Conventional wisdom within Botswana is that the HIV prevalence rate is so high here due to one main factor: relationships with multiple concurrent partners combined with low rates of condom usage. There are deep cultural factors embedded within this, and I have tried to explain some of these in previous posts. Obviously this isn't the only reason, but it is the overall story.
When I first received my PC invitation to work on HIV/AIDS in Botswana, I was so excited. It was my dream placement. I was going to strengthen the community response to the virus. At that time, I knew nothing about the issues at stake in Botswana. But I don't think I ever imagined how much the government was doing to fight HIV--the decade of behavior change campaigns they have undertaken, the money they have poured into condom distribution and the amount of funding put into making antiretrovirals universally accessible to all who need them. These are amazing things and make the situation in Botswana different than most other developing countries. ARVs are not free for people in the states, even. It is unique. Very much so.
But, after a decade of this, there is not a large change in the prevalence rate of HIV within Botswana. I do believe that the youth are using condoms at a much higher rate than in the past. But the prevalence rate remains unchanged. The incidence rate is slightly lower, which pretty much means that HIV-positive individuals are dying at a slower rate, clearly the affect of universal ARVs. But the story is not over. HIV is still a problem in Botswana. Not the only problem, but a significant one, especially when one understands that ARVs will not be available like this forever. The government of Botswana feels like it needs something to slow the tide of HIV. And they think they have found the answer: circumcision.
Historically, male circumcision has been part of the culture in Botswana. Men would undergo the surgery (for lack of a better term) by traditional doctors out in the bush, as part of a manhood ritual. It wasn't very safe. So, in this new campaign, the Botswana government has termed it "safe male circumcision" (SMC), explaining that these operations are done by licensed doctors in clinics and hospitals--very different from the past.
The push for circumcision comes largely from a controlled study conducted in some southern african countries. Results from Kenya showed that men that were circumcised had a 60% more reduction of new HIV cases than the control group--men who were not circumcised. The results from Uganda were 55%.
The basic medical reasons for this relate to the anatomy of the penis and the foreskin. The foreskin contains a porous area similar to vaginal tissue, that can make uncircumcised men more prone to infections and diseases, including HIV. The foreskin also contains a large concentration of CD4 cells, the cells that HIV attacks.
With this information, the government of Botswana has invested handsomely in this campaign. In the absence of obvious behavior change successes, they are grasping at anything that will help--and the SMC campaign seems like the next best thing. But is it really? PCVs are here to support government efforts in preventing HIV and I will do my best to follow suite. That being said, I began to research other opinions on the study and male circumcision in general. Apparently there is a whole population out there that is against circumcision, for very specific reasons.
Although the SMC campaign alleges that circumcised men have less risk of infection, some doctors argue that the foreskin has important uses in terms of protection and reproduction. The basic philosophical argument is that it doesn't allow the penis to function as it was biologically intended to. They also talk about moral issues of having babies circumcised--changing their bodies without their consent. It's not something we think about often in the United States because so many babies are circumcised at birth. Those against circumcision frame it as a human rights issue, not far behind female genital mutilation.
I have not necessarily made any concrete decision on the subject, but I think it needs to be discussed. For me, the circumcision debate brings up larger issues related to western work in Africa and other places. What are we compromising in order to "solve" certain problems, especially health-related ones? It seems like we oftentimes look at the direct pros and cons of something--how many lives will be saved. I don't disagree that human lives are important. One would be crazy to say that. But I think we need to think more holistically, looking at cultural implications of our interventions.
Here are some links for you all to make your own determinations:
The Study and Other "Pro-Circumcision" Sites: