“Sweet-talkin’ man...” – but it’s the “playas” who have plenty of partners,
but little protected sex, who are fuelling the HIV/AIDS epidemic.
In the fight against HIV/AIDS, SA is preparing to circumcise all men, preferably from birth – are we seeing the last generation of boys go to the mountains?
story by PATRICIA McCRACKEN
WHILE mountains as old as time look on, fl ames leap into the winter sky. It’s a heartstopping moment for those watching the blankets that have warmed them and the thatch that’s sheltered them go up in smoke. It’s a moment they’ve begged fathers and uncles to let them face. These days, under the new circumcision law, they’ve also had to receive permission from their doctor and chief. It’s special to so many that they’ve even found ways to recreate it among their difficult new lives in informal settlements. But the ancient rite of passage of circumcision might have to change, say medical experts – and our government is listening to them. Circumcising all males in the country is one of the main goals in the fight against HIV/AIDS in the government’s new HIV, AIDS and STI National Strategic Plan 2007- 2011, launched at the recent 3rd SA AIDS Conference in Durban.
Burning the past?
Proposals to circumcise all males, preferably at birth, could mean we have to rethink an ancient ritual, the way we’ve already adopted weddings.
More than 4 000 delegates reinforced this call for “available and accessible circumcision for every man” at the end of the conference. It was such a hot topic many male speakers even felt they had to declare their status – circumcised or not, that is. It’s a topic that BONA highlighted back in February this year, when its success in preventing HIV/AIDS infection was revealed in Kenya and Uganda. Now that effect has been shown to work in South Africa as well.
But it was also the conference’s most controversial topic because of all the questions it raises. Like, what will happen to one of SA’s most respected traditional rituals? How will women benefit? How will our health system cope? And: is it worth it if people forget to protect themselves in other ways as well? Yet there’s no doubting the evidence. Getting circumcised reduces a male’s risk of catching HIV by up to 60 percent. To some medical experts, that sounds wonderful. To others, it’s not good enough – hardly better than even money. But the planet’s top experts adopted male circumcision as part of HIV prevention as a World Health Nations’ UNAIDS policy earlier this year.
That’s because these experts agree on two things:
- Male circumcision is one of the few tools we have while we wait for vaccines and microbicide gels to become available;
- Male circumcision has to be used in addition to the well-known anti- HIV weapons of condoms, fidelity and abstinence. Experts believe male circumcision can have the strongest impact in countries with HIV rates so high ARV programmes already can’t cope, such as SA. In the next 10 years alone in sub- Saharan Africa, home to about 63% of those living with HIV/AIDS in Africa, male circumcision could help both men and women. That’s by preventing 2 million new HIV infections and 300 000 deaths. In the following 10 years, the impact on the next generation of men and women would be even greater: by preventing 3,7 million new HIV infections and 2,7 million deaths.
Who should be circumcised?
Preferably all males, including adult males of any age who haven’t already been circumcised, say experts such as UNAIDS researcher Professor Bertram Auvert. He wants women of all ages to help bring about change by refusing to have sex with uncircumcised men. But, he repeats, they should see this as an extra weapon against HIV/AIDS and not replacing condoms, fi delity and abstinence.
Why it helps
Circumcision helps protect a man against HIV infection from vaginal intercourse in two ways, explain researchers. The inside of a man’s foreskin is lined with cells that are very vulnerable to HIV infection, so these are removed. Then a new layer called keratin – made of the same protein as your fingernails and hair – grows over the penis and this helps protect it against infection.
Already 30% of SA men are circumcised, but what about cultures where circumcision isn’t practised?
“If the arguments are strong enough, wise people change their minds,” he says. In fact, one nation changed its habits quite recently. In Korea, points out the prof, almost no males were circumcised in 1940. Now about 60% are.
When should boys be circumcised?
Preferably following the Jewish tradition of within a few days of birth when pain is minimal. But at the very least, agreed most delegates at the SA AIDS conference, if circumcision is to help prevent HIV/ AIDS from spreading, it’s best done before a boy becomes sexually active.
But how will traditional leaders take this recommendation, since it interferes with traditions of passage into adulthood in some areas and non-circumcision?
It was agreed at the conference the next step for policymakers is to negotiate this challenge both to a way of life – and a way of earning a living for the iingcibi and babolotsi. But, when for every person who gets a new lease on life with ARVs, another five are becoming infected, this isn’t a time for posturing and more power struggles. It’s a time for mutual respect and joining battle against the common enemy.
Does circumcision always work?
Figures show circumcision cuts men’s risk of catching HIV by just over half. But it won’t protect you against catching other sexually transmitted infections. A condom’s still the best protection for that. And if you let yourself catch an STI, the sores it creates make you more likely to catch HIV. Similarly, if you have unprotected sex before you’re fully healed after the circumcision operation, you’re also likely to catch HIV. The bottom line is that circumcision is a backup to protected sex, not a replacement – and certainly not an excuse for not knowing your status, which less than a third of us do.
What about women?
The vagina is more vulnerable to HIV infection, which is why women anywhere in the world are more likely to catch HIV from sexual contact. In Africa, this is much more likely because many men still use threats and actual violence to stop women getting help and to force women to have sex. Aside from the fact plenty of young women still grow up believing this means a man is showing he cares, this also makes it dangerous for women to insist on safe sex. But that would be their best protection, married or not, as both Dr Mickey Chopra of the Medical Research Council and Dr Olive Shishana of the Human Sciences Research Council showed that the “playas” of any age, whether in their 20s or in their 50s, bachelors or married, have much more unprotected sex than other men.
What about vaccines?
There’re more than two dozen clinical trials of various AIDS vaccines happening in 20 different countries round the world, including South Africa, but an effective vaccine is not expected to become available for about 20 to 25 years. When it does arrive, though, it’s hoped some vaccines will also help those who are already HIV-positive by reducing their viral load and so improving their health.