Saturday, July 20, 2024

To circumcise or not circumcise? That is the question

In Swaziland, it is commonly referred to as the ‘Soka Uncobe’ Campaign. The Soka Uncobe is a PEPFAR backed program that advocates for male circumcision in order to better Swaziland, for a healthier future, one free of HIV that currently has it under its grips. But unfortunately it has been met with great resistance with few men coming forward to circumcise despite being endorsed by King Mswati. Elsewhere in Africa, Kenyan Prime Minister Raila Odinga came under heavy criticism with the Luo tribal leaders as thousands of Luo men rushed to get circumcised after encouraging them to do so. To show solidarity to Raila some Luo Cabinet Ministers and MPs also had to circumcise and declared it publicly.

In some parts of Africa, as is the case in Botswana, it goes along with tribal initiation schools, which in some instances are viewed with great suspicion, mainly because it has profound strong social and cultural connotations and long lasting psychological consequences. It separate Nkwenkwe’s (uncircumcised boys) from Men. In certain tribes that up hold their culture with pride and dignity irrespective of modernity as is the case with Xhosa culture and Kikuyu in Kenya for instance, uncircumcised men are treated as Nkwenkwe’s and circumcision is a common practice among initiates which attracts multitude of attendees. Something that Botswana can perhaps learn from because of the low turnout it is experiencing in its Safe Male Circumcision (SMC) campaign. It may alternatively strike a partnership with the leadership of the tribes that still up hold to their custom and cultural practices and use them as a model in its SMC campaign.

The practice of male circumcision is not a new phenomenon; it has ancient origins dating as far back as the Greek ancient history. In the Semitic tradition male circumcision is linked to Covenant with God dating back to Abraham, Aggleton P (2007), something which is often popularly known as the ‘Galatian Controversy ÔÇô see Galatians 5:6 and Corinthians 7:18:20 All over the world, male circumcision as also argued by Angleton P(2007), has its roots deep in the structure of the society. It is far from being a simple technical act, even when performed in medical setting; it is a practice which carries with it a whole host of social meanings. It is an act linked to deep seated beliefs and ideologies about the social order. Some of these meanings link to what it is to be a man, with circumcision taking place as a rite of passage into adulthood in several African cultures and customs as well as in other settings such as religion. Male circumcision is widely practiced among Jews and Muslims but less among Christians. From the late 19th Century onwards, however, male circumcision also entered into the field of public health.

It is against this background that this article seeks to add a balance and context to current debates concerning male circumcision in the country.

The last few years have seen growing impatience on the part of national progress, international agencies and public health experts to make headway against the Global HIV epidemic. A huge body of knowledge has been created in HIV/AIDS response and its transmission and how to prevent it. HIV prevalence has declined substantially in a number of countries and regions. These reductions represent the payoff from investments made throughout the 1990s and into the century. Commitment of political capital and other resources as witnessed by former President Festus Mogae’s campaign against HIV/AIDS has been trusted into major increases in programmatic effort that have beard fruit in bringing improved outcomes infections averted and lives saved. No one dimensional HIV/AIDS solution has ever become available. Combination prevention is as necessary as combination treatment when it comes to stopping treatment.

Effective HIV prevention thus requires locally contextualized approaches that address individuals, cultural and social norms as well as structures that are grounded in human rights. One such area that has attracted a lot of attention in recent years as a form of intervention that could be used in HIV and AIDS prevention is male circumcision. Its advocacy must be understood within the context of the 2007 International Aids Society Sydney Conference on HIV pathogens. The renewed interest in male circumcision also came as a result of the success of the three randomized trials that were carried out in South Africa, Kisumu Kenya and Rakai Uganda showing 60% relative reduction in HIV risk associated with circumcision.

However, even before the above studies were undertaken there has been growing advocacy for male circumsicion as a means of HIV prevention, commencing first among public health specialist working mainly in the USA and among some of those working in international Organizations and more recently endorsed as part of a comprehensive package of measures supported both by the World Health Organization (WHO) and UNAIDS. These institutions have publicly endorsed Male circumcision as an HIV prevention strategy. Male circumcision has been viewed in the USA in particular as a panacea for a wide range of medical and social problems, historically from paralysis and hip joint disease, anti-social behavior and imbecility.

As witnessed with the current debates on going in the country, male circumcision has been a contested terrain, with opinions differing sharply as to its aesthetic, social and other benefits. Opinions continue to differ sharply as to whether or not to implement this form of prevention or on how quickly to do so. Its critics claim that although there have been frequent claims that male circumcision offers protection against sexually transmitted infections for men especially in developing countries, this assumption is backed by few investigations. They also state that the few investigations do not contain robust controls for confounding factors such as social background, sexual behavior or penile hygiene. The critics also argue that although there have been calls for a radical scaling up of male circumcision throughout Africa; it has not made remarkable achievements in the first world countries. In richer world settings for instance, where well designed population studies have been conducted, the evidence is weak. The US 1992 National Health and Life Style Survey for example found no evidence of a prophylactic role for circumcision and a slight tendency in the opposite direction. That the USA has higher rates of STI, higher rates of heterosexually transmitted HIV infection, high rates of cervical and penile cancer. Yet these are the very diseases that circumcision has been touted as a preventative measure. In the studies undertaken in UK, they argued did not find any significant differences in the proportion of circumcised and uncircumcised men reporting ever being diagnosed with any STI. The study did not also find any association between circumcision and being diagnosed with any of the seven specific STI.

Whilst male circumcision does not provide 100% protection and that condoms remain an important part of HIV prevention, evidence from the recent trials is now trumpeted as ‘truth’. The three randomized trial undertaken in South Africa, Kenya and Uganda now provide firm evidence that the risk of acquiring HIV is halved by male circumcision. Male circumcision is also associated with reduced risk of urinary tract infections, genital ulcers and penile cancer. In areas where HIV -1 prevalence constitute a generalized population epidemic, male circumcision could have dramatic lifesaving effect. The efficacy of male circumcision in reducing female to male transmission has been proven beyond reasonable doubt. In both the past and recent present, the evidence base for the acceptability and prophylactic effectiveness of male circumcision remains to be tested through scale up. Not only does circumcision appear to offer a modern day public health solution, it also carries with it a moral authority that seems difficult to deny.

Thabo Lucas Seleke is a Fulbright Scholar, International Health Policy & Management, Boston, Massachusetts, USA. He writes here in his personal capacity.


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