Bloodborne HIV: Don't Get Stuck!

Although it’s reported as good news, nearly one fifth of South African men surveyed thought that circumcision would fully protect them from HIV. The report concluded that “communication and counseling should emphasize what clinical AMC is and its effect on HIV acquisition“. But communication around male circumcision always appears to be lacking. The dangers of being circumcised in countries where safety in health facilities cannot be guaranteed doesn’t seem to be discussed. Apparently, those pushing for more circumcision are satisfied with their own research, though they don’t appear to have looked into the risks involved.

Aside from problems with botched operations, and they do occur, there is a high risk of exposure to contaminated blood through unsterilized medical instruments in many African countries. You may end up in a showcase circumcision program or you may end up being operated on in conditions that most Africans have to face when they attend health facilities for far more urgent operations and care.

However, despite all the enthusiasm for circumcising 20 million men, and the vast claims of numbers circumcised in Kenya (where most men are already circumcised), only 600,000 in 14 countries are said to have undergone the operation during the current program. One commentator says “it’s really, really difficult to bring this to scale“, which is a delicate way of saying that you can’t expect a massive health program to be carried out in a group of countries where health facilities are scarce, underfunded, underequipped, understaffed and in atrocious conditions. Just have a look at a few Service Provision Assessment reports for African countries.

It’s worth bearing in mind that the 60% protection claimed for circumcision refers to sex without a condom; if circumcised and uncircumcised men use condoms properly and all the time, they will both have the same risk of being infected with HIV. It is also worth remembering that while circumcision may give some protection to men (though the evidence is not strong enough to justify the costs and risks), it can increase HIV transmission to women. It is women who are already infected in far greater numbers than men in most high HIV prevalence areas. As many as 5 women can be infected for every 1 man; mass male circumcision may end up increasing overall HIV transmission.

One of the most ardent fans of circumcision for others is Robert Bailey, who has done much of the promoting in Kenya. He said “We’re hacking away at it every month…those foreskins are flying.” This attempt at humor may come back to bite him, because many clinical trials carried out in East Africa have involved practices that are highly questionable, ethically and clinically. It’s not people like Bailey who suffer the numerous but less media friendly health problems that Africans face. But obsession with HIV, African sexuality, circumcision and the like distracts attention and funding from the real issues. Bailey wants 2 billion for circumcision programs while millions of people are infected with and die from cheaply preventable and curable diseases.

Perhaps Bailey himself might enjoy the experience of having an operation in some of the facilities that the UN cannot guarantee the safety of? Perhaps he’d like his family to sample the delights of badly trained clinical officers (like a nurse, but do the work of doctors because there are too few properly trained personnel)? Like all skin piercing procedures in African health facilities, male circumcision can be very dangerous.

Because there is a lot of money involved, no one wants to stand up to this heavy handed approach to the issue. Uganda’s Museveni has said the operation is not scientifically proven to prevent HIV, which is good, but he has also said that ” only premarital abstinence and marital monogamy are sure to work”, which is not true. Most new HIV transmissions occur in long term relationships, that’s been the case for some time, and not just in Uganda either. And that’s the problem with circumcision: lying behind it is the incorrect assumption that most HIV transmission occurs through heterosexual sex. Countries with high HIV rates need to investigate the relative roles of health and cosmetic facility HIV transmission.