Male Circumcision and HIV (and the controversy)

Finally, we have an acknowledgment of the controversy. Aside from the occasional comments on these pages from Daniel Halperin, acknowledgment of, much less confrontation with, the strong dissent in the HIV/circumcision discussion has been absent. (And if I am wrong, send me the links.)

So why is it that male circumcision has gotten so much boosterish attention from the HIV/AIDS community when “there does not seem to be a significant difference in prevalence between communities that circumcise, and those that do not” ? It’s a good question about which we can hazard a few guesses.

For example, it isn’t a secret that the primary researchers come from circumcising (or formerly circumcising) countries, primarily the United States and Australia. It also is no secret that there is money to be made and reputations to be built, egos to assuage and desperation to stoke by the sudden appearance of a silver bullet. At this late stage, of course, no one would take claims of a silver bullet at face value. So, the requisite warnings with a wink are trotted out: men still must use condoms, it must be part of a comprehensive approach, men want it anyway, etc.

Northern Zambia, where circumcision is the norm, has the lowest HIV prevalence
in the country. But, according to Mutamba Simapuka of the Maina Soko Military Hospital in the capital, Lusaka, the protective benefits are more than biomedical; young men also receive lessons on fidelity in sexual relationships imparted to initiates.

Hasn’t this been obvious from the beginning? Actually no, not to the researchers who are not social scientists. They would rather skip over this bit of social science data because it makes their scientific conclusions shaky at best, and positively harmful at worst.

When northern men migrate to Lusaka, with its looser sexual mores, “their prevalence
rates equate with the local population”, Simapuka told IRIN/PlusNews.

Clearly, a disaster is brewing as the social forces are ignored and hungry pro-circumcision researchers spread their message. What do these researchers do when real world epidemiological data don’t square with their randomized trials? They create speculative mathematical models, of course. More on that later.

First article in PlusNews’s series after the break.

AFRICA: Overview – At the Cutting edge – male circumcision and HIV

Traditional rites are imbued with far more meaning than just removing the foreskin

JOHANNESBURG, 20 July 2007 (IRIN In-Depth) – Is mass male circumcision the new big thing in HIV prevention, or is it a risky social experiment that threatens to divert funding from tried and tested interventions?

UNAIDS is careful in its assessment: “Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’; it doesn’t provide total protection and it doesn’t mean people can stop taking the safe sex precautions they were already using.”

The caution is a response to the excitement – and debate – triggered by the results of three randomised trials in South Africa, Kenya and Uganda in 2005 and 2006, which seemed to demonstrate that circumcision reduced the risk of HIV infection among men by between 50 percent and 60 percent.

After the slow slog of behaviour-change messaging, here was a simple medical procedure – already widely accepted in many African cultures – that could have a significant impact on HIV acquisition. A broad front of UN agencies, key US-based donors and, recently, African health ministers, have been rallying around an endeavour to make the foreskin history.

Dissent

But there are voices of dissent among some social scientists and researchers. They argue that there is not enough incontrovertible evidence to rush to scale-up circumcision (it is still not even certain how a foreskin increases the risk of HIV infection); and why in South Africa, for example, there does not seem to be a significant difference in prevalence between communities that circumcise, and those that do not.

Frustration over the slow headway made by orthodox AIDS programmes has resulted in “a desperation to find something that works, with a growing lobby for biomedical intervention”, Prof Peter Aggleton, a researcher at the University of London, told IRIN/PlusNews. “It involves the construction of an agenda that claims to be evidence based but where the jury is still out.”

The danger that men will see circumcision as a quick-fix snip, ignoring public health exhortations to also condomise and reduce partners, is acknowledged by both sides of the debate. But the dissidents question why any potential dilution of the latex message should be risked when condoms provide close to 90 percent protection, and it has been such a struggle in the first place to persuade men to put them on.

For Richard Delate, communications director of the South African health and education programme of Johns Hopkins University, circumcision is simply an additional prevention method. “But we need to give men a choice … and circumcision provides an entry point where we can enbgage men to talk about their penises in relation to sexual and reproductive health.”

Despite almost a quarter of a century of AIDS awareness programmes, consistent condom use remains frustratingly low, he points out.

But circumcision is not just a medical or cosmetic procedure – for many men it is loaded with significance related to identity and manhood. Social scientists, who feel they have been sidelined in the debate, argue that it is also deeply political, serving as a marker for status, power and social differentiation.

Culture changes

Can a mass rollout work among men in ethnically mixed societies, where foreskins – or their absence – are shorthand for kinship, culture and, almost inevitably, chauvinism? Delate is clear that culture can change: South Africa’s Zulus, who used to be circumcised, obeyed a decree by King Shaka sometime in the 19th century and stopped.

“We need to work with traditional structures to explain to them, engaging not just on circumcision but HIV in general,” Delate said.

In societies that do cut, traditional rites are imbued with far more meaning than just removing the foreskin: it is an initiation into manhood where cultural and behavioural codes are passed on, which could also have an important bearing on HIV transmission.

Northern Zambia, where circumcision is the norm, has the lowest HIV prevalence in the country. But, according to Mutamba Simapuka of the Maina Soko Military Hospital in the capital, Lusaka, the protective benefits are more than biomedical; young men also receive lessons on fidelity in sexual relationships imparted to initiates.

When northern men migrate to Lusaka, with its looser sexual mores, “their prevalence rates equate with the local population”, Simapuka told IRIN/PlusNews.

Traditional methods of cutting, however, are not the safest way to perform the procedure; the point, afterall, is for the initiates to prove their fortitude and endurance. Issues of consent are also a problematic area. “To ensure safe and clean operations, male circumcision should only be performed by well-trained practitioners in sanitary settings under conditions of informed consent, confidentiality, proper counseling and safety,” is the politically correct advise from UNAIDS.

In the end it boils down to money. Circumcision adds a newly found option for HIV protection, but health services in Africa are already overburdened, under-resourced and struggling to provide even the most basic care. Should circumcision be added to that load?

A concern among dissidents is that new financing might be dangled in front of governments to promote adoption, which would “undermine the existing comprehensive and balanced approach to HIV”, according to Aggleton.

The contrary concern is that there will not be enough money. “We will have to look at resourcing to beef up the capacity of health systems, which would have an added benefit [beyond circumcision],” Delate stressed.

Reference

Kiminju, Anthony. AFRICA: Overview – At the Cutting edge – male circumcision and HIV. IRIN PlusNews. July 20, 2007.

[Dead link] http://www.plusnews.org/Report.aspx?ReportId=73184

About David Wilton

Fronterizo, defense lawyer
This entry was posted in Africa, Culture and tagged , , , . Bookmark the permalink.

One Response to Male Circumcision and HIV (and the controversy)

  1. Charles Kabeta says:

    I read this article on Zambia mass circumcision over HIV/AIDS preention with much fascination but at the same time with disbelief on how misguiding the speculation has turned out to be.
    In short, what are we saying or promoting with encouragement of circumcision? Whether its implementation gives tangible evidence towards low rate of infection, the reason behind is disheartening. Circumcision has been practicised in Western, North-Western, Northern, Luapula and even parts of Southern Provinces from time immemorial.With the inception of the pandemic, how many lives have been lost even among circumcised persons.
    I totally disagree with whoever is advocating for such an alternative as remedial to an already menacing phenomena to our Zambia Society.
    Let people spend money on life long prevention that goes with moral education and awareness of the prevence of the sickness that has not found a cure yet. I will still support that stance of the Catholic Church of abstience from early sexual encounter for adolescents and fidelity and Chastity for the married and single alike. If this is taken seriously and inculcated in our Basic Education, High Schools, Colleges and Universities then we can perhaps hope that the reduction in the fateful pandemic could possibly read a significant reduction.
    Please, let me not be misunderstood over my reaction to this article, all I am saying is let us not embrace poison because others in some cited Countries survived it. “It is easier said than done goes the saying!
    Wish to urge our Leaders, NGOs, Churchs and all collaborating partners to have a thorough discernment about this implementation before we regret with an irreversible situation. Our people are not guinea pigs to be experimented upon!
    Concerned Citizen.

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