Using circumcision to prevent HIV infection in sub-Saharan Africa: the view of an African

The East African AIDS epidemic and the absence of male circumcision: what is the link?

There are now two schools of thought about the link between lack of circumcision and HIV infection in Africa. One school is that of Bongaarts et al. (1989), Moses et al. (n.d.) and Caldwell and Caldwell (1994) who use geographical distribution evidence to argue that the association between lack of circumcision and a high level of HIV infection in Africa is so convincing that the likelihood of a link should be recognized and taken into account where possible in the battle against AIDS. Moses et al. (n.d.) have gone further to recommend circumcision interventions for Africa. In contrast, De Vincenzi and Mertens (1994) argue that the evidence for an association, at least from small-scale surveys, is doubtful and hence not conclusive enough to qualify circumcision as an intervention.

My view is twofold. First, as scientists we should look at the existing evidence for and against the hypothesis that lack of circumcision is positively related to HIV infection. Although many studies have shown that there is a significant association between the two variables (Bongaarts et al. 1989; Moses et al. 1990; Caldwell and Caldwell 1994), there is no evidence of a causal relationship between the two. Caldwell and Caldwell (1994) pointed out that Positive association does not necessarily show a direct causal relationship.

De Vincenzi and Mertens (1994) make the salient point that most of the quoted studies were not designed to test a hypothesis about circumcision and did not report their methodological details for evaluation. They claim there is no evidence that enough statistical rigour was applied to the data and where, in small-scale studies, this was done by controlling for several variables like age, number of partners, contact with prostitutes, ethnic origin and birthplace, the results lost statistical significance (Greenblatt et al. 1988). Either those findings that did not fit into the conventional thinking of the hypothesis were rejected by the journals as not interesting, or the researchers did not submit them for publication for fear of rejection.

As in the study by Serwadda et al. (1992), recent work on data from the 1987/88 National Survey of Uganda assumed Muslims to be circumcised and non-Muslim Ugandans not to be circumcised. This was a fair assumption since the cultural groups that circumcise were not included in the National Survey. The study shows an association at the bivariate analysis which disappears at the multivariate level (Tusingwire 1995). Perhaps the fact that the Muslims are more polygynous than other groups eliminates their circumcision advantage.

Another set of Ugandan data that can be used is one based on our recent study of the impact of AIDS on families in six districts of Uganda. One of the six districts, Mbale, is dominated by the Bagisu, the largest of the few cultural groups in Uganda that circumcise boys before they are accepted as men in the society. Other circumcision groups are the Bakonjo, Sebei and Bamba in order of population size. Preliminary analysis of the logistic regression on the Bagisu data indicates that the Bagisu are less likely to be AIDS victims than the other six ethnic groups. Other cultural groups with similar results to those of the Bagisu are the Bakiga of the extreme southwest and the Banyoro of western Uganda. In contrast, the Baganda, Banyankore, Banyarwada and Basoga were more likely to be AIDS victims than the other groups combined. It is difficult to attribute these findings to circumcision levels in the cultural groups because the Bakiga and Banyoro in the former category do not have many circumcised people while a large proportion of the Basoga in the latter group are Muslims and circumcised. A more plausible explanation of the pattern is that the Bagisu, Bakiga and Banyoro are farther from the epicentre of the Ugandan epidemic than the other four ethnic groups. At this stage, it is therefore difficult for researchers to use the available evidence and comfortably recommend circumcision as a policy in combating HIV infection.

On the other hand my second view is based on practical public policy arguments. As an African who has seen Africans perish from AIDS, it is my opinion that any measure which has a chance to succeed in curing AIDS, reducing the suffering of the people from the disease and preventing the infection of HIV should be tried. I believe that it was in this spirit that several drugs including Kemron and AZT were tried on many African patients, despite their known serious side effects. Hence, there is an urgent need to carry out controlled experiments in Africa on the hypothesis of circumcision.

However, I do not agree with Caldwell and Caldwell (1994) when they claim that sexual behaviour is not changing fast, and the use of condoms is not adequate. It is unrealistic to expect the highly traditional societies of sub-Saharan Africa to change their cultures by abandoning their dangerous sexual customs and practices and accepting the alien condom faster than has so far been demonstrated. Brunborg, Fylkesness and Msiska (1993) have found that in less than a decade since the advent of AIDS, Zambian societies have either stopped or modified their centuries-old funeral rite of a brother of the deceased having sexual relations with all the widows.

Secondly, while in 1988/89 the Uganda Demographic Survey reported less than one per cent of national condom use (Kaijuka et al. 1989), Konde-Lule (1992) found that 15 per cent of adolescents in Rakai district used the method, a multiplication by fifteen in a couple of years.

More recently, our national study of focus group discussions in six districts (Ntozi and Mukiza-Gapere 1992) found that elders and youths reported that the previous customary practices for marriage and death that are now considered dangerous because of AIDS are being abandoned or modified to suit the circumstances. It was found that, in contrast to the past situation where wives were shared by brothers among the Banyankore of southwest Uganda (Ntozi et al. 1991, study done in 1984), this custom has disappeared fast over less than a decade. Widow inheritance, previously common to most societies in Uganda, is now a thing of the past for fear of AIDS. The excesses in sexual activities practised by the Baganda of central Uganda during funeral rites and by the Bagisu of east Uganda during circumcision ceremonies, have been considerably reduced. I think the Africans deserve more credit for these fast socio-cultural changes than Caldwell and Caldwell (1994) have given them.

It is important that, while circumcision interventions are being planned, several points must be considered carefully. If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy. In a region highly sensitive to previous colonial exploitation and suspicious of the biological warfare origin of the virus, failure of circumcision is likely to be a big issue. Those recommending it should know how to handle the political implications.

A second public concern will be the expenditure involved in conducting circumcision. If it is on a large scale, some international donors may divert funds earmarked for other social services to this exercise. It will also be the fear of the African governments that in the middle of this exercise some donors may withdraw their funds for political reasons or not be able to pay for the whole exercise including effective follow-up of the circumcision campaigns to ensure no side-effects are left unattended. The reluctance of external donors to pay fully for family planning activities and hence leaving many acceptors with side-effects untreated is fresh in African memories. Governments would therefore not like to start an exercise involving people's suffering that would not succeed with clear benefits to the public.

Thirdly, in some societies of Uganda such as the Bakiga and Banyankore, a circumcised person (owempari) is culturally stigmatized. For instance, circumcised people or those with the foreskin not completely covering the penis are believed to be hot-tempered and unsocial. Sayings such as Kunotabuka nk'owempari (You are as hot tempered as one circumcised) are common in these ethnic groups. It is considered a bad omen for parents to have a child with a penis half covered by the foreskin. This is perhaps why only a tiny proportion of the Banyankore and Bakiga, less than one per cent, is Muslim (Republic of Uganda 1992). Caldwell and Caldwell (1994) suspect that it was difficult for Islam to be accepted by most ethnic groups that did not circumcise because it was considered unnatural to circumcise. This cultural resentment, added to the health issues described by De Vincenzi and Mertens (1994), may make some African governments reluctant to agree to participate in or allow the adoption of a policy of circumcision. It will, therefore, be important for governments in the region to spend a lot of money on educational campaigns before they take the political risk of mass circumcision. Since most African countries have strained economies, it will be difficult to find the necessary funds.

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