UGANDA/ZIMBABWE: More resistence to circumcision for HIV

Zim Eye
August 4, 2012

Uganda's president dismisses circumcision, HIV research

By Tidi Kwidini

Uganda’s president, Yoweri Museveni, has taken a swipe at the current UN backed male circumcision for HIV prevention program massively promoted across Africa, and has cautioned people against considering male circumcision as the remedy and automatic control of HIV/AIDS infection.

President Museveni said that the messages promoting the practice were misguiding and may put the lives of many people in danger since it had not been proven to be scientifically true.

“I have witnessed Muslims and other people from tribes that cherish circumcision like the Bagisu, die of Aids. Therefore, who told [health workers and leaders] that circumcision [prevents] HIV [infection]? ” he said.

Museveni advised leaders and health workers to sensitize the youth about the dangers of peer pressure, saying many young people have been influenced by their friends into engaging in early sex and pre-marital sex and early marriages, not in getting circumcised to avoid being infected with HIV.

“[Leaders and health workers] are busy spreading confusion of circumcision, instead of concentrating on behaviour change,” he said.

His comments come as Zimbabwe’s government health advisor to the president Timothy Stamps also rubbished the method hinting that there was no comparative scientific basis for it.

COMMENTARY
Male circumcision has not only this week been subject of debate but has been for a couple of years. Barely two weeks ago the former Minister for Health Timothy Stamps rubbished a UN backed circumcision program that concluded that male circumcision reduces HIV transmission. Stamps argued that ‘it did not make any difference to the adult prevalence rate stating further that studies undertaken on circumcision had shown that countries such as the US with a higher number of circumcised men had a high HIV prevalence rate.’ Additionally that money should be ‘channelled into saving pregnant mothers who die in huge numbers in the country.’

To a greater extent many would have to agree with Stamps, that rather than channelling money into a project that does not have any guarantees or that would only promote reckless sexual behaviour, the money to jump start this program could be best used in many other areas-one of them being the promotion of sexual awareness and sexual health programs that are much needed, especially in countries where there are high percentages of people contracting HIV/Aids. Male circumcision, the oldest surgical invention that is being pushed as the ‘intervention bullet’ for HIV is not the answer to the ever growing problem of HIV/Aids.

Although there are studies that have suggested that circumcised men are half as likely to contract the virus from unprotected sex as their uncircumcised counterparts, the reality is that circumcision only offers partial protection and there is still a significant risk of contracting HIV and other STI’s if men engage in unprotected sex with an infected partner(s). Further circumcision does not offer the man’s partner any protection from contracting HIV whether he is or is not circumcised.

In addition, this UN backed program will only promote reckless sexual behaviour by irresponsible people who think that circumcision is the new form of protection. However, the actual reality is that condoms are about the most effective way of ensuring that both sexually active males and females are less likely to contract the virus.

Past and present surveys as suggested by (Bourne 2008) have revealed that most men would be willing to undergo the knife. However, the argument is that it would be fairly short-sighted not to consider that while circumcision may offer a 60% chance of not contracting HIV that not coupling circumcision services with education on HIV prevention and safe-sex-provider initiated counselling and testing, as well as referrals would be unwise.

The effect of circumcision on male-to-female HIV transmission has not been extensively researched. Boyle and Hill (2011) highlighted some concerns about the methodology of the three randomised controlled trials (RCT) carried out in Kenya, Uganda and South Africa. They stressed issues to do with researcher expectation bias, participant bias, inadequate double blinding, selection and sampling bias. Wawer et al(2009) in their study on the trials argued that male circumcision was a possible cause of HIV transmission as it was associated with over 60% increased transmission of HIV to female sex partners of circumcised HIV-infected men (Wawer et al., 2009).

The trial involving 922 HIV infected men in Uganda found circumcision did not reduce HIV transmission to uninfected female partners. The findings suggested that the risk of HIV transmission could even have been increased in the six weeks after circumcision due to unhealed wounds from the procedure. However, another study found that male circumcision was not significantly associated with women’s HIV risk.

[The proposition that circumcision itself increases the risk to women has been insufficiently considered.]

Furthermore, HIV and the epidemic reality is that women account for the majority of people who live with HIV in Sub-Saharan Africa. Bourne (2008) suggests that a woman is 8 times more likely than a man to contract HIV during intercourse with an HIV positive partner regardless of circumcision.Therefore it is clear that circumcision is an imperfect way to HIV prevention.

[Therefore the much-touted "60% reduction" amounts to less than 7% reduction in the bigger picture - if it amounts to anything.]

Although the main beneficiaries of male circumcision are men let those who are pro-circumcision not lose sight of the fact that women are stakeholders in these programs. Before such a program can be even considered the main focus should be on areas where funding is really necessary, specifically equipping men and women with sexual advice, including men and women’s health groups and those living with HIV, should be involved in the analysis of how circumcision will affect them.

If there is a possible future for this program, it should be closely monitored and evaluated in collaboration with these health groups. Funding should especially be allocated as well to initiating new research into what biomedical, structural, and behavioural interventions can best help women protect themselves from HIV infection such as microbicides (Bourne, 2008).

Perhaps the most important thing that also needs to be done before this program is considered is to communicate clearly about what male circumcision will, and won’t, do for a man and his female partner(s). Furthermore undertake education campaigns to ensure that women and men have a clear understanding that this program is not an excuse to promote promiscuity.

Circumcision does not completely protect men from HIV and circumcised men should continue using condoms to protect themselves and their partner(s) from infection. It should also be made clear that it is no excuse for females to have unprotected sex with circumcised men as there are no guarantees. Male circumcision is not a vaccine, and it is not a cure-all. It is simply one of the best ways to prevent HIV infections in men. [Simply?]

Charity organization HIV/AIDS Zimbabwe (HAZ) have argued in their review that there are multiple factors that need to be examined when evaluating between male circumcision and HIV prevalence especially in relation to risky sexual behavior, time of male circumcision, education, among other factors. HAZ in their counter argument in relation to Stamps, suggest that policy makers need to implement male circumcision as a public health measure to stop growing heterosexual transmission of HIV in Sub-Saharan Africa and globally, as various findings have otherwise suggested that it is in fact effective in conjunction with contraceptive methods (hivaidszimbabwe.org, 2012). However, the question still remains, is this program crucial enough to divert funds from the real pertinent issues in order to test a theory that might not really be effective?

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