Day: February 24, 2007

Circumspection on Circumcision – Lessons for India

Circumcision May Help Protect Against HIV –

Getting circumcised may reduce men’s risk of acquiring HIV, according to a study conducted in Africa. “Our study shows that circumcised men had 53 percent fewer HIV infections than uncircumcised men,” lead study author Robert Bailey, professor of epidemiology at the University of Illinois at Chicago (UIC), said in a prepared statement.

This study, published in The Lancet (registration and kidney donation required!) adds to the growing body of research suggesting that circumcision significantly reduces the incidence of HIV infection. The doubts on circumcision as a protective factor against HIV are falling away.

But, is this a viable public health strategy? In context, the US health and human services reports an 85% reduction in HIV risk through condom usage. This is probably a conservative estimate. There’s no indication yet that the gains from circumcision and condom use together are multiplicative.

Let’s look at India, for instance. Circumcision is not practiced among Hindus. There is no history of circumcision, and when I was growing up, it was clear that circumcision was for Muslims and Muslims only. It was often laughed about and there was a sense of superiority about not having to mutilate. It was a clear distinction setting difference between “us” and “them”. This article by Jaishanker and Haldar provides some perspective on Hindu-Muslim identities.

Apart from that, the other important identity of Muslim males is circumcision. It is found in many riots that Muslims were victimized based on their religious identity. In the riots if the perpetrators or the police are not able to identify victims with their religion they forcefully remove the pants of the victims to check whether they are circumcised or not. Once they find that the victim is circumcised he is targeted without further analysing which community he belongs to.

For example in Bombay riot (1992) there is a case of man who was frisked by the police for assessing whether he was a Muslim. However, out of fear he gave his name as Raju (a Hindu name) the officer made him take out his trousers and, noticed that he was a circumcised Muslim, and fired at him.

No Hindu parent in their right mind would circumcise their male child. It’s that simple. It’s part of the ingrained Hindu psyche that having an uncut member sets us apart from our Muslim brethren.

Nothing has changed about AIDS prevention strategies. But it’s boring to study the same variables all the time, let’s recap them one more time, shall we!

Education and awareness: Look at this picture from India (from the NFHS Survey):
Now tell me that increasing awareness among women and empowering them is not the most important thing you can do!

Condom use = 85% risk reduction

Nothing more to say. Continuing to improve access to condoms is important. Avert indicates that condom use is very state dependent, especially among sex workers, with Tamil Nadu having an 80-90% use rate and Mysore in neighboring Karnataka having a 9% use rate.

Access to antiviral therapy

India is in a lucky position here with a very well established pharmaceutical industry. So, drugs are likely to be available (patent issues notwithstanding). The issue however is with infrastructure, getting the drugs to the right people at the right time. This 2004 paper from the Indian Journal of Medical Ethics indicates that coverage is spotty at best. India’s National AIDs Control Organization (NACO) recognizes this, but in my opinion does not go far enough to provide free/affordable drugs to infected people, especially to prevent mother-child transmission.

So, to cut a long story short, circumcision in India is not likely to be a factor in the pantheon of choices available. We have a long way to go with our other major AIDS prevention challenges, and I hope this circumcision issue does not become an increasing distraction.