Saturday, November 24, 2012

Aid and Circumcision: Just Because We Can and Because We Want To?

There is a constant stream of argument and counterargument between those who oppose and those who support mass male circumcision (MMC), the one side saying it doesn't reduce HIV transmission and the other saying it does. I am opposed to promoting MMC as a HIV prevention intervention, not because it doesn't reduce HIV, but because the evidence suggests that it only sometimes does. My objection is not that it only reduces transmission by 60%, or whatever figure is currently being bandied about. My objection is that if circumcision is associated with higher rates of transmission in some places and lower rates in others, maybe circumcision itself is not the only factor involved.

Among the mainly non-circumcising Kenyan Luo tribe, HIV prevalence is far higher than among any other tribe in the country. But there is no evidence that it is circumcision alone that results in high rates of transmission. HIV prevalence is also high among women who belong to the Luhya tribe, yet male circumcision rates are very high in this tribe. But in many other sub-Saharan African countries HIV prevalence is higher among circumcised men than it is among uncircumcised men. The problem is, all the arguments that are being used to aggressively push MMC in Kenya are also being used in countries where circumcision looks like it increases HIV transmission. That's if circumcision status on its own has any useful connection with HIV status.

A good example of this phenomenon is Malawi. HIV prevalence among circumcised men is 14%, but among uncircumcised men it is only 10%. While it is not possible to reverse a circumcision operation, pushing MMC would seem to be the most illogical action possible. Apparently the government circumcision program hopes to circumcise 2.1 million males by 2016. But why? Do they want to increase HIV transmission? Personally, I don't think the program will increase transmission very much, because I don't think circumcision status on its own has much impact on transmission, but nor will it reduce transmission.

The government is worried that only 15,000 males have been circumcised under the program, less than 1% of the target population. They feel that "something must be wrong somewhere in the process". Perhaps the electorate is smarter than the government and they can tell that 14% is indeed higher than 10% when you 'do the math'. Maybe some people have noticed the appalling conditions in health services? Or perhaps access to health services is so low that most people don't even notice this any more. Perhaps, like most sexually active men in Kenya, Malawian men just don't see the point in going through the operation. But Malawian men even have the added consideration that HIV prevalence is higher among their circumcised countrymen.

The article says that the Muslim community welcomes the project. But HIV prevalence among Muslims is higher than it is among Catholics, 11.7% compared to 9.4% (although among circumcised Catholics HIV prevalence is very high). In Malawi, as in many high HIV prevalence African countries, prevalence is far higher among urban dwellers than it is among rural dwellers. It also tends to be higher among the best educated, among the employed, compared to the unemployed, and among the wealthiest, and this tendency is particularly strong among wealthy, well-educated women.

Another article claims that Tshwane men (in South Africa) are 'queuing' for circumcision. But this doesn't mean a lot of people are agreeing to the operation, the numbers vaguely referred to seem low; nor does it mean that those doing so are actually men. In this part of South Africa, like in Malawi and Kenya, it is young boys that are coming forward to be circumcised. Apparently they are mostly between 12 and 16 years old. It's a wonder it is even legal to perform an elective operation on such young people.

It could be possible, quite cheaply, to eradicate human parasites that infect hundreds of millions of people. But it seems the aid community doesn't want to do this just because they can. However, with mass male circumcision, the aid community obviously does want to promote the operation as widely as possible, even where the evidence is against it. It is not yet clear why these aid and health professionals want to circumcise tens of millions of Africans, but the reason, according to their own data, can not be HIV reduction. It is hard not to conclude that the aid community is doing this just because they can, and because they want to. But how can this be acceptable?

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



Anonymous said...

There is no medical reason for routine circumcision of boys or men.

The primary zones of male erotogenous sensitivity are the frenulum and the ridged band. These zones are orgasmic triggers. Most people are surprised to learn that the glans penis is one of the least sensitive parts of the entire body. We therefore see: so-called voluntary medical male circumcision (VMMC) in fact is genital mutilation.

There is no evidence that lack of circumcision is a risk factor for HIV infection. Quite the contrary, male circumcision may increase male-to-female transmission of HIV.

CONDOMS protect against HIV, circumcision does NOT.

Edward von Roy

Simon said...

Thanks Edward, I agree that condoms protect against HIV, whether vaginal, anal or various other styles. However, condoms do not protect against HIV transmission through unsafe healthcare, cosmetic or traditional procedures. Circumcision is often performed in unsterile conditions, and standards in health facilities in may developing countries can be extremely low and dangerous. Therefore, it is far more likely that HIV will be transmitted through unsafe circumcisions than through sex of any kind.