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Genital cutting (aka circumcision), condoms and HIV prevention in Africa

It was in 2009 when I got a most provoking announcement from Marie Stopes International - (A UK based sexual health NGO) that in partnership with the Bill and Melinda Gates Foundation, Population Services International (PSI), The Population Council, and Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO), they were going to provide 'voluntary' male circumcision (MC) services to more than 650,000 men in Africa in an effort to curb the HIV epidemic. (There is now a male circumcision for HIV prevention clearing house where all you ever wanted to know about male circumcision in HIV prevention is there). Included with the MC services was going to be 'behavior change communication' to "highlight the need for safer sex practices and continued condom use".

So here's the bit that got my attention: "continued condom use". If they are continuing condom use, what do they need with circumcision?? So if I am one of these 650,000 men, why would I get circumcised for my 60% reduction in HIV infection risk, if I still have to wear a condom??? Why don't I just keep my foreskin and wear a condom???? Consistent use of a condom reduces the risk of HIV transmission between 80 and 90%! Of course, condoms prevent the transmission of other sexually transmitted infections such as chlamydia, gonnorhea, syphillis etc. So cutting reduces risk by 60% and condoms reduce risk by 80-90%. And somewhere inside me (and I wont even bother checking the stats for this) I have a feeling that we could give a man enough condoms for a lifetime for the cost of all the training, healthcare services etc that go into this cutting campaign.

And note that the World Health Organization and UNAIDS both see MC as a key intervention in preventing HIV in Africa. So if in the words of Regina Rabinovich, who was (July 2009) the Director of Infectious Disease Development in the Gates Foundation Global Health Program "Studies confirmt hat safe, voluntary male circumcision has been shown to reduce HIV transmission rates and help save lives", then why do we not have such a campaign among uncut men in the USA and the proverbial North??

So let me get this..... white folks in Europe and America are keeping their foreskins. The ethnic groups in Africa who don't cut avoid cutting as part of their cultural practice. Now perhaps this is where I ask the question about why there is promotion of male cutting at the same time we limit female cutting?? (But I will not revisit the reading of Alice Walker's book in San Francisco so many years ago where the men hijacked the female cutting conversation so that is for another rant). Yes... I know... one is 'voluntary' and one is involuntary.

This 5 year program will end in research findings that will be disseminated widely of course and help figure out how to 'scale up' around the world.

Again, I ask, why would any man sign up to get snipped and then wear a condom?? Is HIV the only sexually transmitted disease that we are trying to prevent or should there not be a broader emphasis on sexual health?

And I was wondering why in countries where basic healthcare is a luxury, that several of the world's leading health organizations, would focus significant infrastructure and fiscal/human resources on cutting the foreskins of African men.

In the meantime, there I was in Uganda, in an area where the percentage of the population that was HIV+ was near 15% and the state run clinic couldn't find a condom anywhere. So I had to hustle several thousand from St Francis Healthcare Services so that women and men could protect themselves. But there are resources for a surgical procedure in rural areas of Zambia, Kenya, Swaziland etc where national networks of public, private and NGO health service providers will voluntary cut men in places where women have a challenging time finding prenatal and delivery services. Nurses were trained in the procedure so that  up to 150 men a day could be cut in some facilities. Now again.... is Africa so flush with nursing capacity that cutting men can fall within their professional purview???

This rant is not to argue the priorities of healthcare service delivery but it is to question the delivery of this particular healthcare 'service'. A service that is so rare in the UK, that people have to travel to find doctors who will circumcise.

So the questions are this: Why Africa? Why circumcision and not condoms alone (as a condom still has to go on top of a cut penis)? Is this a good use of severely limited healthcare resources? Is this a good use of collaboration? And though I dare not say where this SHOULD fall on the healthcare services delivery hierarchy, I'm just wondering if there was nothing else we could be spending this money on? (yes, bad grammar but i'm pissed).

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