienced. But it has also been said that so many people claim to have the special powers required to perform circumcisions that the church had to issue decrees to stop some from practicing. A businessman who is a member of the sect said he had been circumcised at infancy, but expressed some doubt about the effectiveness of circumcision in reducing HIV transmission because prevalence is also high in areas where there are many church members, such as the area he comes from.

So you could easily use the above findings to promote circumcision by reporting the bits that make it seem like an effective and popular intervention. That seems to be what those writing the publicity for VMMC do. The claimed 450,000 people who have been circumcised under the program may be true. But how many are not yet sexually active, no longer sexually active, HIV positive, from tribes that already circumcise or already so enthralled by mainstream HIV rhetoric that they would be circumcised anyway, so they are probably not high-risk in the first place? We may one day get answers to those questions. Meanwhile, those who are most at risk are, apparently, staying away in droves.

This is a useful scenario for those working for the program. If most of those being circumcised do not face high risks of being infected with HIV, they will form a low HIV prevalence group, who all happen to have been circumcised. If most of those who face high risks are currently not being circumcised, they will form a high HIV prevalence group, who all happen to be uncircumcised. And if anyone who is circumcised happens to become infected with HIV, they can be accused of engaging in 'unsafe' sexual behavior. Since most sexual behavior can be construed as unsafe in high HIV prevalenc areas, the VMMC program should continue to look like a great success.

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