Monday, September 10, 2007

HIV, Circumcision, and the Luo People of Western Kenya

The Washington Post ran a story on Friday about the high prevalence of HIV in the Luo tribe of Western Kenya. The article argues that it is due to the Luo tradition of shunning circumcision.

Over the last ten years, large clinical studies have shown an approximate 50% relative risk reduction of HIV with circumscion. I find this counterintuitive. It seems like the foreskin would act like a protective barrier. But this is not the case. A recent review of the subject in the British Medical Journal suggests that the penile foreskin puts men at risk for HIV when it is pulled back during sexual intercourse. HIV can freely enter the non-keratinized mucosa of the inner forskin layer. The outer layer of penile mucosa in circumcised men is keratinized, and therefore more difficult for the HIV virus to enter.

Traditionally the Luo do not circumcise young men, whereas most other tribes in Kenya circumcise boys on the brink of adulthood. The Luo Elders believe that circmcision robs manhood. Instead of circumcision, the Luo traditionally welcomed their young men and women into adulthood by whacking out six front teeth. The Luos I work with in Busia confirm this practice, but say that it stopped back in the 1950s. Many of their parents and grandparents are front toothless.

The Wasington Post's article exaggerates the benefit of circumcision, however. I do not agree with the article's assertion:

AIDS emanated from the jungles of Cameroon or Gabon but hit massive epidemic levels after reaching the uncircumcised tribes around Lake Victoria and, later, southern African tribes that had abandoned their own traditional circumcision rites. These differences help explain why West Africa, where circumcision is routine, has HIV rates much lower than in Southern or East Africa.

Who dreamed that up? How did it get past the editorial staff? It's true that the association between higher HIV risk and lack of circumcision has been shown in many studies, but the effect does not account for the magnitude of AIDS infection in sub-saharan Africa. Lack of circumcision is only one of many known HIV risk factors. Poverty, sexual practices, geographic mobility, prevalence of sexually transmitted diseases, and other complex socioeconomic factors likely all contribute to HIV risk. In the Luo communities, for example, both the fish-mongering economy and the tradition of wife inheritance also contribute to the high HIV prevalence. The practice of trading fish for sex is still a big problem in the fishing communities of Southern Busia district. I do not know much about wife inheritance. I will ask around.

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