VMMC – The Fallacy 

Voluntary Medical Male Circumcision (VMMC) is the (voluntary) surgical removal of part or entire foreskin by a trained health professional. UNAIDS has touted it as a silver bullet in reducing male vulnerability to HIV infection by almost 60% (heterosexual encounters) in Sub-Saharan Africa and other target groups, notably in the USA. Male circumcision, however, is an old practice in Africa, with ancient Egyptian reliefs from the necropolis at Saqqara depicting the practice (2345 – 2182 BCE).

VMMC has been introduced as a cost reduction measure for the nations with the heaviest burden in infections. It was suggested to lower infection rates, with a departure from active campaigns for safe sex, leading to an exciting deviation from the norm among newly circumcised males. They engaged in more risky sexual practices post-surgery due to the misunderstanding that they were now less likely to get the virus (in any instance). 

There has been a steady rise in the number of infections in nations such as Kenya. There is also evidence that the tribes/communities that traditionally circumcise their males now have higher and higher numbers of infections. While the prevalence of the infections seemingly has dropped from 6.9% in the1990s to a paltry 3.53% in 2017 and then rising to 4.5% in 2019, the number of the infected continues to swell to an average of 1.5 million (1.3 – 1.8 million) according to the National AIDS and STIs Control Program (NASCOP).

Nairobi, for instance, leads the pack among all counties. It is the capital, a cosmopolitan city with a majority circumcised male population. Closely behind it are the majority Luo (they do not traditionally circumcise) counties of Homa Bay, Kisumu, and Siaya. These counties are the targets of the VMMC campaign. The burden of HIV is so significant that statistics place some at 1 in every 4 or 5 persons as having the virus, according to NASCOP and the Kenya Medical Research Institute (KEMRI). 

The VMMC campaign, started as a Rapid Response Initiative, with the blessing of the then president, Mwai Kibaki, in 20028 achieved 7,863 circumcisions by the end of the year, with the number climbing 287,026 by June of 2011. On the flip side, between 2008 and 2010, there was a notable increase in the lakeside counties, with Kisumu leading the group. Kisumu city saw a spike in infections and active cases. This begged why the areas with the most significant focus in the fight against HIV would have such a surge. 

The cultural disruption of natives all over Africa, with the introduction of VMMC, alongside erroneous insinuation that it was a silver bullet against the scourge. The rise in infection in the initial three years of the drive shows how poorly thought out the campaign was. The campaign, premised mainly in Sub-Saharan Africa, targets the majority Luo-Nilotic and Bantu groups among whom male circumcision was the exception. 

The UN was concerned about the rising number of cases of HIV in Africa and the cost incurred in medical and social interventions to control it. They were also acting on reports from donors, decrying the increased burden that the cases provided, one problem among many, yet eating a great chunk of funds set aside or collected as an aid to lesser developed nations. The research into the efficiency of male circumcision in the fight against HIV/AIDS is evidence of the disregard for the culture and identity of the target populations and a subtle acknowledgment of the African continent’s collective bargaining capacity in international fora and in-patient discussions. 

The researches carried out in the republics of Kenya, Uganda, and South Africa show that while the loss of the foreskin offers hypothetical protection, there is little understanding of the anatomical advantage a circumcised penis offers. It is suggested that the loss of the foreskin and frenulum and consequent keratinization of the glans and “neck” is what offers the barrier. This remains the choice explanation for heterosexual (vaginal) sex. A poor understanding of the actual mechanism of protection is suspect, for a procedure carrying such grand adjectives, reminiscent of the use of mercury in the treatment of Syphilis in Old England. 

The anatomical loss of 10,000-20,000 nervous endings (Meissner’s corpuscles) is an underrated fact. Lost too is the gliding capability the foreskin offers, and can only be recreated when using a loose-fitting condom, or among men who practise jelqing to elongate the foreskin. This loss, coupled with the loss of tens of thousands of erotogenic nervous endings, causes frequent complaints of reduced sensation, stimulation, and pleasure during sex among recently circumcised adults in many surveys.

Alongside HIV is the study of trends in the spread of other STIs, notably Syphilis. It is, in Kenya, monitored as an indicator of possible HIV infection, due to risky sexual health practices that lead to its spread. It is not lost that the rate of spread of other STIs is on the rise. The increase in preference for unprotected (raw) sex is in part attributed to the loss or reduction in sensory pleasure during sex, postoperatively. This may explain the surge in infection rates in the target counties for VMMC in Kenya. It may also rationalise the continued rise in infection rates in Nairobi and other counties with a majority circumcised population of males. 

Poorly addressed are the lifestyle choices that place one at a greater risk of contracting HIV and other STIs. These include:

  • Drug abuse
  • Unprotected sex
  • Existing illnesses (STIs and UTIs)
  • Sexuality: Orientations, preferences vs the Law
  • Occupational hazards

VMMC is hardly upheld in other nations, with a new argument that it is unnecessary in a section of largely Caucasian majority nations. While it is estimated that only 30% of the world’s population is circumcised, it is curious that it is suggested that only among the uncircumcised that the risk is higher. The argument of the frenulum being the site location is only argued based on in vitro tests. It, therefore, holds that it may not have accounted for the entirety of the immunological capacity of the human body, hence the results remain disputed in peer reviews. 

An argument is placed that there is a laxity of donors to increase funding for other safe sex practices, for financial reasons, and instead insist on the disruptive practice of male circumcision. The advent of emergency vaccine production to help lower the curve of COVID-19 infections and deaths should be a reminder that vested interests lay in the Sexual Reproductive Health space. It is only after the 2019 pandemic that alternatives to conventional vaccines were approved across the board, speaking to the bureaucracies and political hindrances that may have held back medical advances in the eradication of certain diseases. 

37 years of HIV research into HIV against 18 months of COVID-19 do not compare, when the latter has 32 vaccines in Phase III clinical tests and several already approved for worldwide roll-out. The mRNA vaccine approach by Moderna and Pfizer-BioNTech is a greenfield and may offer a quicker response for the rapidly mutating immunosuppressive virus. 

Conclusion

It is a falsity to advocate for VMMC as the gamechanger among a group of persons, disrupting their cultural identity when alternatives exist. It is a lazy stand taken by both the government and other interested groups and organizations in combating HIV. With HIV and AIDS being endemic in Africa, a continent that accounts for a significant number of circumcised males worldwide, then it holds that other regions with a majority uncircumcised population are “safe” from the virus by exposure, hardly due to their anatomy. 

The rapid decline in the prevalence of HIV in other continents, which account for a vast majority of uncircumcised males in the world, shows that alternatives exist, and governments can apply the same without upsetting social structures and cultural identities. The African man viewed his body with almost similar regard as the Greeks did, and as such, it should be maintained as so, for as long as it is tenable. 

Scientific research is itself biased as the hypotheses and funding may predetermine the scope and expected results. If done in a shallow, lax manner, may give relevant results that have nothing but a cosmetic effect (literally). The play of the Religious card and cultural trend change is, in the author’s view, wrong. It is almost an imposition of foreign traditions, language, and beliefs, something Africa is very conversant with, a déjà vu moment.

Interventions for epidemics should be as considerate as can be, and focus more on the day-to-day routines that promote the spread of the target disease rather than the culturally invasive approach used to promote VMMC in Sub-Saharan Africa. 

#stopthecutfoundation