No to Circumcision Against HIV!

Local music sensation Jah Prayzah recently told fans that he will continue holding shows despite the pain that he is in thanks to a recent circumcision procedure. Prayzah has been one of the poster boys for the circumcision-against-HIV movement. There have been calls for all Zimbabwean men to get circumcised in order to help fight against HIV/AIDS. In fact, a budget has been set aside to circumcise 80% of all young men in the next few years. That is the enthusiasm of this movement. However, while I support our efforts to fight AIDS, I do not support the circumcision movement. Besides being hardly effective, it is a waste of resources. It is a good-intentioned initiative rooted in a few studies and fervent international donor 'enthusiasm.' Still, it is misguided.

Where did it start? It started when interested people noticed that HIV infection rates were lower among African Muslim communities than they were in their non-Muslim counterparts. Because circumcision is much more widespread in Muslim communities researchers intimated that circumcision may be partly responsible for the lower HIV infection rates in the Muslim communities. Studies were done in Southern Africa to test this hypothesis. In the more prominent studies, two groups of similar men - one comprising circumcised and the other uncircumcised men, were tested for HIV after being observed for some time. Some men contracted HIV in both groups. However, there were forty to sixty percent more infections in the uncircumcised group than there were in the circumcised one. After correcting for some factors, researchers then concluded that circumcision reduced HIV infection rate by up to 60%. What explains this?

Researchers have hypothesized that the foreskin of a man's manhood has better receptor conditions for the HIV virus. Also, it is the part that is more likely to be damaged and hence more 'porous' towards the HIV virus. There, if the foreskin is removed, a man is less likely to contract HIV during sex. The hypothesis actually makes a lot of sense, and I do accept it. What I do not accept is how this information is used.

Firstly, let me tackle this 60% claim. It should be noted that, when a circumcised HIV 'negative' man sleeps with an HIV 'positive' woman, the man's chance of getting infected by the virus is about 60% less than that of an uncircumcised man. However, the same cannot be said about the reverse scenario: when an HIV 'negative' woman sleeps with a circumcised HIV 'positive' man, her chances of getting infected are not different from when she sleeps with an uncircumcised man. Therefore, circumcision in this respect only reduces the risk for men, and not for women. If we take these two cases as the main ways in which AIDS is spread in Zimbabwe (neglecting homo-sex, mother-to-child transmission and other non-sexual transmission, which collectively account for less than 10% of new infections), we find that circumcision only reduces the overall infection rate by less than 30%. (This is also assuming that man-to-woman infection rate is equal to woman-to-man infection rate). This is not advanced Maths; circumcision only lowers the risk among men, not among women.

It would seem, therefore, that circumcision is only beneficial to men. I will argue later than not only is it not beneficial to women, but it is bad for them. However, proponents of male circumcision have realized this discrepancy, and have therefore added the line "...male circumcision also reduces the risk of cervical cancer among women." This fact is supposed to 'balance the equation.' However, there is indeed evidence that women with circumcised male partners have a lower risk of developing cervical cancer. What is questionable is whether male circumcision is the best way to combat cervical cancer. It is certainly not, but circumcision is thrown into the mix by circumcision-against-HIV supporters so that it does not appear that circumcision only benefits men healthwise.

A major issue with the promotion of male circumcision to combat the spread of HIV is its unintended consequences. Some circumcised men are refusing to use protection during intercourse because they believe that they are safe. I recently read an interview in which a prostitute confirmed this new trend. Even though she wanted to use protection, she claimed, the male customer insisted otherwise because he had been circumcised. As a result, that sexual encounter put both of them at considerable risk, the woman much more so than the man. Had the man used protection, the HIV risk would have been much lower. Even the cervical cancer risk would have been reduced. What's more, if the man had not engaged in risky behavior in the first place, they would both have been 100% risk free! Now, this circumcision band wagon is causing some men to throw protection out of the window because they are protected. Circumcision supporters will argue that they encourage circumcised men to use protection still. Well, then, what would be the point of circumcising in the first place?

The answer lies in the workings of international donors. For them, the statistics make sense. Taking a large population, the HIV new infection rate will be reduced by up to 30% if all men are circumcised(not 60%; see my correction above). For well-intentioned international donors, who are always on the lookout for cost-effective anti-HIV measures, this is a great prospect. However, their zeal overshadows good judgment. Firstly, they do not take into account the behavioral change that circumcision causes. It actually leads to riskier behavior. Some circumcised men wrongly think that circumcision eradicates their risk of contracting HIV through unprotected sex. It also leads women to be less vigilant in protecting themselves, believing that circumcised male partners pose a lower HIV risk. Because of these factors, the lowering of HIV infections through circumcision is partly countered by riskier behavior. However, this is not taken into account in the statistics. Eventually, this circumcision drive diverts attention away from what has actually caused Zimbabwe's fight against HIV/AIDS to be successful thus far. Behavioral change has been cited as having been the most critical factor. The ABC formula (Abstain, Be faithful, Condomize) has been very successful in helping lower our new infection rates. Why introduce a measure that undermines the very formula that has been used successfully? Abstain-Be Faithful-Circumcise is not a suitable replacement. People should never in any way substitute circumcision for condoms.

I would like to point out that HIV infection rates have spiked in the last several months. One of the reasons, observers suggest, is the widespread availability of anti-retroviral drugs (ARV's). Of course, it is not the intended role of ARV's to increase the risk of HIV infection in the population. However, it is an unintended reality. People have seen HIV positive people living 'positively,' and they think of HIV less as a death sentence now. Some people are therefore less scared of the consequences of contracting HIV. This is also partly thanks to an aggressive anti-stigmatization campaign that we have had. I do not at all mean to say that ARV's are bad; no, far from it. I have only used this observation to demonstrate how well-meaning anti-HIV/AIDS measures can have unintended consequences. We should of course continue to provide anti-retroviral treatment to infected people. However, we should be more wary of circumcision, which is not aimed at infected people.

If circumcision will, in perfect conditions, only reduce new infections by less than 30% over a long time, and increase infections at the same time by promoting risky behavior, it is not worthwhile. There are other far more effective ways of fighting AIDS. Those ways are based on informing people about risk eradication. Circumcision does not do that. "Get circumcised, it reduces your HIV infection risk somewhat, but you have to use protection." What this message translates to for many men is "get circumcised and you cannot get HIV anymore." Shouldn't we be spending more money and time telling people to abstain, or to use condoms with their partners? What are we doing circumcising 16 year olds and telling them it reduces their chances of getting HIV if they have unprotected sex? Are we really making this decision out of concern for our youths, men and women? Or are we merely listening to overly enthusiastic, money-bearing international donors?

I think people can get circumcised if they want to. But telling a whole country to get circumcised in order to reduce its HIV-infection rates is misguided. It is also a waste of resources that can be used differently and far more effectively to combat HIV. I think this dangerous message of circumcision against HIV (and cervical cancer) ought to be muted. Instead, we should hear the message: "change your behavior, protect yourself, AIDS kills."

Lesley Nyirenda is a freelance writer who writes for ezimbabwe.wordpress.com and can be reached at lesnyirenda@gmail.com -- ,