Lessons from Swaziland: male circumcision
By Wilson Johwa
31 May 2010 | Government Policy | Circumcision | Prevention
We already know that male circumcision is the next biggest frontier in South Africa's fight against HIV-AIDS.
Enabling policy guidelines are still being finalised before the expected roll-out. This could be anytime soon, most definitely after the FIFA 2010 Soccer World Cup which, mind you, is expected to chew up an extra 1.5 billion condoms that the government is providing.
While doubts and counter arguments follow male circumcision, it is possible that South Africa can learn something from Swaziland. However, unlike South Africa which has a mixed experience regarding male circumcision, the Swazi kingdom has one of the lowest circumcision rates in the world, most of which are performed for medical reasons.
But the scale of the AIDS epidemic made it consider any intervention that would help reduce the scale of the AIDS epidemic. Swaziland has among the most acute HIV epidemics in the world, with HIV prevalence among pregnant women attending antenatal clinics estimated at 42% in 2008.
In July last year the country published its policy on male circumcision to prevent HIV. This followed the findings of three trials – Orange Farm, South Africa, in 2005; Kisumu, Kenya, in 2007 and Rakai District, Uganda, in 2007.
The outcome of the three studies have since been challenged by critics of medically-supervised male circumcision who argue that the studies were not conclusive. However, endorsement of male circumcision by WHO and UNAIDS provided Swaziland with enough reason to draw up its own policy.
The thinking is similar to that of authorities in SA who are considering offering male circumcision as part of a comprehensive package. This includes behaviour change communication, HIV testing and counseling and condom use.
Derek von Wissel, director of Swaziland’s National Emergency Research Council on HIV-AIDS, says male circumcision started with pilot programmes, encompassing “circumcision Saturdays”, that were meant to prepare for a mass roll-out. “We’re now reaching a level where we can say it’s an active programme,” he says. The target is 120 000 circumcisions over the next five years, targeting mainly 18-24 year olds.
Driving the intervention is the Swaziland Male Circumcision Task Force mandated to provide “technical guidance”. Among the members of the task force are health providers, policy makers, people living with HIV, the government’s partners in the health sector and even the media.
The policy says scaling up of male circumcision should be “sensitively handled, with respect shown for Swazi culture and gender implications.” It does not name these gender implications, or dwell on the likely cultural, social and sexual ramifications of male circumcision.
Instead it urges research into the “socio-cultural meanings and impacts of male circumcision” but also says “the need for ongoing consultation and social mobilisation should not hold back policy implementation.” Emphasis on a biomedical intervention is typical of the region’s response to HIV-AIDS.
The policy does not seem to sufficiently interrogate the possibility that support for male circumcision runs the risk of giving the impression that process makes condoms look like an unnecessary extra. This gap was no doubt left for counsellors to fill. Von Wissel says the messaging is strong on the point that male circumcision offers only 60% protection.
Swaziland’s policy on male circumcision came as the WHO and other agencies were already providing technical support to the Swazi government. For example, teams of Israeli surgeons — who circumcised thousands of adult men in keeping with religious traditions during the mass migration of Jews from the former Soviet Union in the early 1990s — had trained at least 10 Swazi doctors and backup staff on how to perform the operation quickly and safely with limited resources.
Inon Schenker, who coordinated the Israeli missions to Swaziland told the Associated Press in 2008 that his organization, the Jerusalem AIDS Project, had several dozen surgeons ready to help African countries scale up adult male circumcision by training local health workers in both surgical techniques and counseling.
As public policy scholars know, policy intentions and consequences barely ever amount to the same thing. South Africa would do well to closely study the Swazi experience before promoting male circumcision as a barrier against HIV. However, Von Wissel says each country must look at its own circumstances, providing for decentralisation and adequate human resources. He plays down the social effects of male circumcision, saying the process is not entirely new to the country. “Swaziland is a country that used to circumcise. The social aspects are not an impediment,” he says.
Wilson Johwa is an HIV/AIDS and the Media Project fellow.
HIV-Twilight for SA teens
By Melissa Meyer
3 December 2009 | HIV/AIDS Awareness | Prevention
Never before has a teen-flick covered issues of sexual risk and abstinence like Twilight and its sequel, Twilight Saga: New Moon – and been this popular.
In both vampire-cult movies, the heroine, Bella, needs to negotiate sex that could have fatal consequences.
In the first film, Bella’s vampire boyfriend Edward, is afraid he might get carried away and bite her. In the second, Bella’s new love interest Jacob, is a werewolf. This too apparently presents potentially deadly obstacles to doing the deed.Their sexual dilemma is the subject of much online discussion where some fans have argued that not being able to “go all the way” makes the Twilight movies sexier.
If box office revenues are anything to go by, young viewers strongly approve of the Twilight series’ interpretation of risky, complicated teenage sex. Whilst the characters might exist in a make-believe place of mythical creatures, the sexual risks they face are not very different from those in the real world.South African teens face Twilight-like sexual negotiations in their relationships every day. There might not be carnal blood sucking or fur-on-skin action, but the risks are much more frightening.
Fortunately, the real-world possibility of death-by-sex is quite easily overcome – wear a condom. And the solution probably requires much less self-restraint than vampires or werewolves would need not to kill their damsels.
Whilst critics have lambasted the films for their cotton-candy like plots, there might be some valuable lessons to be learnt from the Twilight movies:
Perhaps the world needs more sexy Edward-vampires and Jacob-werewolves – not to scare young adults out of having sex, but to draw their attention to the complexities and risks that are part-and-parcel of intimacy.
Maybe that way they too will find that “not going all the way” can be pretty sexy.
Melissa Meyer is a researcher at the HIV/AIDS and the Media Project.
Prevention needs attention!
30 August 2005 | Prevention
We need to be engaging in a constructive discussion and debate on the HIV/AIDS prevention campaigns in South Africa (see more in our Prevention fact sheet). The recent debates in the media about the efficacy of loveLife's campaign is a start, at least, although sadly, they have been reduced to a pinch of mud-slinging here and a dash of bruised egos there.
This is not the first time, I, or many other people I know, have thought about this issue or talked about it. It is nothing new, but something that has been circulating for a while. But two recent events brought it home for me.
Firstly, the annual Ruth First Memorial Lecture was held at Wits University last week. I was delighted and privileged to witness Henk Rossouw's presentation of his fellowship work, entitled The Broken Tin: Treating AIDS without treatment. It is an exemplary piece of journalism on HIV/AIDS and I hope once it is published in full it is recognised as such (any takers for an 11 000-word gem?) An extract from his piece was published in the Mail&Guardian and is well worth the read (though it's accessible to subscribers only). Zackie Achmat acted as a respondent and touched on many issues which are in their own right material for more blogs than I have the energy to pen: the media's failure to take up the STATS SA survey earlier this year which reported an estimated 3-million deaths due to AIDS, the continuing crisis of governance and leadership around HIV/AIDS in South Africa and the continued scientific and political denial of HIV and AIDS which fuels stigma. But it was his comment about the "crisis of prevention" that really got me thinking. He articulated what many of us feel: the prevention campaigns in South Africa are failing us. Miserably.
Between the irrelevant and quite frankly, antiquated "ABC" model and the confusing and obscure loveLife campaign, we are lacking campaigns that really speak to us in ways that resonate with our lived, everyday experiences.
Secondly, there has been renewed debate in the past couple of weeks on the loveLife campaign in the media. In the August 19 Mail&Guardian, Rena Singer questioned the efficacy of loveLife's " unorthodox" and "slick" campaign in the face of some of the challenges we face in this country, such as a rising number of new infections and a serious lack of material and human resources in the public health setting.
Thomas J Coates, in a letter published in the following week's M&G, responded to Singer's concerns by stating that the loveLife campaign is a "grand experiment worth undertaking", meaning that we should let the loveLife "experiment" run its course and then evaluate its outcomes and determine its impact in the same way we would a clinical trial. The only problem is, this is one costly "experiment" to be undertaking - R780-million thus far - and, with so much at stake, the "wait and see" approach doesn't really seem appropriate.
David Harrison, CEO of loveLife, has also entered the fray, accusing Singer of:
"…[promoting] cynicism about the efficacy of South Africa's largest HIV-prevention effort targeting youth without offering insight into a more effective, alternative approach."
Yes, we do need creative alternatives to the existing models of HIV/AIDS prevention in this country. I can't claim the authority to know what these are, but I can certainly give it a bash.
Isn't it time to start asking people about their sexual practices - what they really get up to when it comes to sex? And with this information, to produce prevention campaigns that really address what people are actually doing and how they can make what they are doing a little safer? Perhaps a snippet of anecdotal evidence will illustrate this point. A group of researchers in Kwazulu-Natal found that a lot of young girls were engaging in unprotected anal sex. After some more investigation it was found that the girls had misread the prevention messages they had received on HIV/AIDS. Because the campaigns focus so heavily on penetrative sex and vaginal sex, as if they were one of the same, these girls thought that anal penetrative sex was safe! This also feeds into the wide practice of anal sex as a contraceptive device. Does this not point to the need for accurate, clear messages that reflect our practices and assist us to understand how to keep ourselves safer while engaging in these practices?
What I'm talking about here is the task of taking into account the gendered, social, cultural, economic contexts in which we live - differently, diversely and unevenly - and construct campaigns that really deal with the realities of our lives in a way that helps us to make sense of our practices and what we can do to make them a little safer. This applies to those of us who have penetrative vaginal sex, or penetrative anal sex or oral sex, or sex with older men, or sex outside of marriage with other men or other women. And the infinite possibilities on the continuum from the one to the other.
There is a desperate need for smaller media campaigns that really reach the heart of communities, in which there are people literally dying for more information about HIV/AIDS.
Communities that are flattened by the stigma, denial and silence that persists because of a lack of clear and accurate information on the virus. In places where every young girl seems to have a baby on her hip, and the massive purple and green billboard in the middle of town doesn't really seem to resonate with her life.
When I see these young girls I guess I don't stop to consult them about what they think about the loveLife billboards and I don't ask them whether it provokes within them aspirations for a better, healthier lifestyle. They seem to be too busy getting on with the job of living a reality that pretty much sucks.
And, as an aside, according to Harrison "only" a third of 12 to 17-year-olds are sexually active, his implication being that because the majority of his audience are HIV-negative, it's OK to dismiss them. This kind of attitude prompts me to ask the question: Why are we not directing resources into messages that target those of us who are sexually active and/or HIV-positive and/or engage in practices that aren't necessarily "normative"? Why is it that all these campaigns seem to presume a majority, homogenous, HIV-negative audience?
Harrison is right, we do need to be looking hard for alternatives, for ways to really engage with people to facilitate them making better choices around the kind of sex they are having. I don't claim to have the answers, but give me R780-million, and I'll make sure I do a damn good job finding them.- Natalie Ridgard
