Male circumcision: An HIV prevention strategy?
Written by FAITH NKOMO
Edited by JONATHAN MUNDELL
Male circumcision is an age old traditional human practice. Over the years, different societies and cultures have attached various meanings to circumcision, and to this day, male circumcision is still practiced for a variety of reasons, being very popular in a number of communities around Africa. Recent research on HIV prevention has now attached a completely new meaning to the practice of male circumcision.
Male circumcision is generally performed for hygienic purposes. This is based on the understanding that the foreskin contains moisture from being covered, and if not cleaned properly, dirt could build up, causing bacteria and could thus develop an infection. A circumcised penis is therefore perceived to be far more hygienic, as the tip tends to be drier, and remains cleaner. In addition to these hygiene-related reasons for male circumcision, there are also religious or spiritual beliefs linked to its practice. In some religions for example, a circumcised man is believed to have formed a covenant with God and is perceived as righteous or “right with God”. In other cultures, circumcision is celebrated as a rite of passage into manhood. This is generally conducted by having a group of young men sent to an excluded area where they are taught about issues of manhood in their culture, and then take part in a variety of activities, which are considered to bare lessons necessary for manhood. During this time, circumcision is performed, and the transition from being a young man to becoming a man takes place. These newly delivered men then return home to much celebration.
There are other meanings attached to the practice of male circumcision in different countries around the African continent, the most recent being the current growing interest, and much contention, around the idea of implementing male circumcision as a preventative strategy against HIV infection. The most widely reported studies supporting the prevention benefits of circumcision come from Kenya, South Africa and Uganda, completed in 2005 and 2006. During the trial in Kenya, a trial of 2,784 HIV-negative men showed a 53% reduction of HIV acquisition if circumcised. The trial in Uganda, conducted with 4,996 HIV-negative men, displayed similar results, showing a 48% reduction in HIV infection in circumcised men. In South Africa, a trial with more than 3,000 HIV-negative men showed that circumcision reduced the risk of acquiring HIV by 60%. Medically, it is has been found that male circumcision may act directly to reduce the risk of HIV acquisition, by reducing the ability of the virus to attach to and enter cells. The inner mucosal surface of the foreskin is said to contain a higher density of target cells for the HIV virus than the surface area of the penis. The foreskin is more susceptible to trauma, and thus also to HIV infection. Some researchers have also reported that the circumcised penis is less permeable, and hence make it more difficult for the virus to enter. Therefore, the suggestion that male circumcision is an effective HIV prevention strategy is generally understood to be indirect.
Some groups are taking these findings a step further, amidst uncertainty on the issue. It is reported, for example, that President George W. Bush’s administration will use part of its annual US$ 15 billion global AIDS programme to promote the use of male circumcision in sub-Saharan Africa as an HIV prevention tool. In another instance, Dr. Ibrahim Mohamed, Director of the National AIDS and Sexually Transmitted Infections (STIs) Control Programme in Kenya, has been reported as saying that, "There is a committee working on the policy to include circumcision into the HIV prevention strategy". From these, and others’ point of view, male circumcision has been a welcomed new development in preventative science. However, voices of critique have risen with disdain following these reports, with the concern that such mass implementation could be disastrous, and could lead to a possible rise in HIV prevalence rates. This kind of response to the HIV epidemic would most certainly not serve as a method of changing sexual behaviours in men, which have been the intentions of many HIV & AIDS prevention programmes in the past.
Since the discovery of HIV & AIDS more than 20 years ago, one of the most effective preventative methods against HIV transmission is the use of condoms, during sexual intercourse. The use of condoms is not necessarily an ideal method of HIV prevention; however it is a safer option than suggesting male circumcision as a preventative measure, thereby possibly subliminally giving men the message that they no longer need to engage in “protected” sex. Much earlier in history, an animal’s stomach lining was used as a barrier during sexual intercourse. As the use of condoms progressed over time, latex became the more popular material. Currently, the condom is now not only used as a method of contraception, but more as a barrier against STIs and specifically against HIV infection. Condoms have been tested to be 99% effective, and it is widely reported that the 1% is dependent upon their improper use. Governments around the world have gained trust in the effectiveness of condoms, and in many countries, they are distributed freely. The private sector has of course used the popularity of condoms for their own benefit, by adding more variety to them, the idea behind these variations also to make the choice more creative, and add a ‘fun’ element to their use.
The introduction of condoms as a preventative measure has had a mixed reception around the globe. Some objections to the use of condoms included a reduction in sexual satisfaction, tightness on the penis, and specifically in Africa, some started to attach various conspiracy theories to their promotion. Some suspected, for example, that condoms had been laced with HIV, suggesting that Europeans planned to wipe out the African population, so as to take over the continent and its resources. One more realistic area where condoms have perhaps had somewhat of a negative impact is in the enhancement of the already existing unequal power dynamics between men and women. In relationships, particularly in Africa, men tend to be decision makers with regards to issues of sex. Women in many instances are subjected to their partners’ perceptions of sex, as they tend to rely on their partners for economic resources. Many men regard the use of condoms as unfavourable, and they are often used either improperly or inconsistently, if used at all. Condom use as the main prevention of HIV in Africa has thus become a rather daunting task. The promotion of condoms as a preventative measure has also experienced resistance from the largest Christian denomination, the Catholic Church. The Vatican has issued statements, claiming that condoms do not protect against HIV infection. Many believe that such declarations aim to further instil the practice of celibacy by its single members, and faithfulness between its married members, condemning the use of contraception.
Following the mixed reactions to the inception of condom use as a preventative strategy, and the multitude of research that has been conducted to assess its effectiveness, the idea of promoting male circumcision as a new prevention measure against HIV infection could threaten the foundation on which traditional HIV prevention strategies have been based. Due to the fact that condoms are still not a favourable choice in many sexual relationships, many men may perceive the idea of male circumcision as a new winning formula. This may very well prove detrimental to any attempts to further prevent the spread of the virus, as the general community may misinterpret the difference between the lowering of risks, and complete prevention of HIV infection. It is therefore possible that if not implemented with care, the promotion of male circumcision may simply provide more fuel to an already rampant epidemic.
NOTES:
Faith Nkomo is a Researcher: Gender Issues in Africa at Consultancy Africa Intelligence; Jonathan Mundell is Director: HIV & AIDS Unit at Consultancy Africa Intelligence (jonathan.mundell@consultancyafrica.com).
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