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January 22, 2019

In fight against HIV, we should all be superheroes

A superhero is a kind and compassionate fictional character, often with powers that are beyond that of ordinary mortals. Many superheroes use their extraordinary powers to fight evil in society, often pitting themselves against villains who also appear to have some powers beyond the ordinary, but nothing like that of the good guy.

Modern superheroes, mainly American, are immortalised in comic books and films. Examples include Superman and Iron Man. But every society has one or several such characters. Kenya has Makmende. Almost by definition one habit that superheroes share is the wearing of under-garments over their clothes. It is a habit difficult to understand in terms of utility, except perhaps that in an odd way it does project power; and does help in differentiating the superhero from the ordinary mortal human beings. Given the many ills in our society, one would wish for more superheroes to help vanquish all the evil but any applying to work here would quickly see that many of our problems are obvious but the will to implement the solutions not so.

Since 1984, Kenya has had a raging HIV-Aids epidemic. The numbers have come down from the catastrophic to the horrific. Today the epidemic is classified as a mixed one. There are new infections occurring in the general population and in vulnerable, high-risk groups.  That means that everyone still faces some risk of getting HIV-Aids, but there are also some people who are at much higher risk.

Currently there are about 1.6 million people living with HIV-Aids. Across the country there are considerable variations. Counties in the former North-Eastern Province, the prevalence is just 0.8 per cent, whereas in Nyanza Province counties the prevalence is about 15 per cent, compared to the national average of just under seven per cent. There are many reasons why the disease exists in its present state and therefore there are many strategies being pursued to bring it under control. These range from research in vaccines, drugs, nutrition, surgery, behaviour change and others, any of which or in combination can tilt the fight in favour of better health.

One such strategy is male circumcision. Nobody quite knows the origins of male circumcision. Over time it has been done as part of a religious sacrifice, a rite of passage, as a hygiene measure, as a sign of higher social status, as a sign of humiliating slaves and enemies, as a way of differentiating one tribe from the next. The oldest still available account of male circumcision is an Egyptian called Uha, who writing in 23rd century BC, describes a mass circumcision. Part of cohort of 120 men, he is quite proud of his achievement in bearing the pain without a murmur. Much later in 5th century BC, Herodotus wrote that the Egyptians "practise circumcision for the sake of cleanliness, considering it better to be cleanly than comely”. Historically in sub-Saharan Africa, from Senegal to South Africa, male circumcision has been practiced as part of a young warrior initiation school rite.

Medically male circumcision was, until about 1900, an operation reserved as treatment for conditions local to the penis such as phimosis, a congenital narrowing of the opening of the foreskin so that it cannot be retracted, and penile cancer. Over time though, communities that practised infantile male circumcision began to have the procedure performed by medical personnel.  It is however today in the 21st century in sub-Saharan Africa that medical male circumcision is now a frequently performed operation not for children but for adults as well. The reason is that research shows that medical male circumcision reduces the risk for heterosexually acquired HIV among men by approximately 60 per cent. So in 14 African countries with generalised HIV epidemics (that is more than one per cent of the population is HIV-positive) — Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe — voluntary medical male circumcision is a big programme in the effort to prevent the spread of HIV-Aids. It is estimated that performing 20 million circumcisions would by 2025 lead to 3.4 million less HIV infections.

In general VMMC as the programme is called has been successful in getting adolescents and young men cut. The problem is the older generation, those in their late 30s into their 50s who are still sexually active, but do not want to be circumcised, believing that it is either not part of their tradition or that it is something for young men to do. They will continue to spread the disease. And here is the dilemma. If HIV came from one source, a superhero would be perfect. Within one and a half hours the problem would be sorted. But for HIV the spread is from one person to the next. So it requires everyone to be a real life superhero and manage carefully what is in their undergarments.


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