Friday, May 6, 2011

Male Circumcision and HIV in Africa: EPIC FAIL

We called it, we keep calling it, but will anybody ever listen?

Nothing is more infuriating. Nevermind the fact that male circumcision is being imposed on healthy, non-consenting, sexually inactive minors in Africa, we've been saying that this is exactly what would happen since circumcision advocates began cheerleading for these so-called "mass-circumcision campaigns."

This is wrong, we said. Even if studies were correct, circumcision couldn't hold a candle to condoms, we said. African men are going to get the wrong message, we said. It's going to make the problem worse in the long run, we said.

Millions of dollars in circumcision campaigns later, the chickens are coming home to roost

A new report by PANOS Eastern Africa shows that the circumcision/HIV messages meant to reduce the prevalence of the disease are actually facilitating its spread. The messages create false impressions, especially with regard to multiple concurrent partnerships and male circumcision.

PANOS is a network of institutions world over that carries out research and documentation of development information in marginalised communities. Their report, titled "Communication challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision", shows that the majority of the rural population believe that male circumcision gives a complete protection to HIV/AIDS, while more than 88% did not exactly know what the sexual network was.

The PANOS report can be accessed here:

According to the report, the messages are urban-based with little or no translation for the rural people, while younger people are no longer scared of the HIV pandemic because it is no longer as scary as it used to be. The campaigns being used in Uganda are not addressing the social, cultural and economic issues that underline why people engage in risky sexual behavior, such as being in multiple concurrent partnerships.

The report was prompted by the increasing number of infections every year. Last year alone, 120,000 new infections were recorded. According to one of the lead researchers, Daudi Ochieng, from the Uganda Health Marketing Group, the messages have lost authority and have become cliché. "People are tired of the same old messages, campaigns are vague and boring, there is nothing shocking about them and they lack coherence as everyone gives a different message," Mr Ochieng said.

Also, the Ministry of Health has become complacent about its communication about HIV. "The role of MOH in educating people about HIV transmission seems to have ended with the introduction of ARVS. Once these drugs were introduced, even the international donors shifted from helping institutions like Aids Information Centre and are now helping those offering ARVS and more recently circumcision," a respondent said.

And why wouldn't the Ministry of Health become complacent? Why shouldn't anybody be complacent if all one has to do is get those ARVs and circumcision?

We've been saying that promoting circumcision would be a distraction, a waste of valuable resources, and that it would actually make the situation worse.

It is quite evident that those adamant in the promotion of circumcision as HIV prevention don't understand, nor do they care to understand the social, cultural and economic issues that underline why people engage in risky sexual behavior, and why HIV spreads. More important is securing acquiescence to the idea that "circumcision prevents HIV," and that everybody go run and circumcise themselves and their children than the prevention of HIV itself.

From the beginning
Since "scientists" and "researchers" in the field of "circumcision and HIV" began pushing for the promotion of circumcision as HIV "prevention," objective minds predicted this outcome long before any on-the-ground examination was carried out, and warned that promoting circumcision would be a distraction, if not outright send the wrong message.

In January, 2007, President Yoweri Museveni joined the voices of those warning that messages saying circumcision reduces the risk of HIV/AIDS could derail the AIDS fight. The President's words were also echoed by Ugandan scientists.

In July of that same year, IRIN News warned of cultural practices that encouraged boys to have unprotected sex immediately after their circumcision, where circumcision is already an accepted as a cultural practice.

Ignoring red flags, fixing what ain't broke
IRIN News expressed concern that promoting the idea that circumcision "reduced the risk of HIV by 60%" would send a confusing message to countries where circumcision is already accepted cultural practice, and where the HIV problem was already stable.

"AIDS activists in this part of Africa are worried that the recent findings, based on a clinical trial each in South Africa, Uganda and Kenya, could encourage complacency.

Promoting - or not promoting - male circumcision "is not a concern for us," an official at Burkina Faso's National AIDS Council told IRIN/PlusNews. "It is not included in any of our guidelines, since people already do it... (Hello???)

It is not a new concept: "The idea that circumcision protects against sexually transmitted infections already existed in the villages", according to studies carried out in the 1980s, Niang told IRIN/Plus News...

AIDS prevention workers in Senegal and Burkina Faso are concerned about how this information will be interpreted by people in their countries, most of whom are illiterate.

"This is a scientific approach which poses problems, as they are claiming something, even though it only reduces the risk by 60 percent," said Innocent Sewoa Laïson, senior programme manager of the African Council of AIDS Service Organisations (Africaso) based in Senegal. "There is a risk that this will jeopardise prevention efforts of the last 20 years."

(Is anybody listening?)

Martine Somda, president of REV+, the acronym in French of an association for people living with HIV in Bobodioulasso, Burkina Faso's second largest city, agreed. "This is recent information. We do not intend to disseminate it since it could confuse people and cancel out what we have achieved. This must not work against the use of condoms." ...

With AIDS information widely available, at least in urban areas, ordinary people have also expressed concerns that messages about the protective benefits of male circumcision could "muddy the waters".

"I have known men around me who were infected or have died from AIDS; some were circumcised, some weren't," said Djeneba Kone, who lives in Bobodioulasso.

November 7, 2007, President Yoweri Museveni AGAIN said circumcision should not be promoted in the fight against HIV/AIDS, as it would encourage recklessness among the youth.

"How many Bagisu have died of AIDS and yet all of them are circumcised?"

July 31, 2008, IRIN News publishes this article:
SWAZILAND: Circumcision gives men an excuse not to use condoms

"There is a growing belief among men in Swaziland that circumcision provides complete protection against HIV, a perception that worries non-governmental organisations (NGOs) battling the highest HIV prevalence rate in the world. think they are now immune from HIV contagion," said Siphiwe Hlope, an HIV-positive woman and founder of the support group, Swazis for Positive Living (SWAPO).

Hlope said SWAPO members were becoming increasingly aware of an attitude that circumcision protected men from HIV infection, while also providing an excuse not to use condoms; something Swazi men have long loathed doing.

Joy Magongo, a mother of two whose husband moved out to live with his second wife after the couple discovered they were both HIV-positive, told IRIN: "Men say, 'I've been circumcised. I don't have to wear a condom.' They get infected, and they give us HIV.

"He [my husband] was circumcised and felt he didn't have to wear a condom. When we found we had HIV after testing, he blamed me. He said, 'You brought HIV into this house.' It was because I tested first, when I was pregnant with my second child," she said.

"My husband did not believe he could be HIV-positive because he was circumcised. I did all I could to convince him to test, and he finally did. That was the end. He took another wife and left us," Magongo said. Polygamy is legally recognised in Swaziland.

"AIDS in Africa has a woman's face," Hlope said. "People think the disease originates with women. Why? Because it is the women who are tested first, when they are about to give birth."

She said Magongo's story was an unintended consequence of the circumcision campaign by the country's health ministry and AIDS NGOs. "Families blame women when HIV comes into the house, and it results in all sorts of abuse, from physical abuse to denial of spousal and child support, and loss of property rights."

While not disputing the advantages of male circumcision in reducing the rate of HIV transmission, Hlope said the gender dynamics of Swaziland's culture should be taken into account. The incorrect belief that circumcision was a panacea for the disease was making life more difficult and dangerous for women.

"It's the law of unintended consequences," said a Zambian doctor who treats HIV/AIDS patients at government hospitals, and who declined to be named. "Introducing the procedure, there was insufficient attention given to cultural factors, attitudes and human psychology.

"Many of the men I speak with think circumcision is like an AIDS vaccine (sound familiar?). It's not.
Jackson Dlamini, 25, a strapping man taking a break from weight training at a local gym, told IRIN he was considering circumcision as a way to protect himself from HIV. "This AIDS is bad. Nobody admits they are HIV [positive], but so many people are dying. I don't want to give up sex, so I am getting circumcised," Dlamini said.

When told that counsellors at Mbabane Government Hospital would advise him to carry on using condoms even after the operation, Dlamini said, "It is painful to get circumcised. If I have to wear a condom anyway, what is the point?"

(An intelligent boy! A remarkable boy!)

A recent study by the UN Development Programme found only 20 percent of Swazi men consistently used condoms, which Hlope said probably indicated that circumcised men did not stop using condoms after circumcision, but had never used them in the first place.

Education about circumcision should stress a clear and consistent message that the procedure should be part of the HIV prevention measures, she said. "Until that happens, women will be infected with HIV this way, and ... male circumcision may do more harm than good if it is misused to deny women full protection."

August 13, 2008 - Reuters announces Uganda's decision to launch mass circumcision campaigns in the name of HIV prevention.

Again, the valid concern is raised and completely ignored:
Some experts fear that some of the newly circumcised men may believe they are immune following the procedure -- translating into even more risky sexual behavior.

"All I know is that when I am circumcised, it will not be as easy for me to get infected with HIV/AIDS," said one young man, Kizeja Michael, as he lined up for the operation.
"People who are circumcised are not able to get AIDS," said his friend, Peter Kibatsi.

Report after report, men state their reasons for circumcision
"They say it prevents HIV and sexually transmitted diseases. If that's true, I would definitely go for it so I can remain healthy.

"A while ago a friend and I found out we had the same sexually transmitted disease, and when I began to wonder how that happened, he told me he had slept with a girl I had also slept with in town. He is the one who told me that if we were circumcised, we would not have got sick.

"My girlfriend is still in secondary school and when she is not around I try to abstain from sex, but I'm not always successful. I don't like condoms; if there is a better way to prevent HIV so that I can enjoy sex skin-to-skin, I will do it.

"I don't know exactly how circumcision stops these diseases. If the government would give us more information on how it works, and also if the procedure was free, more people would be interested.

(Or maybe they would think the government was on crack.)

Desparate measures?
But finally, it looks like circumcision promoters don't care anymore how they get men to circumcise, even if it means dishonestly coercing the youth behind their parents' backs, and against their parents' wishes:

"...what is worrying is that information filtering about circumcision is one that has been received with misconception especially amongst the youths and school pupils in particular.

Recently, the Education Post visited Kafue Boys Secondary School where close to ten pupils registered to get circumcised at a local health centre without the consent of school authorities.

Confirming the development, school headmistress Catherine Mutale expressed disappointment at the decision by personnel at the health centre to enlist the pupils for circumcision without the school authorities’ approval.

Mutale learnt about the circumcision campaign at her school through the posters that had been stuck on trees within the school premises and that a parent to one of the pupils had also called the school earlier inquiring on how their child had been circumcised without their approval.

'We found posters promoting circumcision stuck on trees and by the time the deputy head pulled them out ,the pupils had already read the message on the posters and were booked in for circumcision the next day," Mutale said.

The headmistress said she then approached health personnel at Kafue Rural Health Centre over the matter who responded defensively, saying the boys were old enough to make their own decisions. (What they mean is, old enough to dupe with a sense of entitlement...)

"By the time we had gone there, five had already been circumcised, and five more were awaiting circumcision," she said.

Mutale complained that the practice had disturbed some pupils because they were absconding classes due to the nature of the operation.

"Some have been missing class because they are having problems in walking and sitting. Our other concern is on the cleaning of the wounds; we don’t know whether the boys are doing the right thing. They are targeting boys because they want to meet the target. (BINGO.)

Why are they are targeting pupils in boarding schools?" The headmistress queried.

She also sadly noted that there was a misconception amongst pupils that once circumcised they could have unprotected sex without contracting STI’s and HIV.

"These pupils think circumcision is a lee-way to indulge in unprotected sex and now my worry is they may decide to practice this whilst at home during holidays because then the school will have no control over them," Mutale said.

There is reason to believe the "studies" being used to promote circumcision as HIV prevention in Africa, and in other parts of the world, are methodologically flawed. Real world data shows us that a prevalence in circumcision in a population doesn't necessarily "reduce" HIV transmission. Actually, HIV transmission is prevalent in circumcised men in quiet a few African countries, and it is more prevalent in America, where 80% of the male population is already circumcised, than it is in Europe, where circumcision is virtually unheard of. I talk more about this in my post about the San Francisco Circumcision Ban:

And a recent paper goes more into depth regarding the circumcision/HIV blunder in Africa:

But even if the circumcision/HIV "studies" were 100% accurate, circumcision fails. It cannot even come close to working anything like a vaccine, and it is outperformed by condoms.
(60% reduction in HIV transmission over 1.5 years vs. over 90% reduction every single time.)
We have been warning since the beginning of the promotion of circumcision as HIV prevention policy back in 2006, that circumcision fails, and promoting it will backfire. We have warned that it is a pointless distraction and a terrible waste of precious resources that could be put to better use, and it would actually make matters WORSE, confusing the people of Africa. It would give men and women a false sense of security, and it would result in men refusing to wear condoms.

Five years and millions of dollars later, world health leaders continue to be out of touch, and we are seeing the fulfillment of our prophecy. We are experiencing the rape of Africa, yet again, before our very eyes.

To close, here is an example of how the circumcision/HIV message has gone out of control.

May 04, 2011
THE public has received the Male Circumcision campaign "Soka Uncobe" with mixed feelings as some people have come out to say the message was not clear.

A concern has been raised that the kombis which had been branded with the advertisements promoting the campaign display four women, which is said to be confusing as to whether once a person is circumcised they got more women. The logo itself, “Soka Uncobe” has raised a lot of questions as people wonder if by being circumcised it means one “has conquered” and would not get HIV and AIDS.

"If it had been the picture of a family including the wife supporting her man, who goes to circumcise then that would be better, but in this case you see four beautiful women and it says they are going to support you, it is really confusing. Are they now promoting multiple partners?" said one of the people who raised a concern.

Solomon Mndzebele, who is a caregiver under Red Cross, made a personal plea to the ministry of health to remove the message from the kombis stating that it was making his work difficult.

"When you tell people about condoms they would just tell you that they would circumcise and by then they would have conquered HIV AIDS.

The ministry of health tries to explain away the blunder.

Added May 11, 2011
Moved and expanded:

EDIT, May 27, 2011
I found another article that was published early this year. Thought it belonged here:
One man boasts that he got circumcised because it is "nice to have sex without condoms" -- drawing a furious reaction from the recruiters.

"That is NOT what he was told at the clinic!" exclaims Mbogniseni Ndzimandze, the leader of the recruitment team.


  1. That's certainly scary! Those poor people that actually got HIV because they thought circumcision protected them :(

  2. Joseph, your post deserves a standing ovation. It gets to the core of problem. Ideas involving sexual conduct are very vulnerable to vulgar and self-serving misunderstandings. The push for circumcision as an AIDS battling strategy is a splendid case in point. Thus the myth that "a circumcised man can't catch AIDS, and doesn't need to use condoms." Tell that to the 250,000 odd North American gay men who died during the Gay AIDS Holocaust, 1980-2000. The vast majority of those men were circumcised.

    To expect that the typical African male will know how to respond logically and wisely to the claim that circumcision reduces the chances of getting AIDS by "60%" is to expect far too much. Alleged scientific findings cannot be viewed in splendid isolation. We have to take into account that human beings who are illiterate and innumerate will respond to those findings in unpredictable or shabby ways.

    Sure enough, this vulgar corruption has spread like wildfire, and the consequences will be tragic. All the clinical trials claimed to show is that circed men are less likely to catch AIDS from infected women via vaginal intercourse. The trials said nothing about AIDS and gay/anal sex, or about circ affecting a woman's chances of catching AIDS from an infected man. I bet the typical African male does not appreciate the points I am making in this paragraph, because he hasn't been told about them. And even if he were told, he does not have the education needed to appreciate the fine distinctions I am making. People, the germ theory of disease is only about 140 years old!

    The WHO and CDC investigators are impractical fools, willfully blind to how human nature plays out in the real world. The randomized clinical trials are a major scientific scandal waiting to detonate.