Is female participation in voluntary medical male circumcision of any value? Experiences from Uganda

John Byabagambi

Improvement Advisor, USAID ASSIST Project/URC

Uganda adopted voluntary medical male circumcision (VMMC) as part of its comprehensive HIV prevention strategy in 2009. From its inception, the service was designed to target males and most of the efforts were focused on ensuring that as many males as possible were circumcised. In December 2012, a PEPFAR interagency team conducted an external quality assessment for the Uganda program and found several quality gaps. One of the major gaps was the lack of a system for continuous quality improvement. USAID ASSIST was brought on board to provide technical support to VMMC USG implementing partners, health unit teams, and the Ministry of Health to address the quality gaps.

Initially, our focus was to support teams to meet the MoH quality standards that are aligned to the WHO quality standards. However, we soon discovered something very important along the way. Through our interactions with VMMC service providers and clients seeking the service, we realized that the services were targeted exclusively toward male clients, and that it was imperative that we engage the partners of the male clients. The reason for this was because there were various myths surrounding circumcision which led to negative outcomes, and we believed that, by engaging female partners, we could educate them about the process and improve outcomes for males undergoing the procedure.  Some of these harmful myths include:  having unprotected sex after circumcision promotes wound healing; a painless post-circumcision penile erection is an indication of complete wound healing;  as a cleansing procedure, the first post circumcision sexual encounter should be with a partner that will never come into your sexual life again; and there are possibilities that lignocaine may affect penile function and the sooner these effects are tested after surgery through sexual intercourse, the better.

These myths were indeed a point of concern. Here is a service whose main goal is to reduce the chance of HIV transmission, but what is happening is that it’s leading to behaviors that greatly promote HIV transmission because it is promoting unprotected sexual intercourse for clients with fresh wounds, which act as a direct entry portal for the virus! The myths encouraging even males who have been faithful to their partners to have multiple sexual partners- a known risk factor for HIV transmission because of the belief that they need to “cleanse themselves.” (In the video to the right, listen as John explains another challenge related to gender in the Safe Male Circumcision improvement work.)

Through discussions with staff and clients we learned that it was actually the female partners that were encouraging their male partners to have intercourse with other women so that they wouldn’t transmit the bad omen to them, the most common omen being that their foreskins would peel off. Additionally, we heard complaints in which female partners were reluctant to allow their spouses to complete the mandatory six weeks of post-circumcision abstinence to allow complete wound healing. Some circumcised clients reported that when they would inform their partners about the period of abstinence, their female partners would think that their partners were cheating on them, and that it was untrue that they must abstain for that long.

It is against this background that USAID ASSIST team in Uganda thought it would be prudent to bring partners of VMMC clients on board. We developed a list of talking points to guide community mobilizers on how to encourage clients who have partners to bring their partners along with them to the health units so that they receive health education together and have couples’ HIV counseling. Health education covers several “Dos” and Don’ts” including addressing the myths and emphasizing the importance of abstinence.  The teams have also set up health packages for women as their husbands head to the procedure. The females are offered services such as screening for cervical cancer, antenatal care for expectant mothers and education on nutrition. As of March 2014, only 30% of the VMMC male clients had partners attend with them. The teams continue to test various changes to encourage their participation.

For more discussion on how gender considerations can improve VMMC, see the Integrating Gender in Voluntary Medical Male Circumcision technical brief published in March 2014.

 

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Comments

The main myth around circumcision and HIV is that it protects anyone at all. In 10 out of 18 countries for which USAID has figures, more of the circumcised men have HIV than the non-circumcised. This has never been explained. Instead, almost religious faith has been put in the three non-blinded, non-placebo-controlled clinical trials. They were led by circumcision advocates, wide open to experimenter and experimentee effects, and several times as many men dropped out, their HIV status unknown, as were known to be infected. Contacts were not traced, and in at least two of the countries, homosexuality is enormously (even fatally) stigmatised, so underreporting of homosexual behaviour would have been high.

Even if there is some herd-protective effect, that is unlikely to motivate the subjects, who must inevitably expect a high degree of individual protection before they will volunteer. Unsafe sex will inevitably flourish aftter circumcision, quite possibly reversing any overall protective effect.

Thank you for your comments. There have been many observational studies and randomized controlled trials that have proven that medical male circumcision reduces the risk of female to male HIV transmission. Three randomized controlled trials have shown that medical male circumcision reduces HIV transmission from females to males by approximately 60% (see references 1-4 below). This protective effect has also been shown to be sustained up to 6 years after the surgery has been completed (see references 5-6). Concerning the issue of risk compensation, follow up studies has shown that there in one cohort showed that there was no significant evidence to show that male circumcision was associated with risk compensation (see reference 7 below).

1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2(11): e298. doi:10.1371/journal.pmed.002029
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.002029...

2. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007;369:643–56.
http://www.ncbi.nlm.nih.gov/pubmed/17321310

3. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657–66.
http://www.ncbi.nlm.nih.gov/pubmed/17321311

4. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000;14:2361–70.
http://www.ncbi.nlm.nih.gov/pubmed/11089625

5. Mehta A, Moses S, Agot K, et al. The long term efficacy of medical male circumcision against HIV acquisition. AIDS 2013 [Epub ahead of print].
http://journals.lww.com/aidsonline/Abstract/2013/11280/The_long_term_eff...

6. Gray R, Kigozi G, Kong X, et al. The effectiveness of male circumcision for HIV prevention and effects on risk behaviors in a post-trial follow up study in Rakai, Uganda. AIDS 2012;26:609–15.
http://www.ncbi.nlm.nih.gov/pubmed/22210632

7. Kong X, Kigozi G, Nalugoda F, Musoke R, Kagaayi J, Latkin C, Ssekubugu R, Lutalo T, Nantume B, Boaz I, Wawer M, Serwadda D, Gray R. Assessment of changes in risk behaviors during 3 years of posttrial follow-up of male circumcision trial participants uncircumcised at trial closure in Rakai, Uganda. Am J Epidemiol. 2012 Nov 15;176(10):875-85.
http://www.ncbi.nlm.nih.gov/pubmed/23097257

Please see the following link for brief summary (with linked references) of the ethical, legal and methodological flaws with past research informing the present campaign of circumcision-as-HIV-preventative in Africa, some of the adverse consequences of funding circumcision-as-HIV-preventative in Africa (coercion of men and boys to be circumcised; misdirection of limited medical resources from higher priority areas) and the absence of oversight of organisations promoting and facilitating male circumcision in Africa:

http://www.academia.edu/5453317/Response_to_PEPFAR_Program_Expenditures_...

Dear all, thank you for the comments you have made on this blog. I note that most of your comments are on the merits and demerits of voluntary medical male circumcision (VMMC) as an HIV infection prevention intervention. However, the focus of my blog is on role that females can play in VMMC based on the recommendation by World Health Organisation that VMMC reduces chance of HIV infection from an HIV infected female to a none HIV infected male. Until WHO recommends otherwise, I would beg that we keep the focus of this discussion on the topic of my blog and may be raise your concerns on the effectiveness of VMMC with WHO and UNAIDS. However, as someone who lives in sub-Saharan Africa where most of devastation of HIV and AIDS has occurred, we are more than happy to embrace any intervention that reduces the chance of anyone acquiring HIV infection even if it is by 1%. How I wish we had an effective preventive vaccine for HIV or cure for Aids. For now we shall continue to embrace VMMC and ensure that it is implemented as voluntary service and meets the minimum quality standards as set by WHO.
John