More questions on male circumcision and HIV prevention


In July 2010 I wrote an article questioning the promotion of male circumcision as one of the methods to reduce HIV transmission.

My doubts were based on loads of literature which I had gleaned through trying to make sense of how cutting the foreskin would reduce transmission of HIV.

In fact some of the literature I read at that time suggested the foreskin was not there by accident as it has its role in protecting the gland.

In addition, until 2007 most non-governmental organisations were discouraging the practice as they thought it promoted the spread of the virus.

So I wondered why the sudden change. In 2007 the World Health Organisation-UNAids had recommended male circumcision as an HIV preventive measure based on three sub-Saharan African randomised clinical trials in female-to-male sexual transmission in South Africa, Kenya and Uganda.

As usual like many other externally driven campaigns, money poured in and queues formed to chop the poor foreskin off the gland. That mothers were giving birth in their rural clinics and that children were dying due to lack of healthcare, did not matter.

The mans foreskin had to go, thanks to several donors who had made it their responsibility to drive a global health agenda.

When I wrote the article in 2010, the response was overwhelming but mixed. Those who were cashing in on the circumcision campaigns thought I was killing their cash-cow. Of course salaries and allowances were earned, but we may have to regret that decision.

Others especially men were in support of my arguments. I was not against circumcision per se, but I questioned its link with HIV prevention and how donors were fashioning in it our lives. Yes, most of those in the industry took it up as gospel and ran with it.

My proposal then was, we must do more locally-driven research. I challenged our own doctors and the government to look into this issue before it was made public policy.

The few doctors I consulted in South Africa had not given me a positive approval of circumcision as a barrier to HIV transmission.

In fact, some predicted a backlash, while others advised one can get circumcised for other reasons, but not associated with HIV prevention. So if medical practitioners are differing in their private corners and do not endorse the practice, then who can?

Until recently, this year to be precise, Malawi is the only country that had stood firm against circumcision for HIV prevention demanding more research before rolling out male circumcision.

Perhaps they succumb not because they now believed in it, but they have been on the wrong side of the Western donor world.

However, in a recent study published in December last year (just over a month ago) by Thomson Reuters (Australia), the authors, Gregory Boyle and George Hill are challenging the validity of the earlier claims circumcision prevents HIV transmission.

Their argument is based on a recent male-to-female sexual transmission of HIV study in Uganda which, contrary to the earlier claim, shows that circumcision actually increases male-to-female transmission of HIV.

In the male-to-female trial women were more exposed to HIV since some of the male sexual partners subjected to circumcision were already HIV positive. Over the years females have been at risk of contracting HIV as the male circumcision programme conferred overall benefits to women.

And in Zimbabwe, circumcision was believed to be an invisible condom and so many people fell for that.

A Uganda trial which sought to test whether male circumcision could reduce male-to-female transmission was stopped prematurely because 25 (17 male circumcision group) previously uninfected women became HIV positive, concluding that male circumcision could be associated with a 61% increase in HIV transmission.

The study reveals absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials in South Africa, Kenya and Uganda was only 1,3%, relative reduction was reported as 60%, but after correction for lead-time bias, averaged 49%.

The study further cautions that condom use is still essential after circumcision for HIV prevention. This questions the purpose of circumcision if condom use is still needed to prevent sexual transmission of HIV. So who was fooling who?

In fact, the study closes down on any further research into circumcision and HIV sexual transmission as epidemiological data has provided definitive evidence of effectiveness of male circumcision within a given population.

Available epidemiological data in several sub-Saharan African countries such as Cameroon, Ghana, Lesotho, Malawi, Rwanda, Swaziland and Tanzania show male circumcision does not provide protection against HIV sexual transmission as most of these countries have higher prevalence rates among circumcised men.

As usual Africa is an easy target for testing models and seemingly, nobody cares about human consequences of those studies.

And again, Africans for their gullibility, will have exposed their people to models which have not been tested and approved by their own professionals.

And again, it seems where there is money and other benefits, we are willingly submit ourselves to anything even when we know we are not sure.