Circumcision doesn’t replace condoms

In the nation with the highest rate of HIV/AIDS in the world, health workers are worried that men are mistaking circumcision — which studies indicate can reduce HIV transmission — for a fool-proof prevention method.  Here’s an excerpt from an IRIN/PlusNews article:

There is a growing belief among men in Swaziland that circumcision provides complete protection against HIV, a perception that worries non-governmental organisations (NGOs) battling the highest HIV prevalence rate in the world.

In recent years circumcision has been lauded by Swazi public health officials as a procedure that reduces the rate of HIV transmission by about 50 percent, but it is far from the silver bullet solution some men see it as.

“The problem is not with the procedure, but the way it is abused by men, so that men think they are now immune from HIV contagion,” said Siphiwe Hlope, an HIV-positive woman and founder of the support group, Swazis for Positive Living (SWAPO).

Hlope said SWAPO members were becoming increasingly aware of an attitude that circumcision protected men from HIV infection, while also providing an excuse not to use condoms; something Swazi men have long loathed doing.

NGOs and health workers have worried that something like this would happen.  News like this should reinforce awareness of the need to educate people about the benefits and limitations of circumcision.  It would be tragic if its impressive positive imact were to be overshadowed by false hopes and riskier behavior.

Here’s a link to my previous posts on this issue.
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~ by h.e.g. on July 31, 2008.

9 Responses to “Circumcision doesn’t replace condoms”

  1. I think anyone who didn’t think that this can and will happen is foolish. Interestingly enough, the only comment in that piece that made any rational sense is the 25 year old, they interviewed. Jackson Dlamini said, “It is painful to get circumcised. If I have to wear a condom anyway, what is the point?”

    Mr. Dlamini is the only one that has gotten it right, what is the point? When having sex with someone whose HIV status is positive or unknown there are only two choices here. You could get either not get circumcised but you must always wear a condom or you could get circumcised but you must always ware a condom. It’s a shame these NGOs are in this article are blaming the population for not getting the message straight it’s not them it’s just that the message make no rational sense.

  2. A lot of people, NGOs etc. did think this could happen, and expected it. Circumcision is being expanded in a lot of places in Africa because recent studies found it so helpful, and there has been a great deal of talk about cultural awareness and sensitivity, as well as the need for clear communication strategies to help people understand the reality of what circumcision does and doesn’t offer.

    Obviously this story shows that NGOs and health workers have to be very careful about how they promote circumcision and how they communicate with their constituents. But I don’t think that means that the whole idea should be tossed out. Circumcision has been shown to be very helpful in some situations, as recent studies have indicated. HIV prevention is always a frighteningly delicate balancing act. (Just ask anyone who’s familiar with the abstinence/condoms debate.) I think that what the situation in Swaziland really shows is that approaches need to be very careful and nuanced.

    (I’ve posted on this issue a few times in the past. You can type “circumcision” in the search boz on the sidebar, and find these posts, which have links to various news/opinion articles.)

  3. People who love to promote circumcision hate when you bring up the fact that the most advanced countries in the world (with lower HIV rates than the USA)DO NOT CIRCUMCISE their sons. There are only two countries on the planet that circumcise the majority of their infant sons. One does it for religious reasons. The other financial.

  4. Re: “There are only two countries on the planet that circumcise the majority of their infant sons.”

    Just for the record, this isn’t actually true. There are many countries in the world where circumcision is very common, including most of North Africa and the Middle East, where over 80% of males are circumcised. (Male circumcision is common practice among Muslims.)

    For information about the prevalence of circumcision, and a map showing where it’s most common, see this publication from the World Health Organization:
    http://www.who.int/hiv/pub/malecircumcision/infopack_en_2.pdf

  5. No, those countries do it later. The US and Israel are the only countries the circumcise more than half of their newborns. The rest of the English-speaking world tried it, found it didn’t do any good, and gave it up with no regrets.

    You say “Circumcision has been shown to be very helpful in some situations, as recent studies have indicated.” but look at what actually happened in those three studies. They took 10,900 men, circumcised half and found that after less than two years, 64 had HIV, compared to 137 in the other half left intact. That is the whole basis of the much-touted “60% reduction” claim – 39 circumcisions for each HIV infection deferred (not prevented). (The figure would be much higher in the US, with its lower HIV rate.) Not mentioned are the 327 circumcised men who dropped out of the trials, their HIV status unknown. That status could easily overthrow any “protection”. In several African countries, HIV rates are higher in circumcised men.

  6. I think the point is being missed. The point there really are only two options you are either don’t need to be circumcised and always ware a condom or you could get circumcised but you must always ware a condom. Circumcision is not adding anything to the protection equation it is not a method that can stand on its own. So from a logical perspective what is the point? Why would someone opt for a circumcision when it in no way changes his responsibility to protect himself? This needlessly complicates the real message in a part of the world where poverty and levels of education make it especially difficult to articulate the difference between a slight risk reduction and protection. So what has been gained besides the high possibility of confusion?

    The article indicates that only 20% of Swazi men consistently use condoms. Why would someone have any illusion that condom use would increase due to circumcision? After more than 20 years and if you are living there seeing people dieing left and right knowing the cause and knowing how it is acquired they’re at 20%? I figure of that 20% there are some rational thoughtful men who use condoms anyway, since they know its useful. Then there are proabably reluctant users that are using only because of the hard fought campaign to educate men and might just as easily abandon them, how does that percentage break down?

    It might be difficult to notice in a place like Swaziland with such low rates of condom use and high HIV prevalence but in other countries that have seen dramatic reductions through traditional ABC approaches (such as Uganda IIRC) the number of ‘reluctant’ condom users is proabably much higher and in all likelihood this will be seen as the way to relieve themselves of the burden of condoms. It’s not the fault of people in the field (not all at least; perhaps some) but it is the media and even the ‘study’ authors who have over hyped the utility of circumcision going so far as to claim it is a vaccine and are essentially selling them a lemon.

    I am familiar with the abstinence/condom debate but I think this is quite a bit different for many reasons. Most importantly when comparing abstinence and condoms you are comparing two possibilities that can stand on their own. Abstinence is 100% effective and condoms approach 100%. Circumcision can never be in and of itself an HIV prevention technique.

    I think the Australian Federation of AIDS Organizations said it best: “How a man factors the known risk reduction alongside the unknown variables into his sexual decision-making is the important thing. Unless he opts to use condoms with all sexual partners whose HIV status is positive or unknown, he remains at risk of acquiring HIV (and if he does this, there is no need to be circumcised for added protection).”

    What we are going to witness is a slow motion train wreck, it is possible that we will erase many of the gains that were fought for the last 25 years.

  7. Hugh: Apologies for the confusion. I was thinking about countries where circumcision is common regardless of the age at which it’s performed. Muslim boys are often circumcised sometime during childhood (the BBC has a good overview). Circumcision for the purposes of HIV risk reduction is often provided to adult men on their own request. So I’m not sure the question of where circumcision of infants takes place is especially relevent to the discussion. As for what the “English-speaking world” may have decided: well, I’m not sure what speaking English indicates in this scenario, but obviously some societies and cultures continue to approve of the practice. Again, sorry for any confusion my last comment may have caused.

    Joe: Thanks for your thoughts. Don’t get me wrong: I get where you’re coming from. You have some good points. I just want to add a couple more thoughts. I don’t know the details of what health workers are hoping for, but it seems to me that circumcision programs are really meant to provide some protection for people who do not/will not take more effective steps. To take the stats from Swaziland as an example, according to the article about 80% of men don’t use condoms. I think the logic behind circumcision is that if people aren’t using condoms anyway, and can’t be convinced to use them in the future, then it’s better that they have unsafe sex with some degree of risk reduction than that they have unsafe sex without any risk reduction measures. I don’t think much of anyone thinks circumcision is ideal: it’s more a sense of every little bit helps. Of course, some would argue that encouraging circumcision does more harm than good — that’s something that has to be worked out within any given context. But there is logic behind the idea.

    To everyone who’s commented here, let me thank you for sharing your thoughts. I must admit that I’ve been a little surprised that the few times I’ve posted about circumcision they’ve generated so much intense response, but it’s gratifying to see the issues being discussed.

    Best wishes to all,
    h.e.g.

  8. i think this i an important issue. im only 14 and a sexual education site told me that if your not curcumsised u had to wear a condom and if u were u needn’t worry but now i know this isnt true right?

  9. Right!

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