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Changing Behavior to Fight Aids: Overrated

A recent article in Lancet published the results of a study data from two clinical trials in Africa that suggest that circumcision reduces a man’s risk of contracting HIV by as much as 65 percent. Going by the articles in Uganda and Kenyan newspapers, this caused quite some excitement.

According to the medical study, which has been going on in the far western Kenyan district of Kisumu for the last four years, 2784 young men from the area, volunteered to undergo circumcision and to have regular HIV tests.

All of the men were HIV negative when they started in the study. Half of these men, selected through a lottery process, were circumcised immediately, the other half were asked to wait at least two years. Forty-seven of the men who were not immediately circumcised became HIV infected by the end of the study, compared to only 21 of the men who had been selected for immediate circumcision.

This outcome, combined with the results of similar studies carried out in South Africa and in Uganda, led the scientific community to conclude that being circumcised halves the chance of a man becoming infected with HIV through sexual intercourse with an infected woman.

In a continent where AIDS has exacted a heavy toll, and which cannot afford antiretroviral treatment for all the millions of the people infected with the disease, this seemed like incredibly good news.

All of a sudden a quick and cheap solution to reducing the ravages of AIDS seemed at hand; line up all males, nip off their foreskins, and voila, you have reduced the possibilities of future HIV infections by half!

Among the few voices that expressed caution was that of Uganda’s President Yoweri Museveni, who said he didn’t think it was that simple. Museveni should know. Uganda, after all, has Africa’s -- and one of the developing world’s -- best record in reducing HIV infections. In the 1990s, Uganda had among the highest infection rates in Africa of well over 30 percent. In the last eight or so years, it has sliced that down to just under 6 per cent. The awards Museveni has received for this achievement can fill the State House garage.

I don’t know anything about the science of this study to fault or laud it. But its politics are very troubling.

The success of Uganda’s AIDS campaign is attributed to the so-called “ABC” strategy: Abstain, Be faithful, and use Condoms. This has been carried out with an aggressive public information campaign.

In recent years, under the influence of Republican and Evangelical groups, the Bush administration has invested a lot of money and created huge incentives for poor countries to push abstinence.

The ABC, abstinence, and circumcision approaches all have one thing in common: They put a lot of currency on change in behavior as the best weapon to deal with AIDS. A lot of research is going into establishing scientific facts that support the case for behavioral change. Thus, you can’t keep your foreskin. Circumcise, and salvation might be yours.

Africa is poor, and where it has its own money, governments have made the policy choice not to invest it in researching and developing a cure for AIDS. They rather look up to the international community to do that.

Perhaps as a result of the focus on behavior, an awful lot of the scientific work on AIDS in Africa isn’t concentrated on finding cures.

One gets the impression that there is a widespread belief out there that AIDS in Africa cannot be primarily solved by medicine, perhaps because the African is “untreatable”. Therefore the answer is to put a lock on the African peoples’ zippers and knickers, because their promiscuity and diseased nature makes a curative approach ineffective.

In that sense, even those who mean well and are spending a lot of money fighting AIDS on the continent are unwittingly give credence to the image of African peoples as noble savages, like the anthropologists of years gone by.

They are able to save lives, but their obsession with caging people has limited their horizons and the possibilities of achieving some truly great breakthroughs against AIDS.

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Comments (12)

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Aids is another just another viral event. We will adapt and be better for it (I hope). Meanwhile, some die.

Alex L:

It's not abstinence that can make the difference with Africans and AIDS...most Africans where AIDS is rampant don't have many choices about their life styles..the epidemic is because these people are poor and usually, women become prostitutes so they can support their children. Unfortunately, they don't really have much of a choice and when they get AIDS the oldest child is responsible for taking care of the family after their death. Sometimes these children are only 11 or 12 years old. Even education about how to prevent AIDS won't change the fact the these women are still poor and can't find jobs...they are desperate and I think it is important to help these people financially so that they will have choices other than prostitution to put some food on the table for their children. Those are just my thoughts.


Toby Marotta said:

"Since Muslim men who are circumcised for religious purposes tend also to wash their genitals after intercourse and bathe for religious reasons, this post-sex hygiene could well be what is MOST responsible for their reduced risk of HIV infections."

It is really important to read the studies before making such comments.

From the Kisumu, Kenya RCT:

"This trial was done in Kisumu district, Kenya. Kisumu is
the capital city of Nyanza Province in western Kenya and
has a population of about 500 000 residents.25 Most
residents self-identify as Luo, an ethnic group that does not traditionally practice circumcision. About 10% of Luo adult men in Kisumu are circumcised.26 In 2003, HIV prevalence was about 25% in Luo women and 18% in Luo men."

Where does the reference to Muslim men come from? Another study?

HIV prevention is such an important subject it is really important to just stick to the facts.


Promiscuity is the reason why there are so many people in Africa with AIDS. And condoms do nothing but promote promiscuity. Abstinence till marriage is the answer. Pouring in tens of millions of condoms every year, for some reason hasn't stopped the spread of AIDS. AIDS in Africa has actually skyrocketed. Africans must change their behavior, by choosing abstinence before marriage, or die of AIDS. The only countries in Africa where AIDS percenatges are down, are countries that say to their citizens
"Dont have sex until marriage" instead of "Go have sex with who ever you want, but make sure you use a condom." Countries that say the latter have the highest AIDS percentages.

The first case of AIDS was reported when? In the 1980s. Before the "Sexual Revolution" in the 1960s and 70s, when our country was brainwashed, AIDS and a lot of other STDs were almost non existent. Why? because people controlled themselves. Oh yeah no condoms either. How did they do it?


I get the impression that they don't seek cures in Africa, because it's easier to conduct trials of possible cures in more industrialized countries. A whole lot of work is going toward finding a cure, but after 20 years of looking, the best solution right now is to educate people about how AIDS happens and get them to change their behaviors.

James Buchanan:

He who lives by the shlong, dies by the shlong.

Feel free to off yourselves, just make sure your bodies drop where they'll make effective fertilizer for when we recolonize.


It's difficult to say that circumcision reduces AIDS/HIV because when you compare developed countries, the country with the highest circumcision rate (the United States) has the highest HIV/AIDS rates, while the nations with lowest or near non-existent circumcisions (Europe/Japan), is lower.

I just don't understand why it's so difficult for Africa to use the real proven method of preventing AIDS; using condoms and reducing the amount of sexual partners. Many circumcised males may now feel safer and end up having more sex, which can even make this worse. I say we stick with what we know; using condoms and searching for an HIV vaccine.


This perspective is totally incoherent. AIDS can not be solved by medicine because it is essentially grounded in human rights abuses - including sexual/gender based violence, property rights abuses, and evangelical efforts to block access to condoms and accurate information on condoms. It is no coincidence that HIV prevalence is increasing in Uganda despite hundreds of millions of dollars in US aid - Uganda is now in the top 10 US aid recepients - and hundreds of millions more in Global fund dollars - despite evidence of corruption and theft. Studies have found that Africans do not in fact have more sexual partners then others, just more prevalent STIs which increase transmission efficiency and more concurrent partners - rather then sequential - due to a lack of women's rights and economic dependency. In fact too much money is spent on scientific cures and not enough on accountability, transparency and rights.

Toby Marotta, Ph.D.:

Comment sent to The Lancet on 2/24/07
in response to its endorswement of male circumcision for HIV/AIDS prevention

The September 2006 issue of the "Journal of Acquired Immune Deficiency Syndrome" reports on the first scientific medical behavioral study of African men to consider post-sex washing of genitals and bathing after sex in addition to circumcision. This study was conducted under the supervision of King K. Holmes, M.D., Ph.D., perhaps the dean of sexually transmitted disease studies in the U.S.A. This expert study found that post-sex hygiene practices were independently correlated with reduced risk of HIV infections.

The widely overlooked question to be asked about studies of circumcision among African men endorsed by The Lancet and others is: Did these studies also consider the post-sex hygiene practices of the studied men who were circumcised? Since Muslim men who are circumcised for religious purposes tend also to wash their genitals after intercourse and bathe for religious reasons, this post-sex hygiene could well be what is MOST responsible for their reduced risk of HIV infections.

Joel E.:

As a result of the focus on behavior, an awful lot of the scientific work on AIDS in Africa isn’t concentrated on finding cures.

It takes about six months for HIV to mutate to another form that obviates the vaccine created to cure it. Changing behaviour is the ONLY way to stop the problem.

For those who wonder: the Cold virus and the Flue virus cause business to lose a HUGE amount of money every year. The research on that virus has been ongoing since 1910 that I am aware of. I no longer believe there will be a vaccine in the life time of my nephews, but if Africa wants to kill all of its people, it found a dilly of a way to do it.

Zip up or die.


While we search for a cure it only makes sense to teach and follow methods that reduce or eliminate the risk of getting AIDS. Why do you see a political or racial agenda in doing something that will save a person's life? There are lots of everyday precautions we all take to stay alive and for equally good reasons. When the light is red stay out of the crosswalk and when it turns green look both ways and cross carefully. When AIDS is cured we will probably face some other menace and ABC will still be the best alternative just for the sake of good health and survival. There is no agenda -- it's just survival, man.

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