29 September 2008

Kenya: Rethink Male Cut Campaign in the War Against Aids


Nairobi — As debate on whether circumcision reduces the risk of HIV infection or not rages, it is amazing how each side of the divide is getting carried away by emotions to the extent of losing sight of the available evidence.

This reminds me of the saying that "a good slogan can stop analysis for years".

It is true that there is evidence that HIV prevalence is lower among communities that practise male circumcision than among those that do not.

But there is also evidence to the contrary: that HIV prevalence is higher among communities that practice male circumcision than among those that do not.

This sounds somehow confusing, one would say. But in a nutshell, it shows that the evidence on whether male circumcision protects one against HIV infection is mixed.

Unfortunately, both the proponents and the opponents of the protective role of male circumcision have refused to soberly confront this reality, and thus think through an appropriate prevention strategy.

Since so much has been said about studies that show the protective role of male circumcision, I'll talk about the evidence that shows the contrary.

Two datasets from Malawi (the 2004 Malawi Demographic and Health Survey (MDHS) and the 2004 and 2006 Malawi Diffusion and Ideational Change Project (MDICP)) show that HIV prevalence was highest in the Southern region than in the Central or Northern regions.

Yet, a higher proportion of men from the Southern region, compared to those from the other regions, reported having been circumcised.

In contrast, individuals from the other regions were less likely to report multiple life-time sexual partners than those from the Southern region.

They were also more likely to report condom use during the 12 months preceding the survey than those from the Southern region.

At the individual level, HIV prevalence was higher among circumcised than among uncircumcised men. Among circumcised men, those who were HIV-positive were more likely to report multiple life-time sexual partners than their HIV-negative counterparts.

Similarly, among married women with circumcised husbands, HIV prevalence was higher among those whose spouses reported multiple life-time sexual partners than among their counterparts whose spouses reported one life-time sexual partner.

At a recent meeting when I started engaging a fellow participant on this exceptional evidence from Malawi, she got carried away and branded me a circumcision-basher.

She did not even stop to listen to what I had to say. Yet, my intention was to see whether, given the two sets of contrasting evidence, we could think through a better way of confronting the HIV and Aids scourge.

I was surprised at how low some scholars have sunk, to the extent of reducing the debate to "us versus them". It left me wondering how the so-called circumcision-bashers refer to those on the other side of the divide.

To set the records straight, I am not a circumcision-basher, if this refers to male circumcision (female genital cutting is a different matter altogether).

In any case, HIV and Aids should concern everyone and any effort aimed at combating it is laudable.

However, aware of the two sets of contrasting evidence, my concern has always been the manner in which male circumcision is being presented to the public, as if it is the ultimate method of protection against HIV infection.

In my view, the promotion of male circumcision should be accompanied by riders encouraging people to use other means of protection even after the cut.

Otherwise we run the risk of creating the false impression that once a man is circumcised, he can start sleeping around without any care in this world.

Given the evidence from Malawi, one can only shudder at what this might lead to. The Malawi exception also brings into focus the issue of the position of the woman.

It suggests that we can circumcise the men alright, but as long as they remain promiscuous and do not use any protection, their women are still at risk. The question then is, how do we protect the women?

It is against this backdrop that a new way of thinking has started gaining ground within programme circles, what is known in programme parlance as MC-plus (Male Circumcision plus other preventive methods). Isn't this what we ought to be promoting?

Otherwise for more on the Malawi data, visit www.measuredhs.com and www.malawi.pop.upenn.edu for the MDHS and the MDICP data respectively.

In both cases, you will be required to go through a registration process before you are allowed access to the data.

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