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Uganda: 'Circumcision to Prevent HIV' is Giving People False Information

Jennifer Bakyawa

15 October 2008

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interview

There is research suggesting that circumcising men help reduce the chances to contract HIV. Dr. Francis Mwesigye Runumi, the acting Director of Health Policy Planning and Management in the Ministry of Health talked to Jennifer Bakyawa about the relevance of the medical male circumcision research results

In December 2006, the Rakai Health Sciences Programme released results of a clinical trial on medical male circumcision. Were these results relevant in terms of policy for Uganda?

We didn't even know that this study was going on. Several research institutions partner with funders and conduct research. Much research is going on but we don't know exactly how it was initiated. This is one of the researches that was conducted without much of our knowledge. However, when it came out, we discovered that some people amongst us had been informed. We began digesting the results the way they were released in the media; to find out if they had any implications in HIV/Aids control.

We were highly interested given that our main task is to find several practical interventions that can curb the HIV/Aids pandemic. But here was someone claiming to have conducted a study in Rakai on male circumcision and found it to have protective chances. We wanted more details given that we didn't discuss the proposal; didn't know the methodology; how the results had been collected and analysed; and the confidence levels that led them to adduce their claims.

There was a social debate on how Aids has been killing Muslims who were circumcised. How come researchers went to a community and found circumcision to be a preventive measure. If it is preventive in any way, we would have seen Muslims dying less than other religions and tribes that don't circumcise. The researchers were appealing to the Ministry to pursue this as one of the prevention policies.

Reactions were mixed: some people thought it was preventive. A strong side said the study was irrelevant because people have circumcised, still contracted the disease and died. Telling the whole population to circumcise is giving them false information. They would get multiple sexual partners and may die like any other Muslim and tribes that circumcise for religious and cultural practices have been dying. We wanted more information before the Ministry took it up as one of the prevention strategies.

What did the Ministry do when the results were released?

The Director General quickly raised the researchers at the Makerere University School of Public Health. They discussed the results with him. In his feedback to the Ministry's management committee he said he had looked at the results and was convinced that there is room for prevention using this strategy of male circumcision.

Still, questions came up: How many people have been circumcised for a long time but still die? That is when we went a little deeper to understand the possibility of not contracting the disease can be enhanced by being circumcised. Still, there are some doubts. When we look at the cohort of circumcised people that died, there isn't much difference with the one Rakai is claiming.

You said the researchers released the results in the media. Could they have approached this issue of releasing the results differently?

The researchers knew their target audience. But as a Ministry, we felt that we should have had a presentation so that researchers discuss with us our concerns in order for us to understand better.

With time, this picture was corrected. This was something very big. Even when the President (Museveni) heard about it, he wondered if this is something we should push forward. He demanded for an explanation that would convince people that this is a real strategy for recommendation. The President has been an activist in Aids prevention. This was going to interfere with his ABC drive.

Releasing results to the media excited debate about the research but questions were coming to us, yet we had not exchanged views with researchers.

You said that the Director General of Health Services (Dr. Sam Zaramba) invited the researchers to brief him about the study results. What ordinarily would be the ideal approach for communicating research findings?

Many researchers are doing very good work in their institutions. Whenever good results come out and have policy implications, the first thing researchers should do is to approach a policy maker and show them what they have found. Then the policy maker would share with his colleagues to get their opinion. This way, consensus is built right from the start. Good work from researchers may be a small fraction of a bigger picture, which would need to be completed first.

As policy makers, we could advise the researchers to investigate something else based on their results so that everyone sees the final picture. It could lead to a strong policy that would solve some pertinent problems the country is grappling with. When researchers get results they should endeavour to look for people who move things and are likely to use the results. They should discuss the results with them before sharing them with the broad community through the media.

Currently, there is a lot of confusion about the effectiveness of male circumcision against HIV? Why is this so? What can be done to change some of the misconceptions?

There is some physiological science behind circumcision which is not easily explained by the people promoting circumcision. Whenever this is explained, those who understand the science of how viruses and other sexual infections are transmitted, see the rationale of circumcision.

True, as researchers also mention male circumcision does not prevent HIV transmission 100 per cent but there are high chances of reducing this transmission. When one is circumcised the skin on the glens gets a bit tough. The area that hides some germs and infections under the prepuce (foreskin) is exposed. When wounds form, there are quickly identified for treatment. Because the skin is hard, they usually don't have big abrasions staying for a long time.

During sexual intercourse, the virus transmission through these multiple channels is highly reduced, but this does not mean that the virus cannot be transmitted through the urethra.

The circumcised can still get HIV because of secondary infections which the virus takes advantage of. But without secondary infections chances of the virus keeping on the skin are high rather than the foreskin which harbours fluids that transmit the virus. The misconceptions arise out of recognising that there are several tribes which culturally circumcise; a number of people who circumcise for religious reasons but are contracting the disease.

Researchers had to convince us that they followed up the research participants; looked at their multiple partners; their HIV/Aids status and found that there was a tendency of not contracting the disease by these people who had been in the study.

With the exception of the Rakai study and a few others, the layman rarely focuses on research and its usefulness to improving his life. Why is this so?

There are multiple issues and conditions affecting the lay man. He has not organised his mind to see how to sort them out. He doesn't perceive research as capable of minimising his social and health burden. He looks at research as something remote. Many people live in poverty.

They are overwhelmed by many problems including hunger. Whenever one talks of research results they say: "there go the scientists again. Let them tell us the story." There is an element of despair; not understanding how the world has been transformed through research. When we talk of research, many people say, that is what they always hear but they later realise their situation is not changing. It is like a newsbyte passing by.

As a country, what should we do to ensure that it is not only controversial research that is remains of interest to the media but also the public?

The policy makers have a key role to play. Implementation and funding strategies of these policies should be worked out. It is not only convincing people in the research but also in policy that results can greatly benefit the country. The moment that isn't done, research results keep on paper and gather dust on shelves. There should be a strong bridge between the research and policy maker worlds. The researchers can decide what to research on but they should also listen to the pressures in the policy makers' world so that they can pick some and give policy makers answers on a timely basis.

You talk of a bridge between researchers and policy makers? What do you mean by the bridge? Who should build it?

Researchers should organise themselves and identify policy makers where they are. An institution should help create this bridge. The institution should have competent and full time people responsible for searching for researchers; study results; interpreting them in policy form; writing policy briefs and feeding back to policy makers. Such people should be of high calibre, well respected so that policy makers pick interest in listening to what they are saying.

But if good research comes and it is rudimentarily presented, the seriousness behind it may not be well appreciated. Something good may fall on the wayside because of a Minister has refused to give an appointment to a young researcher who has a very good idea.

He would have preferred a professor with grey hair; a renowned one with several publications to give a lecture and this would take route. There is that attitudinal aspect from the policy makers. These are some of the tricks and strategies that can be lined up alongside the bridge to ensure there is a proper linkage.

The interviewer is a coordinator of the Country Communications Programme on Health Research, being implemented with the Council on Health Research for Development (COHRED).

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