Women call for cautious approach to male circumcision

By Henry Neondo

A new report from the US-based body, the AIDS Vaccine Advocacy Coalition (AVAC) and ATHENA Network's Women's HIV Prevention Tracking Project capturing perspectives of women from sub-Saharan Africa, calls for  the cautious rollout of" medical male circumcision, MMC, and "recommends on how to programme its scale-up to ensure MMC is safe and beneficial to whole communities."

Making Medical Male Circumcision Work for Women is the first report from WHiPT, which was launched in 2009 to bring community perspectives, particularly women's voices, to the forefront of biomedical prevention research and the broader response to HIV.

The report highlights community-level support as well as concerns and misperceptions that can hinder effective implementation.

"Women are excited for medical male circumcision because they're desperate for new prevention options, but they lack detailed factual knowledge of its benefits and risks," says Cebile Dlamini of Swaziland for Positive Living. "For example, the fact that it only provides partial protection can be overlooked and some women and men believe once a man is circumcised, he is by definition HIV-negative."

In total, nearly 500 women in HIV-affected communities completed a questionnaire, developed and administered by the women-led WHiPT teams in five countries.

Almost 40 focus groups provided additional information about women's attitudes about medical male circumcision.

Women interviewed in communities, including women living with HIV, raise serious concerns about the impact that the partially effective intervention might have on risk compensation (increased numbers of partners for men and decreased use of condoms by men), sexual negotiation, GBV, stigma, FGM, and resource allocation away from comprehensive HIV prevention, particularly from women-controlled and -initiated prevention tools.

 The women interviewed by and participating in the WHiPT teams also voice additional concerns around abstinence until wound healing post-surgery.

 Data suggest that HIV-positive men who are circumcised and resume sex prior to complete wound healing have an increased risk of transmitting HIV to their female partners compared to uncircumcised HIV-positive men.

 Circumcised partners may or may not know their HIV status because testing is recommended but not required for surgery.

In each country, research took place in different locales, selected to reflect a diversity of circumcision practices, including communities that practice traditional male circumcision and those that do not circumcise, as well as those practicing female genital mutilation.

The majority of teams conducted their research in settings where male circumcision for HIV prevention had not yet been introduced as part of a national HIV strategy. Therefore many reported perceptions and concerns can be integrated into emerging programmes—making this report both timely and urgent.

The Kenyan WHiPT team surveyed women in settings where male circumcision was evaluated in a clinical trial and subsequently introduced.

Reports from women reached by the Kenyan WHiPT team underscore women's fears that male circumcision may lead to changes in men's behaviors and perception of risk.

"The women reported their partners either adapting or continuing risky behavior after 'the cut'", says Carol Odada, from Women Fighting AIDS in Kenya.

The government of Kenya launched its national policy on voluntary medical male circumcision (MMC) for HIV prevention in 2008 in the Nyanza district. At the onset of the project, the Luo Council of Elders from Nyanza rejected the policy on the grounds that it did not appear voluntary. Hence the Ministry of Health and a technical taskforce renamed the policy “guidelines”.

 In step with the guidelines, Kenya developed a national strategic plan for the rollout of MMC, which was launched in January 2010. A communication strategy is in its final stages, and the training curriculum on MMC is in development. In the MMC national strategic plan it is stated that a training curriculum will be developed and shared with all the stakeholders and that trainings will be conducted with the supervision of the Nyanza Reproductive Health Society.

The report documents women's concerns that medical male circumcision might lead to an increase in heightened stigma for women living with HIV.

This would be a result of circumcised men's misperceptions that they could not be HIV positive and/or could not transmit the virus. Thus sex and or safer sex would be less negotiable than before circumcision, putting women at greater risk for gender-based violence and HIV.

The report also highlights perceptions of male circumcision for HIV prevention in the context of traditional practices. Specifically, it underscores the need for communications campaigns that directly address the distinctions between medical male circumcision, traditional circumcision and female genital mutilation.

"Some women report the concern that the promotion of circumcision for men would increase the promotion of female genital mutilation," says Allen Kuteesa from Health Rights Action Group in Uganda.

The myths and misunderstandings identified by WHiPT teams – such as the perception that medical male circumcision is directly protective for women – underscore the urgent need for adequate education campaigns directed at women.

Further, for women to access and act on information related to medical male circumcision and HIV, the information needs to be specifically tailored to women, and the socio-cultural context and realities of women's lived experience need to be taken into account.