This is the last blog post that draws on findings from my visit to Kenya to interview people about HIV and circumcision. We could go on forever mounting an attack on the Voluntary Medical Male Circumcision (VMMC) program, with those in favor mounting a defense. But my main aim was to hear what people thought about HIV and VMMC, why some were convinced and why some were not. And the most stunning finding for me was how little people seem to question the various programs that are presented to them, whether they relate to HIV, health, education or anything else.
While it could be claimed that most people are convinced that circumcision will reduce HIV transmission, most sexually active men seem to be giving it a miss. They make up the most significant group that would face high HIV risk through sexual behavior. The majority of the hundreds of thousands of people that are claimed to have been circumcised under the program are either in their teens or in their early twenties. But they do not tend to face high HIV risk through sexual behavior.
Another group that seems convinced that VMMC will reduce HIV transmission is women. But they, along with most men I talked to, don't seem to be aware that the 'evidence' from various oft cited trials is about female to male transmission, not male to female. Promoters of VMMC say that transmission from males to females will also be reduced because there will be fewer HIV positive men, but they neglect to mention that far more women than men are infected with HIV, even among circumcising populations. In addition, women seemed convinced that circumcision reduces HIV transmission because being circumcised is more hygienic, yet this is not a finding of any research.
A worrying aspect of the association of HIV with hygiene is that many women seem to believe, incorrectly, that they should wash their genitals thoroughly after sex (or before, or both). Research has shown that this tends to increase the risk of infection with HIV and possibly other STIs, and there has even been research into how best to reduce this practice. Penile hygiene is also not so straightforward. Some research has shown that it is better for men to wait a while after coitus and then to wipe with a dry cloth, rather than using water and other agents. This may well be far more effective in reducing HIV transmission than circumcision.
It was shocking to me to find so little doubt about the possible effectiveness of the circumcision program. Sometimes those promoting the program claim that previous HIV prevention interventions have failed or have not worked well enough, even though they need to continue advising people to 'abstain', etc (though this may be a good time to choose more appropriate concepts, ones that people understand). Nobody seems to ask why they should believe that VMMC will work any better than ABC, VCT (Voluntary Testing and Counselling) or various other efforts, or why previous efforts that had so little impact are still being promoted.
Those working on the program are clearly far less convinced about the potential effectiveness of VMMC, though they can be quite defensive. They can cite the various 'advantages' of circumcision, but without the almost religious conviction of people who are not so well educated. But ultimately, they seem to be doing it because they get paid to do so and because they can. It's as if they would immediately get behind a campaign for anything else, should the money be forthcoming.
Sexual behavior change and instances of behavior change were frequently mentioned as ways of avoiding HIV in conjunction with VMMC, particularly condom use. It is clear to people that VMMC on its own is not enough. The head of a clinic that performs circumcisions conceded that behavior change and appropriate advice about genital hygiene may be enough, without circumcision, except for the fact that people do not generally use condoms. But no one questioned the continued need for behavior change if they agreed to be circumcised, nor did they question the need to be circumcised if they did not engage in unsafe sexual behavior.
Several people said they believed HIV was related to poverty, but they didn't ask why poverty reduction was not one of the aims of the VMMC program (or any other large scale HIV program), and only one talked of the need for economic interventions. Those who thought circumcision was 'hygienic' did not ask if access to clean water and adequate sanitation would soon follow, as circumcision without the means for washing would still be completely useless if it was just a matter of hygiene. Similarly, a few associated HIV infection with 'idleness' and several more said it was a matter of unemployment or even boredom. But none asked if creation of employment opportunities was not at least as important as what may only be a slight reduction in HIV transmission.
Although one of the VMMC documents claims that up to one infection could be averted for every 15 circumcisions carried out, the figure during the trials was probably closer to 1/75, so at the community level it's likely to be a lot less effective. But very few raised the issue of methods for HIV positive people to avoid transmitting HIV, even though the VMMC program also circumcises people who are positive and people who don't wish to know their status. We don't have a figure for how many circumcised HIV positive people might result in one or more transmission.
Many people talked about condoms though, perhaps because they were so intent on discussing HIV, they didn't mention their effectiveness in preventing transmission of STIs; only one mentioned condoms as a means of reducing unwanted pregnancy. Perhaps people assumed that the failure of condom promotion programs so far to reduce transmission much is because many people still don't use them, but they didn't raise the question of why people would use them more just because they have been circumcised, or why they should bother being circumcised if condoms work so well.
An interesting question may also be why this campaign seems to be entirely funded by the US, with mostly Americans and American paid people doing the research and implementing the program at all levels. Is there something about American culture that allows such a program to go ahead, with enough public support; or at least, without much effective opposition? One might ask the same question about the ABC (Abstinence, Be faithful, use Condoms) campaign, particularly the version that emphasized abstinence for all, faithfulness for those in a long-term relationship and condoms, but only for those in discordant relationships (where one partner is HIV positive and the other is not).
Both VMMC and ABC sometimes attract similar criticism; for example, would this sort of campaign be carried out in the US and would it work? Circumcision is still quite common in the US among sexually active men, but HIV prevalence is higher than anywhere else in the Western world. ABC (or whatever version they used in the US) failed completely, for HIV, unwanted pregnancy and sexually transmitted infections, which are far less common in many European countries where campaigns resembling ABC or VMMC campaigns have never been considered. Only one person questioned the right of another country to impose this kind of intervention on Kenyans.
My impression is not that the VMMC campaign has failed to persuade people that they should get circumcised. Sadly, I suspect that even a lot of the people who are not lining up to be circumcised think that it really does reduce HIV transmission, they just don't fancy it for themselves. But a lot of parents appear to be giving their consent for their teenagers to be circumcised, so they must have been convinced, whether by the campaign or by their teenagers. But the lack of questioning or debate about VMMC is astounding. In this sense, the campaign resembles many of the HIV campaigns that went before.
Most of the people I spoke to live in terrible conditions and they never asked why circumcision should take priority over decent and safe housing and communities, water and sanitation, accessible and safe healthcare, good education, employment opportunities, infrastructure, facilities for disabled people, and all sorts of other things that are crying out to be addressed. I can not conclude that because people didn't mention any of these that they are therefore not important. But I wonder if what is left unsaid about HIV, circumcision, sexual behavior, health and the rest might also be a lot more important than what is said.