AIDS, abstinence and circumcision

On March 4th, we reported on the UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV. In the following post, Dr Sander Gilman, Distinguished Professor of the Liberal Arts and Sciences and Professor of Psychiatry at Emory University, takes a critical look at policies promoted as an answer to the spread of the epidemic.    

The AIDS epidemic hit Uganda hard in the early 1980s, with prevalence rates up to almost 30% in some urban areas. Following the end of the civil war in 1986, a vigorous government-led campaign saw prevalence declining dramatically until around 2000, and Uganda was hailed as one the few success stories in the continent’s fight against the disease. Then, the situation stabilized, and in some areas has started to get worse again. What happened?

The successful campaign was known as ABC, summarized as: “Sexual Abstinence until marriage; secondly, advising those who are sexually active to Be faithful to a single partner or to reduce their number of partners; and finally, especially if you have more than one sexual partner, always use a Condom.”

American support for HIV/AIDS intervention increased, but the corollary was the expansion of the “abstinence only” program, and the virtual elimination of the “C” from the ABC model. But “abstinence only” clearly did not work any better in Sub-Saharan Africa than it did among those who had taken abstinence pledges like this one in America. Centers for Disease Control (CDC) studies of “abstinent” teenagers showed that they had equal rates of gonorrhea as sexually active ones (albeit in the form of oral and anal infections).

While this approach is now being reversed, and a broader and more comprehensive sex education model has been advocated recently, the legacy in Africa remains.  

And it remains in ways that are rather frightening because they evoke a historical moment that led to quite devastating results. For as money increased and American foreign policy demanded abstinence only in combating HIV/AIDS in sub-Saharan Africa, the 19th century “solution” of circumcision as a major prophylactic against STIs (which proved to be universally ineffective) was reinvented to combat AIDS, even though the studies that argued for this were seriously flawed.

They assumed a causality between adult circumcision and reduced rates of infection in all populations and they looked at populations of circumcising religions including indigenous ones without asking whether belonging to a self-policing religious or social group might be a cause for less risky sexual behavior because of a decreased rate of exposure.  Equally unnerving was the refusal to report the “serious adverse event data” resulting from circumcision itself.

Even during the 19th century, claims for circumcision as a prophylaxis against syphilis (and other STIs) were always countered with the claim that the very act of ritual circumcision actually transmitted syphilis and often caused death or impairment through the surgery itself.  In the 1930s, a proposal in the UK to require infant male circumcision sparked a debate in the British Medical Journal.  

Needless to say, infant male circumcision never became state policy in Great Britain because the science of the time did not support it.  The clearest result of the some one hundred and fifty years of debates about the efficacy of circumcision as a prophylaxis against infectious disease is the determination both anecdotally and epidemiologically that such a procedure has little or no effect on STI transmission. Thus tracing the rates of STIs among those ritually or medically circumcised in the United States showed no difference in rates of infection that could be attributed to circumcision.

The spike in HIV/AIDs in Uganda today is because “… old-fashioned prevention has flopped. Too few people, particularly in Africa, are using the “ABC” approach pioneered here in Uganda” as the New York Times reported on May 11, 2010. The article continued “Science has produced no magic bullet — no cure, no vaccine, no widely accepted female condom. Every proposal for controlling the epidemic with current tools — like circumcising every man in the third world… is impractical.”  And one can add, not proven in terms of any one’s science.  

What is needed in Uganda and elsewhere is what was and is successful in the global West:  public education tied to specific groups that has reduced in many cases risky behaviors, and the funding of HAART (highly active antiretroviral therapy), now the standard of care in the United States, that has dramatically changed the experience of being infected with HIV by offering a means to “live” with a once terminal disease.  This works. Circumcision simply does not.

Useful links

Data on Official Development Assistance to HIV/AIDS control by recipient

Meta-analysis of Development Co-operation on HIV/AIDS commissioned by Finnish Ministry of Foreign Affairs 

HIV/AIDS kills more young women than anything else

HIV/AIDS is now the leading cause of death and disease among women of reproductive age (15-49 years) worldwide. That’s the stark message coming from UNAIDS as it launches the Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV.

Violence against women and girls is the key driver of the epidemic. The risk of HIV among women who have experienced violence, or fear they might experience it,  may be up to three times higher than among those who have not.  These women are less likely to have safe sex, go for HIV testing, share their HIV status and get treatment.

Their inferior social status puts women and girls at risk too.

The infection rate among young women (15-24 years) is three times higher than that of young men in some countries where men are encouraged to have more than one sexual partner and it is common for older men to have sexual relations with much younger women.

When they do get infected, women are likely to face barriers in accessing HIV prevention, treatment and care services because benefiting from services often requires time, money and the possibility to travel that men are not prepared to grant.

Women and girls can find themselves in a double bind. They have to stay at home to look after the family, including HIV/AIDS victims, thereby limiting their chances of earning money and increasing their autonomy.

The death of a partner, whatever the cause, means that many women lose everything and have to adopt what UNAIDS euphemistically calls “survival strategies that increase their chances of contracting and spreading HIV”.

The United Nations Population Fund, UNFPA, is more direct: “Driven by poverty and the desire for a better life, many women and girls find themselves using sex as a commodity in exchange for goods, services, money, accommodation, or other basic necessities.”

Lack of education is also responsible.

The cheapest way to inform people about HIV prevention is through written material such as posters and leaflets. Illiterate women can’t take advantage of this information, which is one reason why they are four times more likely to believe there is no way to prevent HIV infection.


Useful links

WHO site on gender inequality and HIV

Women and health : today’s evidence tomorrow’s agenda a new WHO report reviewing evidence on the health issues that particularly affect girls and women throughout their life

The Global Coalition on Women and AIDS

The Finnish government analysed HIV/AIDS related strategies and key interventions of 25 development partners funding the HIV/AIDS related activities

OECD statistics on aid to HIV/AIDS control in official development assistance programmes

Wikigender was initiated by the OECD Development Centre to improve knowledge on gender equality-related issues around the world and facilitate information exchange