In a hard hitting editorial that raises the spectre of neocolonialism, the South African Medical Journal has condemned the push for mass circumcision of African men as the solution to the nation’s HIV-AIDS problem. The editorial, by the journal editor Professor Daniel Ncayiyana, reviews the evidence for the claim that circumcision reduces the risk of female-to-male infection, and finds it less conclusive than assumed (and far less significant than regularly proclaimed in sensationalist newspaper headlines). The weakness of the case arises partly because the three clinical trials on which it is based were terminated prematurely, and partly because surveys show no consistency in the pattern of HIV infection among circumcised and uncircumcised men. (In some places there is little difference, and in some the incidence of HIV is higher in circumcised men.) There is certainly nothing in the results of the trials to justify the wild claim that circumcision provides “lifelong protection” against HIV; the most that could be said is that in areas of high HIV prevalence circumcision reduces the risk of female-to-male transmission in unprotected intercourse. Despite the much-touted “60 per cent” figure, nobody really knows the extent of the risk reduction in real world situations. Circumcision provides no protection to homosexual men or injecting drug users, and may increase the risk of male-to-female transmission.

The editorial warns that an excessive and disproportionate focus on expensive surgical interventions such as circumcision will discourage condom use (known to be 90 per cent effective against HIV transmission) and deplete the resources needed in other critical health areas (such as malaria and tuberculosis). Already there is evidence that many men believe that the chief advantage of circumcision is that they will no longer have to wear condoms. At the same time, promoters of the circumcision solution still insist on condom use even after circumcision. Clearly, as Van Howe and Storms point out, this demand implies lack of faith in their own prescription: “Circumcision is either inadequate (otherwise there would be no need for continued condom use) or redundant (as condoms provide nearly complete protection).” * The editorial urges South Africa to follow the recommendation of the Australian Federation of AIDS Organisations, which has rejected circumcision and reiterated that “correct and consistent condom use … is the most effective means of reducing female-to-male transmission, and vice-versa.” **

Raising the spectre of human rights abuses and colonialism, the editorial is particularly concerned at the push for universal circumcision of infants and children, despite the fact that the South African Children’s Act specifically prohibits circumcision of boys under the age of 16 years. The editorial notes that much of the push for circumcision in Africa comes not from native Africans, but from international aid agencies dominated by United States funders and policy-makers, and that many programs are funded by the vastly wealthy Bill and Melinda Gates Foundation. It comments that it is “curious and even worrisome that the campaign to circumcise African men seems to be driven by donor funding and research from the North.”

Mutilation of African native bodies by white and Arab slave traders and other exploiters was a sad feature of African experience in the dark days of colonialism, before the various nations achieved independence. In more modern times, western pharmaceutical companies have treated African and other “Third World” peoples as convenient guinea pigs on which to test their drugs – often with tragic results. It is strange to see such similar practices being revived and enforced by benevolent white medical missionaries, but their determination to carve their mark on the bodies of African men certainly looks like a new and particularly insidious form of cultural imperialism.

Source: “Editorial: The illusive promise of circumcision to prevent female-to-male HIV infection: Not the way to go for South Africa”.  South African Medical Journal, Vol. 101, November 2011, 775-776.

References

* Van Howe RS, Storms MR. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa 2011;2:e4. doi:10.4081/jphia.2011.e4

A study of Nigerian prostitutes in 1988 found that, after counselling sessions, condom use increased markedly and that even occasional condom use had a significant protective effect: of 28 women who never used a condom, only eight escaped infection with HIV; but of 50 women who used them in approximately one third of sexual encounters, 27 (54 per cent) avoided infection. It is instructive to compare this with the results of the recent clinical trials of circumcision, which reported a risk reduction of between 50 and 60 per cent: about the same as the risk reduction achieved by condom use 30 per cent of the time. See E.N. Ngugi et al, “Prevention of transmission of human immunodeficiency virus in Africa: Effectiveness of condom promotion and health education among prostitutes”. Lancet, Vol. 332, No. 8616, 15 October 1988, 887-890.

** Australian Federation of AIDS Organizations. Male circumcision has no role in the Australian HIV epidemic. Briefing Paper, 23 July 2007. Available at http://www.afao.org.au/__data/assets/pdf_file/0019/4528/BP0709_Circumcision.pdf