Bloodborne HIV: Don't Get Stuck!

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I have spent the last two weeks in the West of Kenya trying to get people’s views on mass male circumcision, what is called the ‘Voluntary Medical Male Circumcision’ (VMMC) program. I have written notes about my visit on my blog, HIV in Kenya, but I should summarize the main findings here as they are not difficult to summarize, and as male circumcision is a very important potential HIV risk in Kenya. I admit, it has been very hard to find ordinary people who will talk about the subject, though I have found some. But it hasn’t been so hard to get people deeply involved in the VMMC program to argue the case for circumcising millions of Africans. As I shall explain, the case is even weaker than I thought before coming here.

The main finding is that VMMC is driven by money, by donor funding. There are copious amounts of donor funding available for male circumcision, but there are is very little funding for healthcare, unsafe or otherwise, education, infrastructure, employment or any other area of development. Everyone involved in HIV, health, development, etc, needs to apply for donor funding and they know they are wasting their time if they apply for funding for things donors don’t currently place any emphasis on. Everyone knows that HIV projects get funding, but only certain kinds: these must presuppose that almost all HIV transmission is through heterosexual sex. Circumcision ticks all the boxes.

Another finding is that even the proponents of VMMC are not convinced by the evidence for the community level effectiveness of such a program. They accept that the evidence of partial protection gleaned from randomized controlled trials (RCT) suggests that the level of protection that can be expected at a community level may be very low; it may even be cancelled out by other factors that result in increased HIV transmission as a result of VMMC. However, they appear to agree that interventions that have been carried out so far, such as various types of (sexual) behavior change communication (BCC), has not worked very well. Some say BCC hasn’t worked at all.

Curiously, despite the agreed lack of effectiveness of BCC programs, those defending VMMC say that they are not proposing mass circumcision on its own; no, they are proposing VMMC plus BCC. When it is pointed out to them that a program that doesn’t work combined with a program that is unlikely to be very effective still equals yet more ineffective intervention, they tend to revert to the ‘what else can we do’ attitude, along with the argument that it is the donor who decides what gets funded. The most defeatist people I could find were the proponents of VMMC themselves. Most of them didn’t even seem convinced of its potential effectiveness at a community level, all they know is that they will get paid.

It’s been hard to find people who are less closely connected to VMMC to talk, particularly to be interviewed in front of a camera, which is something I have been trying to do. Some of them say they don’t beleive the program will have much effect. But some say they believe it will work. People tend to know that the operation does not claim to give 100% protection but they don’t realize that the 60% protection claimed from the RCTs does not equate with 60% protection at the community level. While 60% (or more, or less) protection is a difficult enough concept to explain, explaining the difference between RCTs and community level interventions is not so difficult; everyone knows that if you pamper people for a while you will get quite different results from when you round them up and squeeze them through some kind of industrial process (ie, VMMC).

We have been bombarded with claims about circumcision giving partial protection against HIV; what has not been so clear is that the evidence for partial protection is itself only partial (pun intended). We don’t know what 60% protection in an RCT would amount to at the community level. Worse still, we need to wait another 6 years to find out, because the 10 year program in Kenya is only in its fourth year. This is not so much a community level intervention as a community level experiment. The only people I’ve found who seem to be aware of this is the proponents of VMMC. Is it unfair of me to compare this to the Guatemala syphilis experiment, referred to by Barak Obama as a crime against humanity? Or is it more like the Tuskegee syphilis experiment, referred to by Bill Clinton as racist?

The victims of this kind of human experimentation without informed consent (people do not consent to being part of an experiment and they are not given adequate information about the risks of circumcision nor the level of protection against HIV they can expect, although that is not even known) are not just the Luo men and possibly infants who will be circumcised under the VMMC program. The sexual partners of those circumcised are also deceived about levels of protection and risk. And even Kenyans who already circumcise, for traditional or other reasons, are deceived about protection and risk involved where HIV and circumcision are concerned, although it does not target them, specifically. So why circumcision? Because the money says so.

For more on circumcision, see also Don’t Get Stuck’s male circumcision section.