Circumcision and HIV: are we being fed on half-truths?

Surgeons perform a circumcision exercise. There is a lot of negative vibe on the subject whether circumcision indeed reduces the risks to contracting the HIV virus. File Photo

What you need to know:

There are concerns to the true story about circumcision. As some people wonder whether it really reduces HIV infections, others feel that the campaign encourages promiscuity among men. But crusaders of medical male circumcision insist the cut reduces the risk to HIV infection

You have probably heard an advert calling upon men to get circumcised - “Circumcision reduces the risk of contracting HIV/Aids,” word goes. However, is this really true? Sylvia, a 27-year-old feels ripe for marriage, but there is a problem. She hasn’t found that man who fits the bill. The men in her age group are just starting out with their careers and with a little money and freedom from the clutches of their parents, they think more in terms of having fun-nights out and parties- till their 30s when they have made strides in their careers and have the money to run a family. All they want is a girlfriend. No babies. No commitment.
On the contrary, quite the go-getter, Sylvia is already at managerial level in a multi-billion company. So the ‘boys’ in her age-bracket are somewhat intimidated and find her too mature because by the end of this year, she will have finished her first three rental apartments with a plan to immediately start on others thereafter.
That is how older married men-10 years and more-have managed to find a soft spot in Sylvia’s life.
“When you have a financial problem, they can easily bail you out with that kind of money because most of them are building as well and properly understand the challenges,” she says.
However, it is the men she is having affairs with that quickly give her this kind of financial help without expecting anything in return. The catch with committed men however, is that they are more reluctant than your ordinary bachelor, to want anything to do with condoms.
“It is alarming the reasons they give,” she says, reeling off some of them. “Some say they itch, some that it breaks the fun because he has to take time off to wear it, some say it burns them, and others that they don’t enjoy it as much. I literally have to fight with them into putting one on but it’s tough,” Sylvia, who says her friends have had similar encounters, explains.
Stories like Sylvia’s may explain the 2009 findings that indicated an increase in the HIV infection rate among married and cohabiting couples to over six per cent in comparison to individuals who were not in a union at 1.6 per cent. In fact, it was found that 65 per cent of all new infections in Uganda occur in married people amongst whom only three to four per cent, regularly tested for HIV.
Armed with this information, the scientists whose role is to see an end to the scourge commendably started looking for solutions to address this problem as thus, rolling out a number of being faithful campaigns including the famous ‘get off the sexual network’ campaign.
Eventually, new research findings came out, showing there is a 50-60 per cent chance of an HIV-negative circumcised man not contracting the disease from an infected female partner. These findings could have been truly godsend, an avenue for reducing on the infection rate especially among the promiscuous men who are reluctant to wear condoms for one reason or another. But there are sections of people, including scientists, raising dust on the findings.
May be, it is the way this campaign is being done that could somewhat be distorting the message. First, stakeholders in the fight against HIV/Aids have been at a loss for some time now. With ARVs, there aren’t as many people dying due to HIV/Aids, a different scenario from the mid-90s when everyone knew someone who had died in a dreadful way due to the disease as thus imparting the fear.
With victims living longer now, the initial terror with which HIV/Aids was regarded, is gone - it is no longer considered a serious threat by the public inspite of the intense awareness campaigns. The rates of new infections instead of going down have actually gone up from 6.4 per cent to 6.7 per cent in the last one year, according to a preliminary Aids Indicator Survey 2011. This means the ABC (Abstain, Be faithful or Condom use) strategy is not as effective as it was in the 90s. And that is why the circumcision findings were probably timely as a way of scaling down the HIV infection rate.
However, one would be excused to think that a cure for the disease has been found given the long queues at the health facilities that are offering free circumcision services. The campaign has been somewhat successful but at what cost.
First, it is not fair on both sexes. For the women, it seems to suggest that they should not worry about their partners straying as long as they are circumcised.
“Just look at those posters with a woman’s saying, “I am proud, I have a circumcised husband because we have less chances of getting HIV.” Isn’t that totally absurd? Isn’t it like saying we can disregard corruption just because it has been done to a smaller degree? No woman would be proud of a promiscuous albeit circumcised husband,” an angry Engineer Geraldine Mwesigye says.
Faith Namulindwa, a social worker, also thinks the campaign is to an inadvertently introducing the idea of promiscuity injecting the idea that men can avoid HIV to a certain extent if they are circumcised; that circumcision is a permanent condom of sorts? Because half a chance at infection is so much indeed if someone’s life is at stake. Isn’t also like taking it for granted that men do not have the ability to stay faithful? Isn’t this an insult to the faithful men out there?
Phillip Ssesazi, a businessman dealing in online forex trading however disagrees with the suggestion that this campaign will only increase promiscuity. Infact, he thinks the campaign is serving the intended purpose of promoting safety, even if it is 50 per cent. “To an African man, having one or two other women he can go to, on that ‘rainy’ day is not being promiscuous. It is only when we are sleeping with five or 10 women that we start to feel a little uneasy, but two three, is normal,” he argues. Ssesazi does not think the men going for circumcision are itching to go on rampage since they now have a permanent condom of sorts. “Men have been straying even while uncircumcised without using condoms or even going for an HIV test with these partners. But now that this option is here, they are thinking, well, just in case she has HIV, I have a chance of staying safe.”
The Public Relations Officer of the Aids Information Centre, Marion Natukunda explains that the circumcision campaign is not being used as that one silver bullet that can pull down the infection rates. “Since no single intervention is 100 per cent effective thus providing total protection, circumcision is part of a comprehensive HIV prevention package in our programme. We are not saying that circumcise and be safe, but that you should use a condom when necessary as well staying faithful.” Dr Vincent Kawooya of Makerere University, School of Public Health, who has participated in developing communication strategies and policy as regards circumcision disputes the notion that men will go on rampage as circumcision offers them some form of permanent protection against contracting the disease. He explains; “We are just adding circumcision to the existing strategies of combatting HIV. It is not a stand-alone strategy and the message has been very clear that it is not 100 per cent safe. Take an example of the malaria medication Coartem, it is a combo of two or three drugs that together, effectively fight the parasite.”
He further explains that those getting circumcised under this campaign undergo counselling both before and after to clearly understand that circumcision alone will not protect them. It is important to note therefore that circumcision alone without behaviour change will not stop the new HIV infection rate.

The debate: others say circumcision only makes the HIV/aids fight absurd

Delilah Tamble says:
The Rakai District study showed no difference in the chances of catching HIV with an intact (non-circumcised) or mutilated penis. This study was closed half way through because too many women were catching HIV. The Head Researcher, Dr Maria Wawer said of the study’s results that “circumcision of HIV-infected men did not reduce HIV transmission to female partners”. The BBC News reported this in 2009, but it failed to get a mention in Uganda’s media.
The South African study also found no definite link between Male Genital Mutilation (MGM) and a lowered risk of HIV infection, likewise intact men did not have an increased risk of HIV, nor did their partners. In their research conclusion they warned against using MGM as a HIV prevention tactic, saying that the risks and life-long negative effects of MGM were not worth the possible, and as yet unproven, protection.
The Garenne study of 2006 was the only study which found any HIV decrease amongst mutilated men, which was in Kenya and Uganda, which is where Jerry Lanier was getting his 50 per cent – 60 per cent. In other words there was about a half/half chance of HIV, which in real terms makes no difference to an individual’s risk. Mr. Lanier also failed to mention that the same Garenne study found absolutely no difference in HIV rates amongst intact and mutilated men in Burkina Faso, Cote d’Ivoire, Ethiopia, Ghana, Niger, Rwanda, Tanzania and Zimbabwe, whilst Cameroon, Lesotho and Malawi had a much higher rate of HIV, as much as a 22.8 per cent increase of HIV amongst mutilated men than intact men. If you are a fan of statistics like Mr. Lanier appears to be this would actually mean that the chances of HIV increase when mutilated, even though by a slight amount; it certainly can not be used to draw the conclusion that mass MGM in Africa could ever hope to decrease HIV.
Not mentioned are two other studies which both found that penis mutilation does not lessen the chances of catching HIV, or any other STI. The studies were done by the US Navy in 2004, and Australia in 2011. According to the Kenya Aids Indicator Survey (Kais) released September 2009, the North Eastern and Coast provinces, where 97 per cent of males were circumcised, registered an increase in HIV prevalence, whilst Nyanza Province, where about 60 per cent of men are intact had the lowest HIV rate in the country. In 1999, Robert Van Howe, MD, subjected the data from 35 articles on HIV/Circumcision to rigorous statistical analysis. Van Howe found that, based on the combined data, “a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis…based on the studies published in the scientific literature, it is incorrect to assert that circumcision prevents HIV infection.”