Simon Collery

Much of the HIV related work that has taken place in African countries over the last couple of decades has concentrated almost entirely on sexually transmitted HIV. There were probably measures taken in the 80s and perhaps even in the 90s to reduce transmission through unsafe healthcare and other routes of infection. But these have been discussed less and less, to the point where it is now generally stated that almost all HIV transmission in African countries (but not elsewhere) is a result of unsafe heterosexual sex.

You may think that this bias towards sexual transmission has resulted in significant falls in incidence (yearly rate of new infections) in countries that have received the bulk of HIV funding. But you'd be disappointed. Uganda has always had a special place in the HIV literature because, whatever happened there in the 80s, HIV prevalence dropped and stayed relatively low since some time in the 90s. But for quite a few years now it has remained stable, only increasing from 6.4 to 7.3% in the last six years. The actual increase, however, is 6% because the population has increased at a high rate.

In contrast, a country where HIV interventions have not been nearly so well endowed is Burkina Faso. Yet HIV prevalence there has dropped by 5% over the last 7 years. Another country where prevalence has dropped in the last 5 years is Zimbabwe, during which time many aid agencies and donors suspended their work in the country. Prevalence has remained stable but very high in Lesotho and Zambia, but it has increased in Ethiopia, Rwanda and Senegal, the last being another country with a special place in the literature because prevalence there never reached very high levels.

So could there possibly be something wrong with the behavioral paradigm, the view that almost all HIV is sexually transmitted? This is not to suggest that HIV is never transmitted sexually, but just to raise the question of how much is transmitted sexually and how much is transmitted in other ways, such as through unsafe healthcare and cosmetic practices. These are not popular questions to raise, but they should be raised now that the orthodox view seems to have such little impact on the epidemics on which so much effort and money have been spent.

People I spoke to in Western and Nyanza provinces in Kenya, and most other people I've spoken to, have assured me that HIV is almost always transmitted sexually. They do, when pushed a bit, mention other modes of transmission, but they don't believe these are particularly important. Some will even tell you about how most people have lots of sex with different people all the time, not usually the person you ask, but other people, naturally. Sex is said to be generally unprotected, involving multiple partnerships, and even concurrent partners. There is also said to be a lot of alcohol abuse, which is seen as inevitably leading to sex and HIV transmission.

It is hard to get people off the subject of sex, the sex lives or others, of course. Even some people working for HIV NGOs realize that not all HIV is sexually transmitted, but they haven't time to research the issue and they will not do so unless there is funding available. There is good money in just accepting the behavioral paradigm. Others dismiss non-sexual transmission and say that it has been shown to be insignificant. I met one person who asked how UNAIDS and the HIV industry could believe that most people had the time, opportunity or inclination to have lots of sex with lots of different people and concluded that they had not actually checked, but such insights are rare.

When persuaded to name modes of transmission other than sex and related activities, some people mentioned unsafe healthcare. Some, independently of the issue of unsafe healthcare, said it was not possible to question anything in healthcare facilities, that the people working in them were secretive. But most people referred to such phenomena as if they didn't think they occurred much. One referred to 'negligent' doctors or quacks reusing sterile needles and others talked of 'village' or 'community' doctors (who are often not doctors at all). A traditional birth attendant said that they often don't have enough sterile supplies themselves, and also that some hospitals, such as village hospitals and dispensaries, are not safe.

Few people mentioned that HIV can be transmitted through unsafe cosmetic practices, such as hairdressers, where razors and other skin piercing instruments may be reused without adequate sterilization. One person had even been warned about such a risk at the voluntary counselling and testing clinic (VCT) where he was tested for HIV. However, he lived on the street, neither unsafe healthcare nor unsafe cosmetic practices are likely to the the biggest risks he faces on a day to day basis.

One difference between sexual and non-sexual risks is that the latter are ones that most people would not wish to take, if they knew about them. If sex is risky, that may not be such a disincentive to some people. If they prefer unprotected sex to using a condom they are unlikely to take much notice of advice to use condoms. But it doesn't seem believable that anyone would prefer to receive an injection from a reused, unsterilized needle. It is unlikely that parents would happily see their children having their heads shaved with a razor that had been used on several others, without any sterilization afterwards.

So what about the current Voluntary Medical Male Circumcision program (VMMC)? Is it safe? Healthcare facilities in Kenya are not safe, research has shown this, without any resulting action to improve safety. Research carried out before the VMMC program started made it quite clear that circumcision in health facilities was very unsafe and circumcision carried out in traditional settings was even worse. But rather than improve conditions in health facilities, a parallel health structure was set up with the sole aim of performing circumcisions. The tens of millions of dollars so long denied to health services was made available to a program that does nothing but circumcise men.

Like many parallel or vertical health programs, a lot of effort went into producing publicity materials claiming that VMMC was not just about HIV, and that it was not only beneficial to men. But this was similar to the research produced to show that such a multibillion program is worthwhile: very unconvincing. Of course, not so much convincing is needed now they have their money. VMMC clinics are probably safe. It's just that other types of health facility are at least as unsafe as they were before. Some probably have fewer trained healthcare workers and some are spending a lot more time on circumcisions, which are never urgent, but are very lucrative.

HIV continues to be treated as if it is in some way different from other diseases, with the result that people can continue to suffer from other diseases, often easily prevented or treated, as long as they are subjected to the popular HIV interventions, that almost always target sexual behavior and now include male circumcision. But targeting HIV as if it is exceptional among diseases has, by and large, failed. If that is because HIV is not always sexually transmitted, male circumcision programs will also fail to have much long term impact on transmission rates. It's almost as if reducing HIV transmission is not really a priority of the VMMC and broader HIV industry.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

This is the fifth post where I summarize another group of findings from my recent visit to Nyanza and Western Provinces in Kenya, asking people about HIV and circumcision. The first, second, third and fourth are all available and the complete findings will also be made available in due course.

HIV is said (by UNAIDS, WHO and various other institutions) to be almost always transmitted sexually in African countries. Therefore, in the highest prevalence parts of African countries, it must be wondered what kind of sex explains such very high rates. For example, in parts of Kenya rates are very low, such as Northeastern Province. In others, rates are high, such as parts of Nyanza and Nairobi. Among the Luo population of Nyanza, HIV prevalence is was said to stand at 20.2% in the 2008 Demographic and Health Survey (DHS), compared to 6.3% in Kenya as a whole (and even lower among the Kisii and Kuria tribes of Nyanza. But Luos don't appear to have any idea why HIV prevalence should be so high among their tribe, compared to other tribes.

A common suggestion is promiscuity. The DHS does find that some 'unsafe' sex indicators are higher for Luos, but some are lower. And overall, Luo sexual behavior does not seem to explain such inordinately high HIV rates. Yet the head of a clinic that carries out circumcisions simply listed promiscuity, along with various other factors that are often cited for high prevalence in other countries. He did not suggest that levels of promiscuity are higher among Luos, or that their sexual behavior is in any way more risky. Nor did he explain why HIV prevalence does not correlate very clearly with sexual behavior, in Kenya or in any other country.

One community leader, when told that promiscuity can also be common among non-Luos (and non-Africans) without HIV prevalence being high, said that Luos have more sex, do not practice circumcision and do not use condoms. A former public health researcher does not believe that circumcision is the reason for high HIV prevalence but can offer no explanation as to why rates are so high among Luos. A high school student said that Luos may not all be promiscuous but a lot of poor people, mainly females, have sex in exchange for money. Others talk about promiscuity as a reason for high HIV prevalence in general, not just among Luos.

The issue of widow inheritance comes up several times but no one can say how common the practice is. One woman talked of lots of women losing their husbands and being inherited, another says that widow inheritance is 'very common'. A pastor of the Nomiya Church said that if you inherit you will be infected and pass the virus on, although his church also permits this practice. The pastor also mentioned 'traditions' in passing and said that some people think HIV is caused by 'chira', taboo. He said that some practices of traditional medicine may also risk transmitting HIV. But he believes HIV transmission is mostly sexual.

A college student said that some males 'get involved' with married women, especially widows who have a lot of money, but he does not mention the practice of widow inheritance. However, a former public health researcher said that widow inheritance is no longer practiced much, except perhaps in remote areas, and is unlikely to be an important factor in HIV transmission. He feels that the same applies to other traditional and tribal practices.

One student suggested that younger females have sex with older males for money, and that this is a result of poverty, but that not many younger males do this. Another student said that Luo teenagers can 'walk with girls' (a euphemism, also used by someone who was told to avoid 'women who walk around') and be infected with HIV that way. A religious leader and a traditional Luo leader said that some women have extramarital sex in exchange for money, both adding that it was as a result of poverty. A market trader said that Luo people like 'raha' (enjoyment, happiness) and translated this as 'prostitution'. She said there were high rates of unemployment among young people and a shortage of money, leading to transactional sex.

A man who performs circumcisions remarked that most people in high HIV prevalence areas were very poor and that some may have sex as there is nothing else to do. Perhaps this can be compared to a discussion I attended among HIV peer educators in a rural area of Western Province, who were being taught that idleness leads to HIV transmission because idle people are tempted to engage in unprotected sex. But more commonly, transactional sex was said to be a result of poverty, to which a lot of HIV transmission is attributed.

The phenomenon of 'jaboya' is often cited as a reason for high HIV prevalence among Luos who are involved in the fishing trade. It is said that fishermen require women to sleep with them if they want to get the best fish to sell. A public health researcher mentioned jaboya as a possible reason for high prevalence in some villages but also pointed out that HIV prevalence can be just as high in villages that have little to do with the fishing industry. But a recent report on HIV prevalence by occupation in Uganda found that HIV prevalence is not exceptionally high among fishermen (or transport workers, who have had the collective finger pointed at them since the early days of HIV).

A religious leader also cited the behavior of fishermen, saying that they 'lured' women with fish and money and engaged in transactional sex. A market trader, not herself involved in selling fish, said that young ladies like fishermen and that they have sex in exchange for fish. But the issue of jaboya was hyped by the media some years ago and there seems to be very little real research into the phenomenon, with citations all appearing to lead to the one, somewhat questionable, source.

Polygamy is a popular hobby horse in the HIV industry, although much of the evidence suggests that HIV prevalence is often lower in polygamous societies. A teenager from the Kisii tribe said he thought HIV prevalence was higher among Luos than Kisii because the former practiced polygamy and the latter did not. A health researcher suggested this as a possible reason for high HIV prevalence among Luos and a community leader said that HIV can be 'brought into the house' (a sort of euphemism) in a polygamous family unit, but this was not just in relation to Luos. She later said that housegirls are often the ones who 'bring HIV into the house'. Housegirls have been blamed for many things in the past, including HIV, although there is no evidence that prevalence is exceptionally high among this group (despite the fact that their employment and living conditions are often appalling).

There are lots of posited explanations for high HIV prevalence among Luos, but many are the same explanations for high prevalence among other groups. The problem is that 'unsafe' sexual behavior (paid or unpaid) does not always result in high rates of HIV transmission, so why should it do so in some parts of some African countries? Other posited explanations are not exclusive to high HIV prevalence groups, do not appear, under scrutiny, to explain anything, or they are not widespread enough to account for very high rates of transmission.

Voluntary Medical Male Circumcision (VMMC) is being sold to Luos as a viable way of reducing sexual transmission of HIV, though they are being told that almost all transmission is sexual. If HIV transmission is almost always sexual, it needs to be shown why it is so high among some groups and not others, and what kind of sexual behavior, exactly, is involved. Otherwise, the industry may have to carry out some much needed research into non-sexual transmission, at least to rule it out, rather than to continue dogmatically denying it exists, without any evidence whatsoever.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Aside from many people in Nyanza that I spoke to being convinced that circumcision reduces HIV transmission, some also mentioned lack of clarity, information bias and/or lack of information, or showed signs of being confused about the VMMC program (Voluntary Medical Male Circumcision). Some said they were completely influenced by the mainstream view about HIV being almost always transmitted sexually in African countries, and that therefore they believed VMMC could be effective. They agreed that there was room for doubt, but also said that they did not have the scope for questioning the mainstream view and they were aware that many funding sources require a strict adherence to this view.

One person working for the program said he was obliged to find and disseminate positive things about VMMC and ignore or quash negative beliefs. Another, who worked in public health, said he and others in the field had to work on programs that would get funding. VMMC gets a lot of funding, as do many projects that assume that HIV is almost always transmitted through heterosexual sex in African countries. But projects to improve health systems, water and sanitation, nutrition or neglected tropical diseases will not generally get funding, unless they can be shown to relate to HIV transmission in some way. Even programs that have no connection with health, education or the like are often required to show how many HIV positive people benefit or how many 'AIDS orphans' will benefit, etc.

Only one person pointed out that circumcision does not appear to protect Americans, yet the funding for VMMC all comes from the US. He feels the program is being forced on Kenyans at all costs and was also aware that HIV prevalence is low in Europe, where circumcision is generally not common.

A traditional Luo leader feels that he and other senior Luos were not given access to all the information available when they were being lobbied to get behind the program, although he was the only respondent to be clearly aware that HIV prevalence is as high among circumcised as uncircumcised Luos. Another traditional Luo leader felt that he and his fellow Luos were not always given clear information and that important issues may not have been addressed, such as the question of why many people in other circumcising populations are HIV positive. He still believes the program can work but also feels that progress needs to be evaluated on an ongoing basis and that adjustments may need to be made over the duration of the intervention.

A senior government officer had given the matter of sexually transmitted HIV a lot of thought and, understanding the connection between circumcision and sexual transmission, did not feel it had ever been explained why HIV prevalence was so high among Luos. He said he didn't think Luo women had 'more sex' than women from other tribes. In contrast, another senior government officer accepted the mainstream view about HIV and fully supports VMMC. A religious leader in Nairobi appeared to know little about HIV, despite working with sex workers, refugees and others thought to be at elevated risk of being infected.

There are several striking examples of gaps and imbalances in the kind of information people appear to have had access to. A local government leader from a circumcising tribe said there are a lot of misconceptions about the sort of protection circumcision gives and that some women think there are no HIV related risks with circumcised men, that they are 'safe'. A market trader, who believes VMMC will be very effective at reducing HIV transmission, also believes (incorrectly) that HIV prevalence is always lower in areas where circumcision is widely practiced. A pastor I spoke to seemed relatively well informed about HIV, but he had trouble separating information from spiritual guidance. A traditional birth attendant, who has also worked as a community health worker, says she is confused about whether circumcision really reduces HIV transmission and would like to know where the idea comes from. She also says that her clients and community understand little about HIV.

A 'street kid' was encouraged to be circumcised by his girlfriend, who believes it 'prevents' HIV, but neither seem to realize that it is only thought to reduce transmission from females to males. Although this man was informed about non-sexual as well as sexual risks, he was not aware that circumcision only reduces transmission through sex. Another 'street kid' had been persuaded to have the operation and was told that it would be more painful if he waited till he was older, but he was already 15 and the claim that it would be more painful sounds quite dubious. People who are considered to be too sick to be circumcised immediately are supposed to be treated first, and then circumcised later. But it seems that people who live in conditions where circumcision would always involve risks for them are not so lucky.

Many spoke of a need for further research, for example, a former public health worker who does not oppose VMMC but does not think it will work very well. He said the evidence for the effectiveness of circumcision in reducing HIV transmission is not strong and that there has been little research into non-sexual modes of transmission, including unsafe healthcare. Someone involved in the program agreed that evidence is weak but said that it is getting stronger as time goes by and that in scaling up VMMC they are also seeking new evidence. The head of a clinic that performs a lot of circumcisions also said the evidence is not that strong and that the level of protection from circumcision may be lower outside of a randomized controlled trial, but that he does not yet know what level of protection can be expected as they are only four years into a ten year program. However, he also said the decision to concentrate on circumcision and less on any other HIV and health interventions was one taken by donors, not by people working in healthcare.

Several people asserted that what they had been told about VMMC was 'science'. A religious leader said we should proceed with VMMC because research has shown that it works. A senior government official describes the 60% protection as 'scientifically proven'. But a senior public health expert working on the program did not emphasize scientific certainty at all, saying that 'you don't know until you try it' and that this is always the way in science and public health. He did emphasize agreement among normative agencies, donors and the great majority of scientists, though. He pointed to the evidence that is being gathered about the effectiveness of VMMC since the program started, rather than the evidence from several randomized controlled trials.

People who refer to 'scientific' and 'official' findings are often thinking of three randomized controlled trials that purport to show that circumcision reduces sexual HIV transmission. But they are unaware that it was not shown that all incident infections during the trial were sexually transmitted. A number of people seem to think that circumcision reduces HIV transmission per se, although it is only thought to reduce transmission from women to men. No one raised the possibility that the operation may not reduce, and may even increase transmission, from men to women. The potentially dangerous fact that HIV positive people can be circumcised under the program, whether they know their status or not, was not raised except by someone working for the program.

Sometimes the VMMC propaganda machinery is very efficient. People I spoke to do not adhere to the 'no risk' myth about circumcision, the belief that once you are circumcised you don't need to take other precautions. On the contrary, most people mentioned the 60% figure and added that other precautions were still necessary, often without any further questioning. Some do attribute the 'no risk' myth to others, however. But whether circumcised or not, many are clear that the effectiveness of VMMC still depends on individual sexual behavior.

Despite this, one man who works in a VMMC clinic does not seem to believe that people will take behavior change related precautions once they are circumcised, especially as behavior change communication does not seem to have had much impact in the past. He believes that VMMC may provide some protection even to those who do not use condoms, and (somewhat inexplicably) that the combining of circumcision with other precautions will work better than they did before VMMC was implemented.

Only two people talked of deliberate transmission of HIV. The first said that HIV positive people did not want to die alone and that they would 'donate' their HIV to as many people as possible. She also believes that there are several signs by which one can tell a person is HIV positive. She thinks VMMC will help but that HIV positive people need to be more careful. The second is a traditional birth attendant and she also uses the term 'donate', saying that this is sometimes a revenge for being infected. Apparently associating being HIV positive with particular behaviors, she said that HIV positive people drink a lot in bars as they 'donate' HIV.

I was surprised to hear a health worker on the VMMC program saying that women on antiretrovirals can be the most desirable in a community as they look so healthy and fat. But a senior government officer said almost the same thing when asked to give her opinion on HIV and circumcision. A mother and housekeeper said that if someone is thin and then receives ARVs, they get fatter and change in other ways too. But she also said that you can tell when someone is infected because they have spots and boils, different skin color and that the part of the face next to the mouth is fatter.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

The Integrated Regional Information Networks (IRIN) is a humanitarian news agency, part of the vast United Nations network of offices doing all sorts of things that are not always very clear. 'Bridging the Information Gap', as IRIN like to say. I was reminded about some of their stories when I was asked to do one of those online surveys that they use to show how wonderful they are. I happened to check through my blog and found I had cited an IRIN source over 20 times and it was almost always accompanied by some expression of disagreement. For example, IRIN is probably the source of the 'HIV positive Swazis eating cow dung because they don't have any other food to take with their antiretroviral drugs' story.

If the Wikipedia entry for 'Jaboya' is anything to go by, IRIN is also the main source for that story too: "an economic system common in the fishing towns of Kenya, on Lake Victoria. It is a system where the fishermen in the region form relationships (commonly sexual) with women in the communities who wish to purchase the fish to take to the market to sell. It is not uncommon for both the fishermen and the women to have multiple partners. As a result of the vast web of these relationships, the Jaboya system is said to account for the rampant increase in the HIV prevalence in the region. It has also caused the mortality rate in the region to increase." All 11 references come from IRIN.

So I wasn't surprised to hear about the jaboya system when I went to places near Lake Victoria to ask why so many people there are infected with HIV, a sexually transmitted infection, even though people all over the country have sex, yet prevalence is far lower almost everywhere else. IRIN's film 'Deadly Catch', is cited all over the web, in mainstream and less mainstream media sources. Like the story about eating cow dung, the story of women having sex with fishermen, bus drivers and market traders really captures journalists' 'imagination', a ready-made story about how Africans are easily different enough for a difficult to transmit virus like HIV to infect up to a quarter of adults in some areas around Lake Victoria.

I'm not saying IRIN made up the whole thing, I'm sure at least part of the film is based on something that happens in the area where they made the film. But I think the phenomenon is need of a bit more research and analysis. For example, how many people, exactly, are involved in this practice? Saying this or that is 'common' doesn't really tell you anything. It is vital to know what other health risks people face, sexual and non-sexual, in order to understand the exact role this phenomenon plays in HIV transmission. Are there other diseases involved, sexually transmitted and otherwise? A brief film is great for grabbing headlines, but short on analysis. It came out seven years ago and has been widely cited, but what do we know about the practice now?

It could also be expected that jaboya or something similar would be practiced in other fishing communities, at least around Lake Victoria. But recent figures from Uganda show that HIV prevalence among fishing folk is about the same as the national average. Prevalence among long distance drivers is only a bit higher than average. In fact, the highest prevalence is found among civil servants, at more than twice the national average. Of course, news agencies like IRIN now have to go into overdrive trying to explain how civil servants face such high risks, forgetting to explain how the terrible risks faced by fishermen and transport workers appear to have magically dissipated.

The IRIN correspondent blusters about civil servants: "These people [civil servants] are always in workshops, where they meet and interact with many people. They have little time to spend with their families. This gives them enough time to have 'side dishes' [extra-marital relationships]," said Samuel Lyomoki, a member of parliament representing workers, told IRIN. "They are involved in reckless behaviours. There is a need to sensitize and take services like counselling and voluntary testing to them." I wonder how many of the workshops 'these people' attend are about HIV. Note also the mention of 'side dishes', another term that appeals to journalists.

Another beloved explanation, repeated by many when asked about high HIV prevalence among Luos, is polygamy. Some Luos do practice polygamy but there is no evidence that levels are higher in Luo areas than in other places where HIV prevalence is a lot lower. Why would it result in higher rates in just some areas? And, as the IRIN film notes, some women are 'inherited' by a relative of their husband if he dies. Of course, there is nothing about how common widow inheritance is, just the assertion that it occurs, or is 'common'. Some people will tell you that it is no longer common; but it fits in well with the story about 'traditional' practices, which are 'bad', compared to modern practices expounded by forces of good, such as the UN and it's multitude of agencies and sub-agencies.

Years of this kind of propaganda by IRIN, the UN, the US Center for Disease Control (CDC), the WHO and others means that you will hear exactly what you expect to hear if you ask people. Luos wheel out the usual about promiscuity, lack of condom use and a handful of other phenomena that have been dug out to make HIV prevention more appealing from a publicity point of view. And people have been persuaded to give their consent (arguably 'informed' consent) for their teenagers to be circumcised. Most sexually active people are saying no to circumcision, but those running the program don't really care, they get paid anyway.

Something that comes across clearly in the IRIN film, though it is not a particular focus, is that many people around Lake Victoria live in great poverty, receive very little education, live in appalling housing and dreadful environmental conditions. Health services are minimal, not particularly accessible and the health burden is very high. There are few employment opportunities and there is little in the way of entertainment. There may be brief references to these circumstances, but the thrust of the film is that people have a lot of unsafe sex a lot of the time with a lot of people.

IRIN know how to put together a tear jerker and the entire film is shamelessly exploitative, both of the respondents and the audience. But analyzing evidence of HIV in terms of what kind of sexual behavior must have caused it, then analyzing evidence of any kind of sexual behavior in terms of what levels of HIV transmission will result, leads to a lot of circular reasoning. IRIN's claims about jaboya may now require some further research (as may their claims about dung-eating Swazis), and they should make more effort to find out why civil servants face such high risks of being infected with HIV, aside from spending a lot of time in workshops.

There are questions to be answered, truthfully this time. It's very likely that we were wrong about fishermen, sex workers, long distance drivers, 'housegirls', teachers, people who live close to Lake Victoria and various other groups who have had the collective finger pointed at them. It seems we were also wrong about civil servants. However, though high HIV prevalence among them could indicate sexual risk, it could also indicate non-sexual risks, such as through unsafe healthcare, to which they have far better access than unemployed people and those in informal employment (the majority).

We have not shown that HIV is always or almost always transmitted sexually, so we can not go from HIV infection to inferring levels of unsafe sex; nor can we go from evidence of unsafe sex to predict that HIV prevalence is high or that it will become high in the near future. We must know that by now, but we still keep on doing it. IRIN is famous for it and if they really want to do research to 'improve' their services, they should have a look back through their own disgraceful record when it comes to honest research and analysis.

The second grouping of data collected in Kenya is about negative perceptions of circumcision, which are currently less numerous than positive perceptions (the subject of yesterday's post). But one of the most powerful arguments against the voluntary medical male circumcision campaign (VMMC) is that HIV prevalence is also high among circumcising peoples, even among Luo populations. The figures cited by those promoting VMMC are for all Luos, among whom HIV prevalence is high, compared to all non-Luos, among whom HIV prevalence is generally a lot lower. Many Luos are uncircumcised and many non-Luo Kenyans are circumcised. So this is said to be evidence that circumcising hundreds of thousands of Luos, perhaps even millions, will reduce HIV transmission.

The flaw in this argument is that about 20% of Luos are circumcised, for various reasons, including religious, medical and perhaps others. But HIV prevalence is roughly the same among circumcised and uncircumcised Luos. So, even if circumcision protects non-Luos, it doesn't appear to protect Luos. The surprising and disappointing thing is that Luos themselves don't seem aware of this. Some were aware that HIV prevalence can be high among circumcising peoples, but only one seemed to know that HIV prevalence among circumcised Luos is about the same as among uncircumcised Luos. This suggests clearly that the difference in prevalence between Luos and non-Luos probably has little or nothing to do with circumcision status.

I spoke to several people who worked in public health and they knew about the above flaw in the VMMC campaign's arguments, but they should have known also that the evidence currently shows that the operation does not protect Luos. One community leader points out that, though it is US money that is pushing this campaign, many circumcised Americans die of AIDS. It was a traditional Luo leader, a 'Luo elder', who knew that Luos don't seem to be protected by circumcision. But he and other traditional and political leaders agreed to promote the campaign for the good of public health. He and some other elders are now calling for further discussions to clarify these issues.

There is a Christian sect called the Nomiya Church that practices circumcision on 8 day old infants, and any other church member who wishes to be circumcised. One of their pastors told me that only about 40% of members are circumcised. But the church is almost exclusively a Luo church and despite many members being circumcised, HIV prevalence is very high in areas where the Nomiya Church is strongest. The pastor and his bishop agree with this, but they appear to feel that circumcision is more of a spiritual intercession than a public health intervention.

Others I spoke to felt that VMMC would not reduce HIV or would not reduce it much. One community leader advocates against circumcision and he wonders why the US feels it is acceptable to insist that Kenyans and Africans 'need' this intervention, for which they are willing to shell out several billion dollars. He said there were people circumcised under the program who subsequently became infected with HIV. Several public health researchers I spoke to, some who worked for the VMMC campaign, did not even pretend that they thought VMMC would reduce HIV much, if at all. But several of them also pointed out that there was money in VMMC, which means that it will take priority over anything else.

A few people expressed opposition to forcible circumcision, which has been happening on and off for many years. While this is not directly related to VMMC, witnesses to a recent forcible circumcision said the mob involved claimed they were 'kicking AIDS out of Africa'. Some just shrug their shoulders when asked about forcible circumcision, much as they do when asked about other mob activities, such as lynchings for alleged robbery and other offences or assumed offences. Several expressed complete opposition to infant circumcision, but not many. They don't seem to be aware that there are currently trials of infant circumcision in the area. There is no evidence that infant circumcision has any public health benefit relating to HIV, but evidence can always be manufactured.

Only one person spoke of the irreversibility of circumcision in relation to infants; only one spoke of human rights and informed consent; very few mentioned pain. None at all mentioned adverse events, such as infection, scarring, permanent injury, dysfunction, excessive bleeding and the like (although the most alarming evidence of these was collected by the people who are now running the VMMC campaign). Many mentioned 'hygiene', as if uncircumcised men can't clean their penis and as if all circumcised men do clean theirs. But no one mentioned the conditions they lived in: slums, mud houses, piles of smoldering rubbish, stagnant puddles, rotting waste and open defecation, which results in a contaminated water supply which is used for drinking, cooking and cleaning.

Even a 'street kid' who was circumcised under the program, and was still in great pain when I talked to him, didn't ask how he was supposed to keep the wound clean while living on the street, let alone how having a circumcised penis would protect him from the many diseases stemming from inadequate water and sanitation that account for a huge proportion of morbidity and mortality, even among those who are not forced to live on the streets. How someone could persuade him to have an unnecessary and invasive operation, collect him from the street, give him some written instructions and deliver him back on the street again is beyond belief.

Issues of irreversibility, informed choice and human rights are raised in Western countries, such as the US, and rightly so. But circumcision is associated with a very different set of issues in a country like Kenya, where the vast majority of people live in poverty and appalling housing, only have access to unsafe healthcare facilities and receive an atrocious education that often ends far too early in life. It's not that circumcision is killing so many people but that so many preventable illnesses and social problems are killing people and the US has decided that circumcision is what they need. The above conditions are experienced by most Kenyans, circumcised or not, so what will be done once everyone is circumcised? Perhaps Bill Gates (he funds some of the research) will pay someone to invent an antidote to post-circumcision sepsis.

Several of those involved in pushing VMMC have no illusions: it's about money. Some of them admit that they don't believe it is a useful public health intervention. One didn't admit that, but he did say they are still collecting the data and it's looking better and better as time goes by. Meanwhile, all uncircumcised Luo men (and boys and infants) and their sexual partners have become so many million guinea pigs in this big experiment. Religious leaders have come to see HIV as a way of attracting followers, so they are not complaining. Long held cultural prejudices about circumcision making a boy into a man have greatly assisted the program. So the time-honored combination of money, religion and political power is being used to misinform people whom they claim to be supporting, leading and informing.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

A fairly typical headline on AllAfrica.com: Zimbabwe: Investment in Maternal Health Critical. You could put any sub-Saharan African country in the title at any time and you would have a ready-made story. Around the world, one woman dies from complications relating to pregnancy and childbirth every 90 seconds. For Zimbabwe, the figure is about 10 women and girls a day. The "prevailing maternal mortality rate stands at 960 deaths per 100,000 live births, up from 725 deaths per 100,000 in 2009/2010, while child mortality rate is at 86 per 1,000 live [births]."

Zimbabwean Deputy Prime Minister Thokazania Khupe wants to address these issues by scrapping maternity fees at hosptials and clinics and she has sourced $40 million to subsidise the cost. But this is said to be far too little to have much impact on mortality and the scheme has already been suspended.

It may seem daunting to raise sums like $40 million in a hurry, or even higher sums. But it seems Zimbabwe does have a lot of money at its disposal, money which would be far better spent on maternal and child health. Another AllAfrica.com story says that a USAID funded program aims to circumcise two million Zimbabwean men by 2015. As only 55,000 have so far undergone the program, there must be a lot of money left over. Whether you take the ridiculously low price claimed by circumcistion enthusiasts of about $60 a head, or the more realistic $120 a head, that's still a lot of money, between $117 and $233 million.

Why do I think this would be better spent on maternal and child health? Firstly, because HIV prevalence is roughly the same among circumcised and uncircumcised Zimbabweans. In other words, circumcision hasn't made any difference so far, why should it do so in the future, aside from the fact that proponents of mass male circumcision programs really really want it to work? Secondly, circumcision is only claimed to reduce transmission from women to men, not from men to women. The operation may result in increases in transmission from men to women and infections are already far higher among women.

The country has between three and six times the amount of money they need to substantially reduce maternal (and infant) deaths; spending it on a mass male circumcision program will not reduce HIV, and may even increase it. So why the hesitation? Even if UNAIDS insist that they can only spend this money on circumcision, Zimbabwe would be better off saying no to it. They have nothing to lose by asking.

Most of the deaths are easily preventable and the amount of money available is substantial. The amount saved by not increasing HIV transmission may also prove worthwhile. The article continues: "Africa faces a health-worker crisis: on average, there are only 13.8 nursing and midwifery personnel for every 10,000 people. In the poorest countries, this ratio is less than 1 per 100,000 people". Mass male circumcision programs require huge numbers of health personnel to be retrained, and then their time and attention are diverted from all other health issues. Instead of being trained to carry out circumcisions, additional personnel could be trained in maternal and child health, so that everyone, whether rich or poor, urban or rural dwelling, can have access to decent healthcare. Apparently "80 percent of midwifery posts in the public sector are vacant".

This model could be repeated throughout Southern Africa because it is intended to circumcise 20-40 million men, representing between $1,200,000,000 and $2,400,000,000 if the cost is about $60 per head and up to $4,800,000,000 if the cost is a more credible $120 per head. In addition, the net contribution of circumcision to HIV reduction across 15 high and medium prevalence countries is zero. Many infections from males to females may even be averted, releasing even more funds for maternal and child health.

While circumcising between 20 and 40 million men may seem like non-starter, development programs often seem to take a rather oblique approach. In an article about Kenya, 'Boosting contraceptive use to cut unsafe abortions', you might think providing safe abortions would have a more direct impact. Uptake might be higher too, given that there are many reasons for not using contraceptives. Even in countries where abortions are illegal, ensuring that healthcare is safe and accessible could be a far better way of meeting some women's reproductive health needs.

One of the people interviewed in the article says how confused she was about contraception and suggests that those around her were also confused. But some of the biggest and best funded NGOs have been pushing contraception aggressively for decades in African countries. It doesn't yet seem to be apparent to these NGOs that people who have been denied basic education and health for generations are a lot more difficult to provide for.

Vertical health programs, such as the ubiquitous 'family planning' programs, may be well meaning and often well funded, but understanding of complex issues requires at least some basic education. Simplifying the issues may result in people being able to trot out what they have been force fed on cue, which is great for publicity, marketing, monitoring and evaluation purposes, but it doesn't lead to understanding.

One of the most aggressively marketed contraceptive methods is injectible hormonal contraceptives such as Depo Provera. These are not only expensive, but they have been linked to increased HIV infections among women and increased transmission of HIV from women to men. Appropriate and safe reproductive health may cost a lot less than heavily marketed and overpriced commodities. But instead of finding ways of replacing Depo Provera and similar methods with safer methods, which may also mean lower costs, some contraception obsessed NGOs, backed up by the commercially aware WHO, have issued confusing advice, and continue to push something that could be increasing HIV transmission, with the justification that it is very effective at reducing conception.

Several people working on the mass male circumcision program in Kenya told me that they concentrated on circumcision because there was funding for it. If there was funding for other programs, they would apply to implement them too. There was opposition to circumcision when it was first mooted, but those who really really wanted the program to go ahead took steps to reduce that opposition. If it can be done with circumcision, why not abortion? What kind of cultural and religious objections can people have to abortion that they wouldn't also have to underage sex, extra-marital sex, procrastinated rape, rape and other phenomena that may result in attempted  and unsafe abortions?

Development priorities may well be, as some say, all about money; but there seems to be a lot of money around. However it needs to be spent on programs that improve people's lives, not ones that provide some benefit that may be more than offset in some other way. If Luo politicians, Luo people and the populations of many other African countries got behind mass male circumcision, why not invite them to choose development programs that are genuine priorities rather than donor obsessions? The same NGOs will have their snouts poised over the trough, it's all money to them. But there are beneficial ways of spending it and most Africans probably know what they are. Western donors clearly don't.

It's remarkable how many different areas of daily life people who have heard of the Voluntary Medical Male Circumcision program (VMMC) in Kenya associate with male circumcision, and its claimed effectiveness in reducing transmission of HIV, and even various sexually transmitted infections (STI). Many of the things people talk about when asked about VMMC have little to do with the program and do not correspond to any of the findings of the three randomized controlled trials (RCT) commonly used to justify the plan to circumcise between 20 and 40 million African males.

Some tell you that sex is better, for men and for women, more satisfying, more pleasurable. This seems like a rather subjective argument for carrying out an invasive operation on millions with the aim of reducing HIV transmission, especially as those carrying out the program are also urging people to have fewer sexual partners, to wait until they are married, etc. One man I spoke to said it's easier to put on a condom if you are circumcised. He runs a large clinic that carries out VMMC, among other things. He agreed that the relative ease of putting on a condom is not a scientific finding, though. One can hear similarly subjective appeals to the aesthetic appearance of circumcision.

However someone else I spoke to, who has been involved in 'mobilizing' people to be circumcised, said that for every person who says sex is better after being circumcised, or that putting on condoms is easier, and various other claimed 'advantages' of the operation, there is someone who will say the opposite. More tellingly, he said he felt under pressure to emphasize the 'advantages' and claimed advantages of circumcision and ignore or dismiss any perceived or claimed disadvantages.

Over 80% of Kenyan males are circumcised as an infant or as an adolescent, for cultural or religious reasons. As a result, a lot of people will already tell you that it is better to be circumcised. Those who do it for religious reasons follow the relevant teachings of their faith. And those who do it for tribal reasons follow their tribal customs. Among those who are circumcised for tribal reasons, it is a rite of passage. It is the time when a boy becomes a man. Even adults who are not circumcised, whether they belong to a circumcising or non-circumcising tribe, are considered to be mere boys, unfit to take part in adult affairs, including leadership. Most of the uncircumcised males in Kenya are members of the Luo tribe.

The above mentioned RCTs did not make any such claims about unfitness for government, of course. But they were used to persuade Luo elders and Luo politicians to get behind the campaign, particularly by openly declaring their support for it, by stating in public that they would not, as Luos, object to circumcision on the grounds that it is not part of the Luo tradition, even by getting circumcised themselves if they had not already been circumcised for some other reason. The fact that many senior Luos got behind the campaign is said to be one of the reasons for objections to it being dropped. This didn't result in large numbers of Luo adults agreeing to be circumcised, but it did result in large numbers of Luo parents, apparently, given their consent for their teenage boys to be circumcised.

Perhaps members of other tribes will no longer be able to say that Luos are not manly or mature, or that they are otherwise unfit for government on the basis of their circumcision status. But it seems unlikely that inter-tribal animosities will be assuaged so easily. The fact that mobs carrying out forcible circumcisions have been heard to claim that they are 'kicking AIDS out of Africa' may suggest that 'traditional' reasons for certain practices can readily be supplemented with non-traditional justifications. Indeed, the association of circumcision status with HIV status may already enforce the already high levels of stigma and discrimination faced by HIV positive people.

But one of the most invidious of all the inappropriate arguments for VMMC is the appeal to hygiene and cleanliness. One of the RTCs did find evidence that HIV transmission may be related in some way to genital hygiene. It was found that men waiting for a while after sex and then cleaning with a dry cloth, rather than soap and water, gave better protection against HIV than circumcision status. In other words, uncircumcised men could reduce their chances of being infected by employing appropriate hygiene measures. But those measures do not appear to be a part of the current VMMC campaign.

On the contrary, people I asked about hygiene and cleaning practices said they washed straight away, with soap and water. One even said you must wash before and after sex. While these beliefs may not relate directly to the VMMC campaign, nor do they appear to have been addressed by the campaign. There are things people should know about genital hygiene, but washing immediately after sex and using water, soap and even disinfectant may increase HIV transmission, rather than reduce it. The VMMC campaign appears to tap into some existing beliefs about hygiene that could be modified; but this doesn't appear to be one of the aims of the program.

Perhaps one of the reasons why those promoting VMMC are so reluctant to discuss the importance of genital hygiene is that they know that hygiene is a long standing and, so far, intractable problem, that goes way beyond HIV and STIs. The health of everyone is compromised by lack of access to clean water and sanitation. Removing foreskins does not improve hygiene if the very conditions that enable health and safety are missing; it could even increase the risk of those circumcised, especially in the months following the operation. Even health facilities often lack access to water, sanitation, soap, disinfectant and other supplies that are vital to ensure adequate levels of infection control.

People's beliefs about hygiene may be influenced by the constant mention of germs in TV advertisements for soap, disinfectant and other hygiene related products. Several people I spoke to talked about germs and dirt, apparently believing that circumcision would help with these problems. But even they agreed that being circumcised is not enough to ensure that a person washes properly. The hygiene related products they mentioned, Smile (brand of soap), Jik (brand of bleach), Dettol (brand of disinfectant) and Omo (brand of soap powder), are useless in the absence of clean water and sanitation.

It is shocking enough to find that the VMMC campaign doesn't appear to address people's knowledge of genital hygiene, nor even to attempt to address lack of access to water and sanitation, which proponents are well aware is vital to all aspects of health, not just sexual health. But it is also disappointing that the people who tell me that circumcision is 'cleaner' do not also complain about problems like lack of running water, open defecation, pools of stagnant water, piles of smouldering rubbish and deplorable housing. Given the state of the slums where the majority of urban dwelling Kenyans live, do they or those promoting VMMC really think male circumcision is a priority, even a sexual health priority?

Proponents of VMMC can be vague about who makes up the 450,000 who have already been circumcised under the current program. Even they have admitted that a lot are teenagers, rather than adults. Some are not Luos, they are members of tribes who would be circumcised anyway. But how many of them are adults, particularly adults who are at high risk of being infected with HIV and who, the story goes, would be protected by 'up to 60%' if they were circumcised? And how many are people who live in such appalling conditions that circumcision, or even HIV, are not among their top priorities, nor even among the highest health risks they face?

Those working on the VMMC program are well aware that most people who are claimed would be protected by the operation have not agreed to be circumcised, and that most people who have agreed are at low risk of being infected with HIV. They just seem completely unconcerned by these matters. The reasoning seems to be that VMMC attracts a lot of funding, whereas genital hygiene does not. Health in Kenya will never improve appreciably until clean water and sanitation are accessible to all; they are even prerequisites to the effectiveness of all other health provision and all other fields of development. But it's VMMC that has attracted the money, therefore circumcisions will be carried out. The consequences, in economic terms, the only terms that count, are mere externalities.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

There are many anomalies in arguments claiming that mass male circumcision can be used to reduce HIV transmission. But in Kenya, the biggest anomaly relates to the Luo tribe; over 20% of Luos are already circumcised, yet HIV prevalence is almost the same among circumcised (16.4%) and uncircumcised men (17.3%). These figures were available to those who have been promoting the current Voluntary Medical Male Circumcision (VMMC) program, which has been going on for 4 years and reports that 450,000 men (though most of them are said to be boys) out of a target of 850,000 have already been circumcised, and the program has another 6 years to run.

Not one person I spoke to seemed aware that, whatever level of protection the operation is claimed to give (everyone says 60%), circumcision does not appear to protect Luos. Those I spoke to who were promoting VMMC didn't mention this anomaly, though they must be aware of it. But ordinary Luo (and non-Luo) people are convinced that lack of circumcision is one of the reasons for high HIV prevalence among members of their tribe; also, that almost all HIV is transmitted through heterosexual sex. How can people be so convinced of this, especially when you consider that many ask why HIV prevalence can be high among circumcised people in some countries, and even among some Kenyan tribes?

Another thing that no one seemed aware of is that you can not compare HIV prevalence among circumcised and non-circumcised members of non-Luo tribes. There are too few uncircumcised non-Luos to make any kind of comparison. The neighbouring Luhya tribe, who believe their practice of circumcision protects them to some extent from HIV don't even seem to notice that it does not protect Luhya women, among whom HIV prevalence is 12%, 50% higher than the national figure for women and more than 6 times higher than among Luhya men.

Those promoting the program appear to have concentrated on generalized figures that, taken on their own, suggest that HIV is associated with low circumcision rates. They have studiously avoided mentioning that there are as many figures available showing that HIV is also associated with high circumcision rates. In other words, the data on circumcision and HIV prevalence is ambiguous. Some of the people I discussed this with are now asking why they were told that they should get behind this program, and why the reassurances they received were based on incomplete data.

The Kenya Demographic and Health Survey says: "Although it may seem that low rates of circumcision may account for much of this difference [in HIV prevalence among Luos], surprisingly, Luo men who are circumcised have roughly the same HIV prevalence as Luo men who are uncircumcised (16 percent compared with 17 percent). These findings indicate that multivariate analysis including circumcision status and risk factors for HIV transmission is needed to better understand the relationship between circumcision and HIV transmission in Kenya."

So where is the analysis that explains the above anomalies? All the analysis I've seen shows that, if circumcision gives some protection against HIV, and it may give some slight protection in carefully controlled conditions, it is not clear how or why it would give protection. It is not known what mechanism is behind this protective benefit. So the circumstances under which this mechanism may work are also unclear. Those promoting VMMC are not just feeding people the convenient bits of data, they are papering over the gaps in the data with hot air.

Even the randomized controlled trials did not exclude from their figures the people who were infected non-sexually. This is crucial, because VMMC assumes that almost every HIV positive person in Kenya was infected sexually and that the main risks HIV negative people face are sexual. The trials did not establish this, they simply assumed it. Therefore, proponents of VMMC are not in any position to make promises about protection against sexual HIV transmission; they don't even know what proportion of HIV transmission among participants in the randomized controlled trial were infected sexually, let alone in the population as a whole.

Far from being an shining beacon to the uncircumcised populations of high HIV prevalence African countries, the VMMC program in Kenya should serve as a horrific example of what can result from public health programs that are based on selective use of data and lies. There are billions of dollars behind this program, but the Luo people should not be participants in an experiment to which they did not give their consent, and for which the outcome was already known before the program started. Whether it is driven by cultural superiority, academic hubris, political machinations, huge amounts of money or a combination of all of these, this program needs to be investigated fully before it goes any further.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]