Sunday, November 11, 2012

Limited Funding & Political Support; Will Circumcision Program Collapse in Uganda?

The main drivers of the voluntary male circumcision (VMMC) program in Kenya appear to be money and politics. Those implementing the program are not particularly convinced of the effectiveness of the program, but they know that millions of dollars have been stumped up for it, and they want some of it. Political leaders have agreed to support circumcision, ostensibly on the grounds that it reduces HIV transmission, but probably because there are good political reasons for doing so.

For a start, most Kenyans are circumcised, and they believe that someone who is not circumcised is a mere child, and not fit to run the country. The Luos don't traditionally circumcise and this is often held against them when it comes to elections, though it is unlikely that tribal disagreements will dissipate just because Luo leaders agree to be circumcised.

It's hard to know where female political leaders fit into this particular scenario, but they seem to be behind VMMC as well. Women I talked to seem oblivious to the fact that VMMC does not even claim to reduce HIV transmission from males to females. They have been convinced that fewer HIV positive men will automatically result in fewer transmissions to women. That this depends on the assumption that almost all HIV transmission is through heterosexual sex does not seem to bother them.

Something no one seems to be aware of, male or female, is that the Luhya, their neighbors in Western province, practice circumcision. Yet HIV prevalence there is high overall, and more than five times higher among women than among men. More Luo women than Luo men are infected, but the difference is only about 40% (as opposed to over 80% among the Luhya). If I was a Luo, I wouldn't place that much faith in the effectiveness of VMMC, especially when it comes to reducing infections in women.

Things appear quite different in Uganda, and I wonder what is really going on there. Has the safe male circumcision (SMC) program really managed to attract 380,000 Ugandan men? It seems likely most of them were boys, which is the case in Kenya. But the two main drivers in Kenya are less prominent there; according to the SMC coordinator, "Pepfar [President's Emergency Plan for AIDS Relief] has given us funds to circumcise 750,000 men. We will mobilise other funds from the government, UN agencies and partners".

Will 'other funds' be forthcoming to circumcise an additional 3.45 million men (or boys)? We could be talking about between 200 and 400 million dollars, at a time when funding is shrinking. In addition, Uganda hasn't exactly made themselves very popular; three major donor countries have just suspended funding pending investigations and a lot of money has gone missing, though nothing close to the figures required to fund a big circumcision program. While Kenya may have a kind of first mover advantage, it seems Uganda and other countries may not even get enough funding to circumcise the millions of people planned.

Abandoning the VMMC program would be good news for countries like Zimbabwe, where HIV prevalence is high, money is in short supply and HIV prevalence is higher among circumcised men than it is among uncircumcised men. There are plenty of better things to spend money on.

But in Uganda, apparently SMC does not even have political endorsement. The program is not integrated with other health services (which makes it little different from other HIV programs), but it is not even integrated with other HIV services. Apparently President Yoweri Museveni has criticized the program, which is surprising, given his enthusiasm for earlier programs that looked even less likely to be effective than circumcision.

Given the money, political support, aggressive promotion and popular rhetoric about circumcision in Kenya (to say nothing of the fact that most people seem quite uninterested), perhaps their claimed achievement of 450,000 circumcisions over about four years is credible. But without political support and with only a fraction of the money required, it would be surprising if Uganda's SMC program got any further once the money runs out. If it does, what will they cut back on: trained staff, already in short supply? Or will they cut back on facilities, equipment, safety, follow up care, or just all health provision that does not relate to circumcision? Perhaps they can do without the anesthetic, or just reduce the dosage, reuse syringes or gloves?

No amount of aggressive marketing can drive a mass male circumcision program if the money is not there. Without money, political support will quickly melt away. The puny 'public health' arguments for the program, which seem so 'compelling' when supported by a few billion dollars, will be seen in their true light once the funding dries up. If the circumcision program collapses, perhaps Ugandans will even find better ways to spend their dwindling health budget and redeploy their few trained health professionals. But perhaps Ugandans will first try to find out why HIV transmission rates are still so high after years of massive spending on HIV and hardly any spending on other health issues. And that can only be a good thing.

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


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