Educating Religious Leaders Improves Uptake of Male Circumcision in Tanzania Interview with:

Jennifer A. Downs, M.D., Ph.D. Assistant Professor of Medicine and Microbiology & Immunology Department of Medicine Weill Cornell Medicine Center for Global Health New York, NY 10065

Dr. Jennifer Downs

Jennifer A. Downs, M.D., Ph.D.
Assistant Professor of Medicine and Microbiology & Immunology
Department of Medicine
Weill Cornell Medicine
Center for Global Health
New York, NY 10065 What is the background for this study? What are the main findings?

Response: Between 2002 and 2006, three large randomized controlled trials in sub-Saharan Africa demonstrated that male circumcision reduces new HIV infections in men by approximately 60%. Based on these findings, the World Health Organization recommended male circumcision as an HIV prevention strategy in countries with high levels of HIV and a low prevalence of male circumcision. This led to prioritization of 14 countries in Eastern and Southern Africa for massive scale-up of male circumcision beginning in 2011.

In many of these countries, the uptake of male circumcision was lower than expected. In northwest Tanzania, where we work, there are a number of barriers to male circumcision. Some of these barriers are cultural, tribal, economic, and religious. We conducted focus group interviews in 2012 that showed that many Christian church leaders and church attenders in our region in Tanzania had major concerns about whether male circumcision was compatible with their religious beliefs. This led us to hypothesize that the uptake of male circumcision could be increased when religious leaders were taught about male circumcision, with the goal that they would then be equipped to discuss this issue with their congregations. How did you test this hypothesis? What are the main findings?

Response: To conduct our study, we worked with male circumcision outreach campaigns from the Tanzanian Ministry of Health. These outreach campaigns would arrive in a village and provide male circumcision at the village’s local health center for several weeks to months. The Ministry of Health campaign provided drama and open-air announcements about male circumcision, but did not specifically educate religious leaders. We worked with the Ministry of Health to identify 16 villages that would receive this circumcision campaign. All villages received the standard teaching from the Ministry of Health. Then, in addition, in 8 of these villages, we provided an educational seminar for religious leaders from all Christian denominations during which we discussed the religious, cultural, and historical aspects of male circumcision. The church leaders themselves then decided how to bring this education back to their congregations.

In all 16 villages, we determined the total number of men who sought circumcision during the time of the outreach campaign. We found that, in the 8 villages in which the religious leaders did not receive the educational seminar, 29.5% of the total male population sought circumcision. In the villages in which the religious leaders did receive the educational seminar, 53.8% of the total male population sought circumcision. In addition, in the villages that received the educational seminar, 30.8% of men who sought circumcision stated that they had heard discussions of male circumcision in church. In contrast, less than 1% of men stated that they had heard this topic discussed in their churches in the villages that did not receive the educational seminar.

If we were to expand our work to the entire country of Tanzania, we estimate that our strategy would lead to 1.4 million more circumcisions and would therefore prevent 65,000 to 200,000 new HIV infections in men in Tanzania alone. What should readers take away from your report?

Response: Our work shows that, in a setting in which people are strongly committed to their religious beliefs, healthy behavior can be promoted by working with a community’s religious leaders. The Pew Research Center conducted a large survey in 19 countries in sub-Saharan Africa in 2010 that showed that most people in sub-Saharan Africa are devoutly committed to their religious faith, with 80-90% in most countries describing religion as “very important” in their lives and attending services at least weekly. This situation is extremely different than it is in many Western countries. The longer that I work in Tanzania, the more I become aware that the Western impulse to separate religion from medicine does not make sense in Tanzania because almost the entire population is deeply committed to their religious faith and practice.

I think that our study proves the validity of the concept that a cross-disciplinary collaboration that strives to educate and equip religious leaders is a powerful way to promote healthy behavior. We worked closely with our Tanzanian colleagues to design and implement an educational seminar that would be relevant in our setting. There would likely need to be some adjustments to make this relevant and appropriate for other settings, but the concept would not change: addressing people’s health behavior by reaching them through their religious leaders can be an effective way to impact health-related behavior. What recommendations do you have for future research as a result of this study?

Response: We hope very much that our study will inspire other investigators to study the applicability of our findings in other countries, among other religious groups, and with a focus on other health topics. We are beginning to do this in our setting by moving beyond Christian communities to look at health care interventions among Muslim groups and to work to address other health-related behaviors.

The other essential research priority, which is highlighted by the work we did for this project, will be to learn to build cross-disciplinary collaborations to achieve effective health interventions. Our study team included not only physicians and public health officials, but also religious leaders, regional community leaders, and educators. Each member of our team was vitally important to the success of our project. I hope that our work will encourage similar interdisciplinary work in other settings.

We are grateful to the Bill & Melinda Gates Foundation, the National Institutes of Health, and the Mulago Foundation for their financial support of this project. Thank you for your contribution to the community.


Educating religious leaders to promote uptake of male circumcision in Tanzania: a cluster randomised trial

Downs, Jennifer A et al.
The Lancet , Volume 0 , Issue 0 ,

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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  • Ronald Goldman, Ph.D.
    Posted at 21:16h, 20 February Reply

    Claiming that circumcision prevents a health problem is a compulsion of circumcised men to have done to others what was done to them. Historically, this compulsion has led to over 200 potential health claims for circumcision. All have been refuted. Thirteen national and international organizations recommend against circumcision.

    Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. The investigators did not seek to determine the source of the HIV infections during their studies. They assumed all infections were heterosexually transmitted.

    Many HIV infections in Africa are transmitted by contaminated injections and surgical procedures. The absolute rate of HIV transmission reduction is only 1.3%, not the claimed 60%. Even if the claim were true, based on the studies, about 60 men had to be circumcised to prevent one HIV infection.

    Authorities that cite the studies have other agendas including political and financial. All other national and international organizations that have positions on circumcision oppose it. Research shows that circumcision causes physical, sexual, and psychological harm, reducing the sexual pleasure of both partners. This harm is ignored by circumcision advocates. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Even HIV/circumcision studies advise using condoms. With condoms circumcision adds no benefit to HIV prevention.

  • Mark Lyndon
    Posted at 12:55h, 20 February Reply

    Male circumcision is a dangerous distraction in the fight against AIDS.

    From a USAID report:
    “There appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher.”
    (this will include men who were circumcised tribally rather than medically, but they and their partners may also believe themselves to be protected, and the whole rationale for the RCTs into female-to-male transmission was a purported correlation between high rates of male circumcision and low rates of HIV)

    It seems highly unrealistic to expect that there will be no risk compensation. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”. This figure seems to have been unchanged in 2012.

    A study in Zambia found that “30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV.”

    It is unclear if circumcised men are more likely to infect women. The only ever randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised:

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.

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