Churches Are Using Circumcision to Battle HIV in Tanzania

Antiretroviral therapy for HIV has saved countless lives, but public health experts believe we could be doing a much better job at preventing the spread of the virus in the first place, especially in sub-Saharan Africa. This region is home to close to 70 percent of the estimated 36.7 million people worldwide living with HIV and also has the highest rates of new infections. Researchers from Weill Cornell Medicine think there's a new strategy worth trying: teaching religious leaders about the benefits of male circumcision.

The authors of a new study in The Lancet—which was funded in part by the Bill & Melinda Gates Foundation and the National Institutes of Health—noted that circumcision is an effective strategy to prevent HIV transmission in heterosexual men. A 2009 review of three large studies done in African countries found that men randomly selected to be circumcised had between a 38 and 66 percent lower risk of contracting HIV than men in the control group.

To that end, the World Health Organization recommends that countries with HIV epidemics and low circumcision rates offer the procedure to their citizens for free. In 2011, the WHO even set up targets for voluntary circumcision in 14 sub-Saharan African countries: they hoped to hit 20.8 million by 2016, but by the end of 2015, only 10 million men were circumcised.

One reason for the lackluster adoption rates could be that the practice of male circumcision has religious significance for many cultures. Based on previous work in Tanzania, the researchers knew that some Christians considered the procedure to be a Muslim practice and were concerned that programs offered by the government were really attempts to convert them. (Ninety-three percent of people in Tanzania see religion as an important part of their lives, with 83 percent attending religious services at least once a week.) So for this new study, they worked directly with church leaders to see if such education efforts would make a difference.

Between June 2014 and December 2015, the Tanzanian Ministry of Health took its voluntary circumcision outreach campaign to the northwest region of the country, where the dominant Sukuma tribe doesn't traditionally practice circumcision and 95 percent of the population is Christian. Experts believe the baseline circumcision rate before the campaign was about 20 percent.

Clinicians held meetings, passed out brochures, and offered free HIV testing and counseling and free circumcisions for men and boys of all ages over a period of three to six weeks. The researchers identified 16 villages where the campaign would visit and told village leaders about their study and got permission to conduct it. They split the villages into two groups: Eight of them just got the information from the campaign (this was the control group) while the other eight had their religious leaders attend a seminar about the medical and cultural considerations of circumcision. (The seminars were co-taught by a Tanzanian pastor and a Tanzanian clinician who worked with the Ministry of Health campaign.) Per 2012 census data, there were about 86,500 men in the intervention villages and 58,500 men in the control villages.

Members of the campaign recorded the number of circumcisions as well as men's stated reasons for getting the procedure. When the researchers compared the numbers to the census data, they found that 52.8 percent of men got circumcised in the villages where church leaders learned about circumcision, versus 29.5 percent in the control villages. (Interestingly, rates varied a lot from village to village: from 21.9 percent to 99.1 percent in intervention villages and from 7.4 percent to 49.9 percent in control villages. But, overall, involving religious leaders was more effective.) Men in the control villages were also significantly more likely to say that discussions in their church was their reason for having the procedure (30.8 percent versus 0.7 percent).

The church leaders could choose to volunteer information to their congregations if they wanted, or they may have simply had private discussions with men. Lead author Jennifer Downs, an infectious disease specialist at Weill Cornell Medicine, said in a release: "The strength of our approach was that we equipped religious leaders with information and education, and then they could teach their congregations as they saw fit, which ensured that our approach was contextually relevant."

If the intervention was applied to the entire country, the authors estimated that it could lead to 1.4 million more circumcisions, which could potentially prevent between 65,000 and 200,000 new cases of HIV infection. They noted that public health experts should consider using this model in other at-risk countries as well and they wonder if it could help promote other healthy behaviors.

The authors noted there was a small risk that people could have heard about the intervention (or control) going on in another village, which could have changed their decision on whether to have a circumcision, but the region is fairly rural and they said there's minimal contact between villages. Plus, the study relied on census data from 2012 as it was the most recent available; if it's out of date it could affect their estimates.

The WHO says circumcision is just one element of a HIV prevention strategy which should also include HIV testing, counseling, and treatment as well as promotion of safe-sex practices like consistent condom use. But other influential religious leaders—namely Pope Francis and his ilk—still waffle on whether using condoms is evil or not, so there's a ways to go.