Monday, October 15, 2012

Circumcision: Neither Right Nor Wrong, Just Funded

Aside from many people in Nyanza that I spoke to being convinced that circumcision reduces HIV transmission, some also mentioned lack of clarity, information bias and/or lack of information, or showed signs of being confused about the VMMC program (Voluntary Medical Male Circumcision). Some said they were completely influenced by the mainstream view about HIV being almost always transmitted sexually in African countries, and that therefore they believed VMMC could be effective. They agreed that there was room for doubt, but also said that they did not have the scope for questioning the mainstream view and they were aware that many funding sources require a strict adherence to this view.

One person working for the program said he was obliged to find and disseminate positive things about VMMC and ignore or quash negative beliefs. Another, who worked in public health, said he and others in the field had to work on programs that would get funding. VMMC gets a lot of funding, as do many projects that assume that HIV is almost always transmitted through heterosexual sex in African countries. But projects to improve health systems, water and sanitation, nutrition or neglected tropical diseases will not generally get funding, unless they can be shown to relate to HIV transmission in some way. Even programs that have no connection with health, education or the like are often required to show how many HIV positive people benefit or how many ‘AIDS orphans’ will benefit, etc.

Only one person pointed out that circumcision does not appear to protect Americans, yet the funding for VMMC all comes from the US. He feels the program is being forced on Kenyans at all costs and was also aware that HIV prevalence is low in Europe, where circumcision is generally not common.

A traditional Luo leader feels that he and other senior Luos were not given access to all the information available when they were being lobbied to get behind the program, although he was the only respondent to be clearly aware that HIV prevalence is as high among circumcised as uncircumcised Luos. Another traditional Luo leader felt that he and his fellow Luos were not always given clear information and that important issues may not have been addressed, such as the question of why many people in other circumcising populations are HIV positive. He still believes the program can work but also feels that progress needs to be evaluated on an ongoing basis and that adjustments may need to be made over the duration of the intervention.

A senior government officer had given the matter of sexually transmitted HIV a lot of thought and, understanding the connection between circumcision and sexual transmission, did not feel it had ever been explained why HIV prevalence was so high among Luos. He said he didn't think Luo women had 'more sex' than women from other tribes. In contrast, another senior government officer accepted the mainstream view about HIV and fully supports VMMC. A religious leader in Nairobi appeared to know little about HIV, despite working with sex workers, refugees and others thought to be at elevated risk of being infected.

There are several striking examples of gaps and imbalances in the kind of information people appear to have had access to. A local government leader from a circumcising tribe said there are a lot of misconceptions about the sort of protection circumcision gives and that some women think there are no HIV related risks with circumcised men, that they are ‘safe’. A market trader, who believes VMMC will be very effective at reducing HIV transmission, also believes (incorrectly) that HIV prevalence is always lower in areas where circumcision is widely practiced. A pastor I spoke to seemed relatively well informed about HIV, but he had trouble separating information from spiritual guidance. A traditional birth attendant, who has also worked as a community health worker, says she is confused about whether circumcision really reduces HIV transmission and would like to know where the idea comes from. She also says that her clients and community understand little about HIV.

A ‘street kid’ was encouraged to be circumcised by his girlfriend, who believes it ‘prevents’ HIV, but neither seem to realize that it is only thought to reduce transmission from females to males. Although this man was informed about non-sexual as well as sexual risks, he was not aware that circumcision only reduces transmission through sex. Another ‘street kid’ had been persuaded to have the operation and was told that it would be more painful if he waited till he was older, but he was already 15 and the claim that it would be more painful sounds quite dubious. People who are considered to be too sick to be circumcised immediately are supposed to be treated first, and then circumcised later. But it seems that people who live in conditions where circumcision would always involve risks for them are not so lucky.

Many spoke of a need for further research, for example, a former public health worker who does not oppose VMMC but does not think it will work very well. He said the evidence for the effectiveness of circumcision in reducing HIV transmission is not strong and that there has been little research into non-sexual modes of transmission, including unsafe healthcare. Someone involved in the program agreed that evidence is weak but said that it is getting stronger as time goes by and that in scaling up VMMC they are also seeking new evidence. The head of a clinic that performs a lot of circumcisions also said the evidence is not that strong and that the level of protection from circumcision may be lower outside of a randomized controlled trial, but that he does not yet know what level of protection can be expected as they are only four years into a ten year program. However, he also said the decision to concentrate on circumcision and less on any other HIV and health interventions was one taken by donors, not by people working in healthcare.

Several people asserted that what they had been told about VMMC was ‘science’. A religious leader said we should proceed with VMMC because research has shown that it works. A senior government official describes the 60% protection as ‘scientifically proven’. But a senior public health expert working on the program did not emphasize scientific certainty at all, saying that ‘you don’t know until you try it’ and that this is always the way in science and public health. He did emphasize agreement among normative agencies, donors and the great majority of scientists, though. He pointed to the evidence that is being gathered about the effectiveness of VMMC since the program started, rather than the evidence from several randomized controlled trials.

People who refer to ‘scientific’ and ‘official’ findings are often thinking of three randomized controlled trials that purport to show that circumcision reduces sexual HIV transmission. But they are unaware that it was not shown that all incident infections during the trial were sexually transmitted. A number of people seem to think that circumcision reduces HIV transmission per se, although it is only thought to reduce transmission from women to men. No one raised the possibility that the operation may not reduce, and may even increase transmission, from men to women. The potentially dangerous fact that HIV positive people can be circumcised under the program, whether they know their status or not, was not raised except by someone working for the program.

Sometimes the VMMC propaganda machinery is very efficient. People I spoke to do not adhere to the ‘no risk’ myth about circumcision, the belief that once you are circumcised you don’t need to take other precautions. On the contrary, most people mentioned the 60% figure and added that other precautions were still necessary, often without any further questioning. Some do attribute the ‘no risk’ myth to others, however. But whether circumcised or not, many are clear that the effectiveness of VMMC still depends on individual sexual behavior.

Despite this, one man who works in a VMMC clinic does not seem to believe that people will take behavior change related precautions once they are circumcised, especially as behavior change communication does not seem to have had much impact in the past. He believes that VMMC may provide some protection even to those who do not use condoms, and (somewhat inexplicably) that the combining of circumcision with other precautions will work better than they did before VMMC was implemented.

Only two people talked of deliberate transmission of HIV. The first said that HIV positive people did not want to die alone and that they would ‘donate’ their HIV to as many people as possible. She also believes that there are several signs by which one can tell a person is HIV positive. She thinks VMMC will help but that HIV positive people need to be more careful. The second is a traditional birth attendant and she also uses the term ‘donate’, saying that this is sometimes a revenge for being infected. Apparently associating being HIV positive with particular behaviors, she said that HIV positive people drink a lot in bars as they ‘donate’ HIV.

I was surprised to hear a health worker on the VMMC program saying that women on antiretrovirals can be the most desirable in a community as they look so healthy and fat. But a senior government officer said almost the same thing when asked to give her opinion on HIV and circumcision. A mother and housekeeper said that if someone is thin and then receives ARVs, they get fatter and change in other ways too. But she also said that you can tell when someone is infected because they have spots and boils, different skin color and that the part of the face next to the mouth is fatter.

Billions of dollars have been poured into HIV, although transmission rates (incidence) do not seem to have changed much in the last ten years in Kenya (or even Tanzania or Uganda). So people can be expected to be familiar with the HIV flavor of the month, which in Nyanza right now is circumcision (VMMC). Gone are the days when the first thing some would talk about is ABC (Abstain, Be faithful, use Condoms) or even VCT (Voluntary Testing and Counselling). Abstinence was mentioned twice, condoms were mentioned perhaps because they are a focus of the circumcision program, but being faithful was barely mentioned and being tested was only mentioned once. No one used the term 'ABC' at all.

Various elements of the VMMC party line are repeated with almost religious fervor by most people when you ask them about their views on HIV and circumcision. Even Luos repeat the various posited explanations of exceptionally high HIV prevalence in their own tribe, though these explanations are both insulting and unsupported by evidence. Many object that HIV prevalence can also be high in circumcising populations but, despite being given no adequate response to this, an alarming number seem to have given their consent (arguably 'informed' consent) for their teenage boys to be circumcised. It seems that in the HIV industry there is no right and wrong, only funded and unfunded.

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


1 comment:

Soggy Mom said...
This comment has been removed by a blog administrator.