Alaska Despatch
July 5, 2012
Adult circumcision push fails in AIDS prevention campaign
By Alex Duval Smith
EZULWINI, Swaziland — At a working men’s bar in a
down-at-the-heel part of town, a group of laborers are ordering a round
after a long day when the talk turns to the uncomfortable subject of
adult male circumcision. The procedure is being carried out as part of a
campaign to reduce the spread of HIV here in this tiny kingdom in
southern Africa, which has the world’s highest prevalence rate for the
AIDS virus.
For S.K. Maseko, a 41-year-old father of five who works as a caddie
at a local golf course, the decision to lose his foreskin in March was a
good one.
Like most men interviewed for this story, Maseko explained that apart
from a moment of pain from the jab of a localized anesthesia and a bit
of discomfort for a few days of healing, the process of circumcision was
relatively painless. And, he added, there are distinct benefits beyond
that fact that it affords protection against HIV.
"Sex is better now,” he says.
"With circumcision, my wife is happy," he adds with a smile.
But his drinking buddies at the Makhonkhosi Wine & Malt bar are
not convinced and not certain they would volunteer for the procedure –
even if it could save their lives at the epicenter of the AIDS epidemic
in southern Africa.
Billy Saulus, 49, an auto mechanic, has refused to go, fearing that he may already be HIV positive.
''What if I go along to be circumcised and the doctors insist I be
tested? What if I am HIV positive and the wound does not heal properly?
I think I will just continue with condoms,'' said Saulus, who has three grown children.
In an ambitious goal – some would say audacious – the United States
wants to accelerate the pace of male circumcisions to support 4.7
million procedures in the developing world by the end of next year, up
from 1 million at the beginning of this year. But its failures in
Swaziland have given everyone – even the US global AIDS Ambassador Eric
Goosby – great pause whether that goal announced by President Obama can
be reached.
Late last month, Goosby said the US could still do it, but he
acknowledged that scaling up male circumcision was much harder than
expanding AIDS treatment or protecting newborns from infections by their
mothers.
The goal here was to circumcise 80 percent of all men aged 15 to 49 in a year. The result was that
roughly one in four underwent the procedure.
What went wrong? What are the lessons from this landlocked country
between Mozambique and South Africa with a population of just 1.3
million?
Here, say experts, a concoction of long-entrenched local traditions,
false rumors, economic pressures, and gender imbalances added up to
falling far short of the goal.
[And the bland assumption that they know better than the men what is best for them.]
But there was another problem: the US government and others simply
misjudged how long it takes to institute a procedure in a culture that
has no history with circumcision. US experts set expectations far too
high, many believe.
Since 2007, the United States, through the President's Emergency Plan
for Aids Relief (PEPFAR), has spent more than $140 million from 2007
through 2011 on every aspect of the battle against AIDS in Swaziland,
including institutional support, training, care and prevention. But
prevalence rates have remained high. Among men between 15 and 49 years
of age, 26 percent are HIV positive.
Based on evidence from other African countries that female-to-male
transmission of the virus can be reduced by 60 percent if men are
circumcised,
[Oh really?]
PEPFAR last year added an additional $15.5 million in funding for an
ambitious ''accelerated saturation initiative'' to circumcise 80 percent
of HIV negative men between ages 15 and 49. A year later, 23 percent
had undergone the procedure. Some critics suggest the campaign, called
Soka
Uncobe (''circumcise and conquer''), may have been counter-productive
to on-going efforts to promote condom use and behavior change.
Tough Sell
Muhle Dlamini, a 50-year-old environmental health scientist with the
Swaziland National Aids Programme, which is part of the health ministry,
said that officials knew the campaign would be a tough sell.
''We are not, culturally, a circumcising country,
...
The country is culturally polygamous, but economic hardship has led
to the decline of legal marriages in favor of sex with multiple
partners.
''Men cannot afford dowry payments,'' said Dlamini, ''but they continue to have sex … So you find that
multiple concurrent partners are increasingly the norm.
Economic pressures also lead to more inter-generational sex with
so-called 'sugar daddies' and other sex for money or favors.''
...
The 2011 mass circumcision effort started from a low base, and there
appeared to be considerable demand from men. The government, as well as
several non-government organizations — such as the long-established
Family Life Association of Swaziland (FLAS) and Population Services
International (PSI) — had begun promoting and offering adult male
circumcision in 2006.
Zelda Nhlabatsi, director of the Family Life program, said her organization could not keep up with demand.
''People had heard of the Orange Farm experience, a celebrated study
in South Africa in 2002 to 2004 which found that circumcision cut
transmission (by as much as 60 percent).
[But only from women to men, if that.]
South Africa being next door, people felt that if it worked for them
it could work for us. The government brought in Israeli doctors to train
Swazi doctors in how to circumcise under local anesthetic. PEPFAR
supported the renovation of our clinics. Demand was enormous. We were
really keen to take the program to scale.''
Enter the Futures Group, a Washington, DC-based company that was
awarded a contract by PEPFAR for the $15.5 million circumcision program
without a competitive tender. The project management firm was tasked
with using the $15.5 million in funding to turn the culturally
conservative, non-circumcising Swaziland into a land where 160,000 men
would be willing to volunteer for the procedure. It was a tall order to
begin with.
US army mobile surgical tents were brought in and about half the
total budget was spent on hiring expatriate surgeons to train 200
clinicians. Celebrity endorsements were secured from a leading musician
and from “Mr. Swaziland,” the annual winner of a national pageant for
men. Matchboxology, a South African advertising agency with a
track-record in AIDS messaging, produced films, livery for minibus
taxis, flyers, and billboards.
The Futures Group seemed to have thought of everything, including
royal backing. In July 2011, King Mswati III stood before an audience of
3,000 people and declared, ''Soka Uncobe must be the motto now for all
men to go for male circumcision.''
Mixed Messages
Yet ask Swazi AIDS professionals about the campaign and many will
privately — for fear of jeopardizing future US funding — term it
a
''disaster,'' a ''nightmare'' and ''an exercise in bullying.” Prominent
AIDS activists said the regular meetings they attended were used by
Futures Group to rubber stamp decisions, rather than consult.
Mahlubi Hadebe, prevention coordinator with Swaziland's National
Emergency Response Council of HIV/AIDS (NERCHA), was among those
critical of the Futures Group and its approach.
Hadebe said, ''It went wrong from the outset. Futures Group just
would not listen. The promotional materials featured drawings of people.
But I as a Swazi, want to see a real Swazi's face. The demand-creation
approach was all wrong: To convince a Swazi man you need time, you need
to go and see him. You have to identify thought leaders in communities
and use them to convey the message. Billboards do not work.
''Some of the messaging hit the wrong note. 'Lisoka lisoka ngekusoka'
— which literally means 'the lover boy is a lover boy thanks to
circumcision' — appeals to the playboy in the man. It is off-putting to
married men,'' said 47-year-old Hadebe.
Family Life’s Nhlabatsi said the Soka Uncobe name sent the wrong message.
''To me it does not to so much mean 'circumcise and conquer' but more
'circumcise
and be done with it' which is a dangerous message. It could be
interpreted as meaning that once men are circumcised they no longer need
to use condoms,'' said Nhlabatsi.
Studies in South Africa, Kenya and Uganda have found that circumcised men are at least 60 percent less likely to pick up HIV.
[It's like a drumbeat, isn't it?]
Still, the groups carrying out the circumcisions must grapple with
conveying the message that even after the procedure — which requires men
to abstain from sex for six weeks — condom use remains crucial.
Rhoy Shoshore is a 31-year-old doctor with the Family Life
association who has carried out the procedure on more than 1,000 Swazi
men.
He said, ''We talk to the clients about the importance of condoms before the operation. … But
you can never be sure how much they are taking in. And with teenagers it is difficult as
the Education Ministry does not want us to talk about condoms in schools, only fidelity and abstinence.''
Emma Llewellyn, the British HIV technical services director at PSI,
previously worked in Kenya where she spearheaded the country's first
''rapid results'' circumcision campaign in 2009, but she said
Swaziland’s culture has presented challenges to the campaign.
In Kenya, she explained, ''We did 30,000 men in 30 days. The campaign
is now repeated by local organizations during every Christmas holiday.
But Kenya is very different. The majority of the country's 42 tribes
traditionally circumcise.''
Futures Group’s Shannon Hader, the organization’s director of health
and systems solutions, told GlobalPost that the results of Soka Uncobe
had indeed been something of a disappointment. But she dismissed most of
the criticism of Futures Group’s approach, and particularly its failure
to consult the Swazis themselves.
Hader said, ''This was the first time any country, starting from a
fairly low base, tried an accelerated saturation initiative aiming to
capture essentially a whole population in 12 months. We learned — and
this was a global 'learn' that will serve us elsewhere — that it is not
because you build the service that you create the demand.”
She specifically denied that the campaign had led to risky practices,
adding, ''I have not seen any evidence that that is what played out.”
Moving Forward
At the US embassy in the capital, Mbabane, PEPFAR country coordinator
Chris Detwiler insisted that Soka Uncobe had been born out of a request
from the Swazi government in February 2010. He explained that Futures
Group was awarded a contract without a competitive bidding process based
on the need to ''implement a stand-alone, time-limited campaign that
did not overburden
an already strained health system.”
Detwiler denied the campaign had misfired, saying, ''We have heard
that accusation but the process was not a top-down approach. It was
driven by the Swazi government and came with extensive consultation in
the form of weekly and monthly meetings. We will do better going
forward.''
Around the country, three months after the Soka Uncobe campaign
ended, publicity material is still visible on some billboards and
minibuses. Clinics have large boxes full of its distinctive orange
leaflets. But PSI and others say they are in a ''taking stock'' phase.
''We have to look at how to move forward,'' said Llewellyn. ''We need
to look at what we do with the Soka Uncobe brand, which after all, the
king launched.”
Both PSI and the Family Life association are concentrating on 'back to school' campaigns.
'
Teenagers are an easy target group,'' said Nhlabatsi. ''You get parental approval and then you have a busload of them.''
The future, said NERCHA's Hadebe, is in expanding the circumcision of baby boys within seven days of birth.
[With no evidence whatsoever that this has any effect on HIV.]
''I think we may just have to accept that we are going to miss much
of the population which is currently sexually active,” Hadebe said. “I
think we need to put our energy into neo-natals. But even there we have
obstacles to overcome.
We are still legally obliged to obtain paternal approval to circumcise a boy
. This is a challenge given the number of single women giving birth.''
[Paternal or parental? But it sounds like they'd do it without asking if they could.]
The men at the bar in Ezulwini have other concerns. One man, a
divorced 45-year-old lawyer who did not wish to be named, said he used
condoms with all his partners, except his steady girlfriend. ''
She
does not want me to be circumcised because she thinks it will make me
reckless,” he said. “She believes I will take less care to use condoms.
Personally, what makes me reluctant is the requirement that you have to
go without sex for six weeks. I would find that difficult.”
The motor mechanic Saulus added that he had heard stories of
circumcision clinics selling foreskins to witchdoctors. Someone he had
spoken to knew someone who had become sterile, he claimed. Saulus and
several other people at the bar also said the book of Deuteronomy in the
Hebrew Bible, or Old Testament, condemns the practice. In fact, the
Hebrew Bible is consistently in favor of circumcision, which is still
observed in modern secular and religious Jewish communities.
[Who'd have thought that "Hebrew" would become a weasel-word. Few of these men will be Jews, many will be Christians, and the New Testament does condemn (religious) circumcision.]
But Maseko dismissed his buddies' claims. Sex, he insisted, was
better than ever and he said he would be sure to continue telling his
friends.
Asked whether he had continued to use a condom since the operation, he said he hadn't because he had only had sex with his wife.
''They are all just afraid of the pain,” he said of his drinking buddies. “They will come around to it.''
