Tuesday, October 16, 2012

Circumcision: Lake Victoria Overrun by Red Herrings and Cod

This is the fifth post where I summarize another group of findings from my recent visit to Nyanza and Western Provinces in Kenya, asking people about HIV and circumcision. The first, second, third and fourth are all available and the complete findings will also be made available in due course.

HIV is said (by UNAIDS, WHO and various other institutions) to be almost always transmitted sexually in African countries. Therefore, in the highest prevalence parts of African countries, it must be wondered what kind of sex explains such very high rates. For example, in parts of Kenya rates are very low, such as Northeastern Province. In others, rates are high, such as parts of Nyanza and Nairobi. Among the Luo population of Nyanza, HIV prevalence is was said to stand at 20.2% in the 2008 Demographic and Health Survey (DHS), compared to 6.3% in Kenya as a whole (and even lower among the Kisii and Kuria tribes of Nyanza. But Luos don't appear to have any idea why HIV prevalence should be so high among their tribe, compared to other tribes.

A common suggestion is promiscuity. The DHS does find that some 'unsafe' sex indicators are higher for Luos, but some are lower. And overall, Luo sexual behavior does not seem to explain such inordinately high HIV rates. Yet the head of a clinic that carries out circumcisions simply listed promiscuity, along with various other factors that are often cited for high prevalence in other countries. He did not suggest that levels of promiscuity are higher among Luos, or that their sexual behavior is in any way more risky. Nor did he explain why HIV prevalence does not correlate very clearly with sexual behavior, in Kenya or in any other country.

One community leader, when told that promiscuity can also be common among non-Luos (and non-Africans) without HIV prevalence being high, said that Luos have more sex, do not practice circumcision and do not use condoms. A former public health researcher does not believe that circumcision is the reason for high HIV prevalence but can offer no explanation as to why rates are so high among Luos. A high school student said that Luos may not all be promiscuous but a lot of poor people, mainly females, have sex in exchange for money. Others talk about promiscuity as a reason for high HIV prevalence in general, not just among Luos.

The issue of widow inheritance comes up several times but no one can say how common the practice is. One woman talked of lots of women losing their husbands and being inherited, another says that widow inheritance is 'very common'. A pastor of the Nomiya Church said that if you inherit you will be infected and pass the virus on, although his church also permits this practice. The pastor also mentioned 'traditions' in passing and said that some people think HIV is caused by ‘chira’, taboo. He said that some practices of traditional medicine may also risk transmitting HIV. But he believes HIV transmission is mostly sexual.

A college student said that some males ‘get involved’ with married women, especially widows who have a lot of money, but he does not mention the practice of widow inheritance. However, a former public health researcher said that widow inheritance is no longer practiced much, except perhaps in remote areas, and is unlikely to be an important factor in HIV transmission. He feels that the same applies to other traditional and tribal practices.

One student suggested that younger females have sex with older males for money, and that this is a result of poverty, but that not many younger males do this. Another student said that Luo teenagers can ‘walk with girls’ (a euphemism, also used by someone who was told to avoid 'women who walk around') and be infected with HIV that way. A religious leader and a traditional Luo leader said that some women have extramarital sex in exchange for money, both adding that it was as a result of poverty. A market trader said that Luo people like ‘raha’ (enjoyment, happiness) and translated this as ‘prostitution’. She said there were high rates of unemployment among young people and a shortage of money, leading to transactional sex.

A man who performs circumcisions remarked that most people in high HIV prevalence areas were very poor and that some may have sex as there is nothing else to do. Perhaps this can be compared to a discussion I attended among HIV peer educators in a rural area of Western Province, who were being taught that idleness leads to HIV transmission because idle people are tempted to engage in unprotected sex. But more commonly, transactional sex was said to be a result of poverty, to which a lot of HIV transmission is attributed.

The phenomenon of ‘jaboya’ is often cited as a reason for high HIV prevalence among Luos who are involved in the fishing trade. It is said that fishermen require women to sleep with them if they want to get the best fish to sell. A public health researcher mentioned jaboya as a possible reason for high prevalence in some villages but also pointed out that HIV prevalence can be just as high in villages that have little to do with the fishing industry. But a recent report on HIV prevalence by occupation in Uganda found that HIV prevalence is not exceptionally high among fishermen (or transport workers, who have had the collective finger pointed at them since the early days of HIV).

A religious leader also cited the behavior of fishermen, saying that they ‘lured’ women with fish and money and engaged in transactional sex. A market trader, not herself involved in selling fish, said that young ladies like fishermen and that they have sex in exchange for fish. But the issue of jaboya was hyped by the media some years ago and there seems to be very little real research into the phenomenon, with citations all appearing to lead to the one, somewhat questionable, source.

Polygamy is a popular hobby horse in the HIV industry, although much of the evidence suggests that HIV prevalence is often lower in polygamous societies. A teenager from the Kisii tribe said he thought HIV prevalence was higher among Luos than Kisii because the former practiced polygamy and the latter did not. A health researcher suggested this as a possible reason for high HIV prevalence among Luos and a community leader said that HIV can be ‘brought into the house’ (a sort of euphemism) in a polygamous family unit, but this was not just in relation to Luos. She later said that housegirls are often the ones who ‘bring HIV into the house’. Housegirls have been blamed for many things in the past, including HIV, although there is no evidence that prevalence is exceptionally high among this group (despite the fact that their employment and living conditions are often appalling).

There are lots of posited explanations for high HIV prevalence among Luos, but many are the same explanations for high prevalence among other groups. The problem is that 'unsafe' sexual behavior (paid or unpaid) does not always result in high rates of HIV transmission, so why should it do so in some parts of some African countries? Other posited explanations are not exclusive to high HIV prevalence groups, do not appear, under scrutiny, to explain anything, or they are not widespread enough to account for very high rates of transmission.

Voluntary Medical Male Circumcision (VMMC) is being sold to Luos as a viable way of reducing sexual transmission of HIV, though they are being told that almost all transmission is sexual. If HIV transmission is almost always sexual, it needs to be shown why it is so high among some groups and not others, and what kind of sexual behavior, exactly, is involved. Otherwise, the industry may have to carry out some much needed research into non-sexual transmission, at least to rule it out, rather than to continue dogmatically denying it exists, without any evidence whatsoever.

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


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