This op-ed was originally published in The Monitor (Kampala) on
12 November 2007
Dr. Moses Bateganya
I write to share my opinion with others following an article that quoted President Museveni’s speech to the youth. I write to add my voice on the issue of “the role of male circumcision in Uganda’s fight against HIV.”
Male circumcision is a promising addition to Uganda’s HIV preventive strategies and once implemented it has potential to reduce HIV infection among circumcised males. Uganda and the rest of the world are fortunate to have an additional intervention that will support the fight against the epidemic. However wide-scale implementation is premature in Uganda.
First, although several research studies that compared circumcised and uncircumcised males in several African countries including one from Rakai district in Uganda showed that circumcised males were less likely to acquire HIV than their uncircumcised counterparts, there is a big difference between what can be achieved in a study setting and the results of a public health intervention. Conditions in a clinical trial are carefully controlled and results may not really be as glowing as those from a study situation where both the study staff and participants are well motivated.
For example while side effects from surgery were minor under study conditions, they may be enormous under field conditions given the current challenges faced by Uganda’s hospital surgery departments such as few and less motivated personnel, lack of proper equipment, shortage and frequent stock out of drugs and consumables.
Secondly, there may be behaviour disinhibition where people who are circumcised may incorrectly assume they are not at risk of HIV infection. Such an incorrect conclusion may lead individuals who are HIV-negative at the time of circumcision to maintain or increase their current level of HIV-risk behaviour putting themselves and their sexual partners at risk.
Similarly, HIV positive individuals may seek surgery and incorrectly think they will not transmit HIV. Hospitals implementing circumcision may not have the capacity to screen all their clients for HIV before offering circumcision, thus circumcised males may create another risk category in HIV prevention.
Male circumcision may also take away resources and attention from other prevention methods that have effectively reduced the HIV prevalence in Uganda, namely abstinence, faithfulness and condom use. In fact, those prevention efforts have already earned Uganda the coveted position as an international success story in reducing the number of people being infected with HIV (though this assertion is still being questioned and is an open debate; what worked in Uganda?).
The cost for each circumcision in the Rakai study was over $60. This is a cost ten or more times the annual budget for health for an individual. Is it worth diverting the prevention budget away from methods that seem to work for a fraction of the cost to try something that has only been tested in a study setting? I don’t think so.
Dr. Moses Bateganya is based at the University of Washington, Seattle
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45 comments:
i urge ALL of you with some sort of title to your name to do more than write blog articles about this issue.
MANY people, even in North America are starting to use these studies done in africa as REASONS for why they are circumcising their own sons.
we HAVE to get the information out there that AIDS is not like a COLD or FLU virus... its a behavioural illness.. you get it by practicing unsafe sex with infected individuals.
which means that CONDOMS, EDUCATION, and STD TESTING are the ONLY necessary steps needed to stop the HIV problems, in relation to sex.
wear condoms, don't sleep around (especially with random prostitutes) and get regular testing to make sure you are still clean, and same with your partners!
thats it!
circumcision takes away from the REAL solutions. im sure cutting off parts of a female would make some random statistical difference as well, or hey, how much HIV prevention would occur if we just chopped off the entire penis.
lets not let the circumcision-advocates dupe the world into promoting a damaging procedure in the name of health IN YET ANOTHER country. we're still recovering from all their preaching about circumcision benefits over here in North America.
We need to be cautious with regard to this issue of male circumcision and HIV. Those of us from traditionally circumcising cultures for religious or cultural reasons would be heartened to know that male circumcision has a significant health benefit with regard to HIV/AIDS.
Those from traditionally non-circumcising groups may be tempted to try to undermine the proven scientific evidence of the protective effect of male circumcision rather than embrace a 'foreign' practice even if it may save the lives of thousands of their own people.
I personally an outraged that Dr. Moses Bateganya in his Op-Ed dares to question whether $60 spent on reducing the risk of HIV infection and an early death with worth it. The US government has offered to make funds available if countries have concrete plans to offer safe hospital circumcisions. Are we Africans now accepting that an African life is worth less than $60? What a disgrace.
Apart from the debate amongst Africans ourselves we also need to watch out for interference from US and western fringe groups who are anti-circumcision at any cost. The Internet is full of groups dominated by gay men who promote the foreskin as a result of their own sexual preferences.
Condoms are only effective if used every time. While condoms use should be strongly motivated it should also be used together with other strategies such as faithfulness, less partners and also male circumcision.
Why do some people and groups always seek to place their own personal agendas above the health and safety of others. This is also a disgrace.
Nice comments. I would just add that in most countries with generalised epidemics, marriage and regular partnerships are additional risk factors to those that were previously thought. So not just randon prostitutes anymore!!!! but others too can infect or be infected! Hope you all didnt miss the compeling speech of King Country Councilor Julia Patterson while introducing the equally moving documentary on channel 22!
Just to defend my OP-ED opinions. I do not doubt for any moment the circumcision studies that have been published. The evidence was very clear. My argument is that roll-out on a massive scale should be carefully thought out. I am grateful that funding is availabe to circumcise people, BUT...more money will be needed. The same people will need to use condoms, reduce the number of sexual partners, be treated for and prevented from STDs.
Given, according to UNAIDS, that less than 15% of people in SSA are aware of their HIV status, (after so many years of lots of money given for VCT. HIV testing needs to reach all men before they are circumcised! That will not happen in a few weeks.
I have worked in places where women came back with sepsis and broken episiotomies because their parners could not wait for them to heal before having sex. I cannot rule out similar similar happenings for men. Sexual behavior is much more complicated that what is immediately obvious at least in Uganda and many Sub saharan African Countries.
So while i support circumcision, its implementation should follow massive educational campains, hospitals need to be equiped, HIV testing increased to exceed the current estimates, and other prevention methods sustained.
Moses
African women most often do not have control over whether or a condom is used. If a circumcised man has half the risk of HIV infection then that confers some benefit to the women doesn't it? Having our male children circumcised will not only given some level of protection but also provide our sisters with less risk of HIV infection through unprotected sex over which they have no control. The clinics that would offer circumcision could also gives check-ups for other medical problems at the same time and even vaccinations if needed so I think many good can come from this if correctly thought out.
clearly we are all only interested in doing what is best for these people, and whats best for stopping HIV.
in my opinion, circumcision devalues the purpose of the foreskin. people associate risks and hatred towards a body part that is healthy and beneficial in nature.
if african women do not have control over whether their partner wears a condom...
...then THAT is what we have to fight to change.
don't be so short-sighted.
and to joshua, when you say
" Are we Africans now accepting that an African life is worth less than $60? "
that was NOT the point at all. those 60 dollars would be MUCH better spent on OTHER measures. education, condoms, liberating the african women. circumcision is not the answer.
its the circumcising cultures that consistently devalue the human body, and the foreskin, and wish to inflict their customs onto others. i resent your comment about how anti-circumcision advocates are nothing but gay men who have a sexual preferences for uncircumcised men. what a ridiculous thing to say.
also...
why isn't it that the studies test cutting off the labia of females, even though some might suggest that would reduce HIV?
its a terrible idea, of course, the point being that we will only ever find the answers to the questions we ask. studies are being done to test the benefits of circumcision, because circumcising cultures think circumcision is wonderful.
lets do a study that tests the results between a man who gets std tests, and the education to understand how HIV is passed around (information which would be made available to the women as well) and its negative effects, and what they have to do to avoid it... and PLENTY of condoms.. also, locations where he and his partners can get tested before having intercourse...
....and then lets compare that with how effective it is to circumcise a baby, and then let him out into hiv-ridden africa.
which would you RATHER spend your money on? which situation would be more effective?
Dr Moses missed the point on money when he put focus on the cost of circumcision and ignored the cost of ARVs and treatment of other opportunistic diseases. This I agree with brother Joshua is a big mistake. It is not about money it is all about those cultures that do not traditionally circumcise having to begin to do so and their doctors having to learn the skills. There is a whole mindset change needed. To listen to the American gay try to say the foreskin has some purpose that is still valid makes me laugh. Does the gay man not know that we were circumcising here in Africa before we wore clothes so we know there is no need to a skin protection. Most of us who were circumcised as young men had experienced sex before circumcision and know that the foreskin has no benefit in that situation. Rebecca is correct in what she says and we African men must accept that we don't prefer wearing socks in bed which is dangerous for our women and ourselves. We cannot rely on condoms and we cannot rely on the advice of gay Americans. Thank you Dr Moses for raising the topic for discussion.
Dear all
This is certainly getting interesting to the point that we should have a panel discussion next quarter. Invite key people to discuss the studies and HIV prevention efforts. I dont want to be drawn into discussing whether circumcision is good or bad. That discussion is outside the theme of the "circumcision/HIV prevention discussion in resource limited settings". My argument is that in a country with 30 miliion people, prevalence about 7%, with only 10-15% aware of their HIV status,and a few of those who are aware of their status still do not have universal access to ARVs and are still dying of opportunistic infections, malarias and have multiple partners. What would you do now if you were given 60 dollars per person! apart from buying a few SUVs for the project staff, what would you else would you spend that money on......ALOT
all the best on World AIDS Day.
Moses
Robert Dube... stop being a troll.
i am not American or gay. and if i was, that would have NO merit on my opinion, or the validity of yours.
don't use slander to make my opinion appear less than it is. that is NOT very mature.
do not use circumcision as an excuse to allow your men to continue to not use condoms, and not give women the rights they deserve.
Moses.. you don't want to be drawn into the discussion about whether circumcision is good or bad, but in the end.. isn't that exactly what this is about? the foreskin is INCREDIBLY sensitive.
visit this link to see a study that deals with this very subject
http://tinyurl.com/yrly3g
originally published in the British Journal of Urology.
lets deal with the BEHAVIOR problems that cause AIDS to spread.. lets listen to REASON!
Joel..
The original OP-ED and discussion was timeliness implementation of massive male circumcision in Uganda as an HIV prevention tool. Sort of finding out whether this was the time to implement it on a wide scale given the results of three main randomised studies. People may also want to read the Cochrane review on the subject published a few years ago and which is probably being upraised to include the three main studies.
Moses
Joel,
thanks you for coming out on this issue.You admit that your belief that the foreskin is 'sensitive' drives your interest in this matter. As I said those who have had sex before circumcision know that the foreskin is not a factor in relation to sexual experience. So I leave you and the gay agenda at this point.
In areas of Africa we still have those who are suspicious of vaccinations, refuse to donate blood and even those who refuse to believe that the tiny mosquito can cause a human death (malaria). We should not expect traditionally non-circumcising societies to rush to embrace male circumcision in an instant.
Should those who understand the benefits from male circumcision with regard to HIV infection bother to try to educate people in this regard? Is it the responsibility of those with a 60% lower risk of HIV infection to advocate among the non-circumcising? Or should they just be left to debate the subject until there is no one left, except old women and young kids, to debate it? Should we bother to advocate for vaccinations among those who are suspicious of the concept?
I remember the saying, you can take a horse to water but you can't make it drink. If these people are intent on mass suicide then what can we do about it? What should we do about it?
This is by far the most interesting discussion that I have seen on our IHP blog...good work! Keep posting articles and comments. Thanks for all of your input!
Robert Dube... you barely deserve a response after your clearly delusional reply to my comment.
you think that i am gay because i think the foreskin has value? i hope i am not the only one to see your poor understanding of the real issue.
i've said it before, and i'll say it again... our funding and our resources should go towards EDUCATING people about what HIV is, and how they are getting it.
we should spend our money on making sure there are condoms available for all!
we should spend our money on setting up std-testing clinics.
circumcision is NOT the answer. its debatable benefits are only seen when condoms are not worn..
...lets not waste our time trying to "kind of help" the HIV problem, when we should be spending our time and money teaching people how to avoid HIV in the first place.
i've said it before...HIV is not like the flu! you don't just "catch" it.
Joel it is clearly obvious that you have no understanding of Africa and HIV/AIDS situation on the continent.
Your desperation in demanding everything other than male circumcision exposes some agenda which you may wish to seek therapy for.
The condom promotions by organisations such as PSI have just not worked as well as they had hoped.
Testing where facilities exist has not been a success either. Most people just don't want to know.
People generally know about HIV/AIDS and safe sex but all that flies out the window after a few drinks.
So we do really need a public health policy to help reduce the spread of HIV across a given population. Male circumcision will help with that across a population but nothing will help the truly promiscuous individuals.
Your ideas are from another planet. Here we need African solutions to African problems. Against the death and suffering caused by HIV/AIDS your campaign to save the foreskin sounds ridiculous. Can't you understand that?
In Friday's New Vision newspaper there is report on the planned roll out of free male circumcision services in Uganda. The last paragraph of the article sums up quite well indeed. "To work effectively, circumcision should be widespread, be medical, be followed by abstinence for at least six weeks and be used as a complementary strategy to ABC." I think also circumcision should be carried out at age before becoming sexual active in good medical situation.
Joshua... is your claim that Africans are not capable of practicing safe sex?
that we should just cut off parts of their bodies because clearly they are not willing to learn?
i understand that the problem is huge.
i find circumcision to be incredibly short-sighted... not to mention that it punishes the entire african male population because we have given up on their ability to practice safe sex and undergo std testing?
i truly believe that the money would be much better spend increasing the education... explaining the severity of the situation.
clearly if theres people are still not wearing condoms, they have not fully comprehended the situation, and could use more education.
i think your suggestion that i should seek therapy says something about your OWN hidden agendas.
On AIDS Day research was published that said that risky sex behaviour is increasing in South Africa. This was in despite of millions being spent on education. Even President Mbeki said that people were not listening to the calls for being faithful and condom using. My God South Africa, 6 million HIV positive and still people don't care.
i understand this is a huge problem, and i really am not here to suggest that extreme measures need not be taken...
...i just think the approach STILL lies in education.
we need to try new and multiple forms of educating people...
shock tactics... maybe even! getting people they respect on board, and having them stand up for the issue.
the point, i think, is that it is a MENTAL shift that is important. we can't just assume these people WON'T change, and so we should just cut parts off of their babies, and their children.
wrong message, wrong approach, WRONG!
the money could be spent in SO MANY other ways!
Dear all
I think some people have stopped listenning to the OLD prevention messages. The disease has changed. Initially the messages were shocking like "AIDS kills". That message may not hold today!when people are "not dying" anymore! at least not in the same numbers. We need to identify different ways of giving the information.
Moses
In many areas in Africa the AIDS situation is so bad that people will try just about anything to be protected or to get cured. Remember how the public have flocked to people who claimed to have a cure or some special potion. Research has shown that in a community where all the men are circumcised there will be a much lower number of HIV infections, not none but a much lower number. It is not surprising that such news reinforces the commitment to male circumcision in communities that already practice it and creates a demand for the procedure in communities where traditionally male circumcision is not practiced. It is good to see that good medical facilities are being made available to those who want to be circumcised when funding is available. We don't want our continent destroyed by AIDS.
Update on circumcision in Uganda
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=49327
Moses
i just don't get it.
shouldn't we be spending our money making sure that people have the choice to practice safe sex, instead of spending it to make unsafe sex slightly less unsafe?
/sigh
The donor money being spent on circumcisions of males is as much a public health value as is vaccination. A circumcision makes for clean and healthier altogether. Male circumcision is important not only for HIV reductions but also for general hygiene and cleanness and improves health of females from less infections and diseases. New hospital facility will make it possible for boys to be treated as well. As nursing sister I support male circumcision for public health reasons.
basic hygiene is all that is required to keep a penis clean.
its easier to keep an uncircumcised penis clean than to keep a womans vagina clean.
but yet we KNOW that cutting off a womans labia is not the answer.
lets not forget that people deserve the option of having their entire body.
i doubt you would willingly give up any of your currently owned body parts, because SOME people are too lazy to clean themselves, or wear a condom.
its easy to support a procedure that removes a body part you never experienced.
frankly, im disturbed by the large numbers of people who support circumcision, with seemingly skewed realities on what they hope to achieve.
think about how many cavities you could prevent by having a childs teeth all removed at birth.
how many womens lives you'd save from breast cancer by having babies breast-buds removed as an infant.
these are not GOOD solutions! and neither is circumcision.
stop trying to play god.
UNAIDS country coordinator Dr Kékoura Kourouma has called for circumcision of Rwandans males at a tender age to be circumcised to help protect against future HIV infection. Seems male circumcision is like a vaccine for HIV.
Sister Miriam, please ignore the rude gay as he has no contribution to make other than rudeness. I apologize for his rudeness on behalf of this website.
Hi Ihper!
You have all exhaustively discussed this circumcision issue and have contributd wonderful ideas. I am planning to write a follow up letter to the Ministry of Health in Uganda with your great suggestions. Can you each give me YOUR two points for and against male circumcision as an HIV PREVENTIVE STRATEGY at this point in the fight against the epidemic! Just bullet points! Happy Holiday! Moses
Joel, Africa is not a very gay friendly society not because you love other men but because what you do with them. It is unnatural. Sorry. Please go away.
Dr. Moses: My comment is as follows:
Apply the ABCC in the best combinations to suit a particular community and it's HIV problem.
That would be to encourage abstinence, faithfulness to a single partner, circumcision, the use of condoms.
i think your words speak for themselves.
what a joke. i hope no unfortunate souls ever take a word you say seriously.
* Remembering that mass circumcision would take place in communities where the men are not circumcised there would need to be proper medical support for the operation itself and for post op caring.
* That as a result the men (and their partners) may enjoy sex more often even without a condom.
* The number of HIV infections would drop in the community by much.
*Penis hygiene improves and diseases will reduce and that will make women and women partners happier.
Hi Miriam byt this statement "* That as a result the men (and their partners) may enjoy sex more often even without a condom" are you implying that after circumcision people should not use condoms? Do you think that should be promoted? Circumcision or no circumcision I think condoms shuld still be useful as a measure against HIV and other STIs.
Happy Holidays
Moses
"Circumcision or no circumcision I think condoms shuld still be useful as a measure against HIV and other STIs."
agreed. although if people were to wear condoms, and properly, the positive effects of circumcision would be completely erased, as both men would have virtually identical amounts of protection.
you could argue that they would remain more protected even if there was a condom breakage. however, that protection is minimal, considering you tend to stop having sex when you notice a breakage, and put on a new condom.
studies have not focussed on the way condoms change the amount of protection of circumcised and uncircumcised men, but i think common sense explains that when the area circumcised is covered by a condom, that area is protected.
my guess is that AIDS transfer would be happening from other body parts if people were to be more stringent about their condom use.
unfortunately many places are not receiving enough condoms... from the statistics i've heard, its something like, under 5 condoms per couple per year. we need to send MORE condoms with our funding.. not circumcision tools and training.
also, money for educating people about how AIDS is happening, some africans have been lead to believe its the condoms that are giving them AIDS. some have been lead to believe that having sex with babies cures AIDS. education is NEEDED!!!
lets do whats right here.
Dr Moses I mean by that it may lead to less use of condoms or more risk sex. You asked for positive and negative comments. There was a study in Kenya which found no more risk behavior after circumcision. I have to state the possible even if not that likely.
You find that report here:
Circumcisions not leading to increase in risky sex in Kenya
http://www.aidsmap.com/en/news/281ADC9B-AB02-49BE-AC1E-6A986B5823B2.asp
Did you read of "A study of condom distribution and promotion in Uganda has found that whilst education in condom use increased uptake, it did not lead to consistent use in the following six months. Men in the intervention group went on to have a larger number of sexual partners and were somewhat less likely to use condoms with casual sex partners than the control group."
http://www.aidsmap.com/en/news/4E172283-15D5-446A-8CF7-97BCD5B7C8C1.asp
Also: "a 2004 Cambridge University study published in the journal Science found that a reduction in sexual partners and later age of sexual debut were the factors responsible for a reduction in HIV incidence in Uganda, not condom use. Furthermore, a study by the Columbia University expert Maria Wawer, presented at the Twelfth Conference on Retroviruses and Opportunistic Infections in February 2005, found that in Uganda’s Rakai district's increased condom uptake had nothing to do with the reduction in HIV prevalence, and that reductions in incidence pre-dated the promotion of condoms by Uganda’s government."
This gay fool is trying to sell Africa something that is not working.
Thanks again!
From all the arguments its emerging that circumcision has a role but so do other prevention methods. It also means that no single strategy is 100% effective. I would agree that ABCCD is the approach and that all prevention methods should recieve equal attention and VERTICAL programs such as those promoting only circumcision or ONLY abstinence may be more harmful than beneficial. If women are poor, they will still have no say in determining condom use. If hospitals and health staff are poor they are going to be attacted to vertical well paying programs and this will hurt primary health care. If people dont understand why they should be circumcised, they will feel confident that once circumcised, they will never get HIV. Moses
Dr Moses may I suggest that we try to understand that circumcision is a public health issue. Just like with say the Cholera vaccine we give it to everyone in the affected community to break the cycle of infection- transmission. Do we worry about whether people who have been given the vaccine will deliberately drink any water or eat any food? Does that mean that we don't give the vaccine to anyone because a few may behave stupidly? Of course not.
Mass male circumcision is aimed at the public health of the community where it will lead to a 60%+ drop in female to male HIV infection and with fewer infected males in the community there will be fewer females infected. So across the whole community there will be an appreciable drop in the rates of infection.
There will always be those individuals who are promiscuous and have many partners and do unprotected sex. But the evidence is that this may not get worse after circumcision.
See here: http://tinyurl.com/3ctqnw where the researchers found in the year after circumcision “at no point during this year was there any appreciable reported excess of risky sex or unprotected risky sex among circumcised men.”
This public health intervention if carried out across Africa would prevent 2 million HIV infections and 300,000 AIDS deaths over then next ten years and 3.7 million infections with 2.7 million deaths in the following ten years. These deaths will mainly be among non- male circumcising cultures. (see http://tinyurl.com/ytpf2z )
So over the next 20 years unless mass male circumcision is adopted the foreskin will become the biggest cause of death on the African continent after malaria.
don't you see the ERROR of accusing the foreskin of being the problem?
the problem isn't the foreskin, its the behavior.
we have to change the WAY these people behave. they aren't allowed to go sleep with hooker and pass it on to their families... circumcision does nothing to stop this behavior.
you might be 60 percent less likely to contract the disease (or you might not be)... but you aren't at risk for AIDS only once. if people continue to have unprotected sex with infected individuals, you're eventually going to contract it.
condoms are a cheaper method, they don't remove any body parts from non-consenting individuals, etc.
condoms must be paired with continuing education. that takes funding.. funding that needs priority over money spent to fund circumcision.
how can someone claim that circumcision can prevent AIDS but condom use doesn't?
that must require an especially large amount of brain damage.
There are some hard truths about condoms and condoms use in Africa. Where has the use of condoms been really effective? The evidence from the Kajubi study in Uganda indicates that gains in condom use seem to have been offset by increases in the number of sex partners. So it is obvious that to promote condoms to the exclusion other preventive measures is not a sane approach. We should not let anti-religious groups and anti-circumcision gay groups have any say in what preventive measures are implemented in communities across Africa.
ya, condoms and education, and std testing. i've said it a hundred times.
preventative measures prevent the behavior that causes the problem... not completely ignore it!
if people aren't learning well enough, or fast enough, you don't cut off part of their penis because you give up on trying to teach them!
you can lead a man to water, but you can't make him drink.
but you CAN drink the water yourself, and teach him how water is good for you.
you don't bash him over the head with a rock and force feed water into him when he's unconscious!
http://www.nytimes.com/2008/02/04/us/04immune.html?ex=1202792400&en=2b70b01dc67e0ae5&ei=5070&emc=eta1
Thought I would share this article with you.
Moses
http://www.nytimes.com/2008/02/04/us/04immune.html?ex=1202792400&en=2b70b01dc67e0ae5&ei=5070&emc=eta1
Thought I would share this article with you.
Moses
Well, I don't agree that circumcision could help prevent being victimized to sex-related diseases as some of my friends have become prey of this.
Anyway if circumcision takes place in Uganda, we can do nothing.
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