This essay was submitted to Open Philanthropy's Cause Exploration Prizes contest.

If you're seeing this in summer 2022, we'll be posting many submissions in a short period. If you want to stop seeing them so often, apply a filter for the appropriate tag!

Editorial note on this document

Current research has shown that voluntary male circumcision has shown to reduce the chances to get HIV infection and other sexually transmitted infections. Health care providers should inform all uncircumcised adolescent and adult males that male circumcision reduces, but does not eliminate, the risk of acquiring HIV and other STIs during heterosexual sex. (CDC 2014)

The document was written to showcase the importance of Voluntary Male (VMC) Circumcision amongst male populations of the two regions. Research conducted by CDC and UN Aids has proved that VMC has led to reduced infections among the Luo and Luhya communities both of Nyanza and Western Regions.

The paper tries to demonstrate the effectiveness of VMC obtained among these communities.

My major constraints in writing these paper were lack of logistical support to transverse these two regions and much of the evidence is based on both literature and desk top reviews 

Sources of uncertainty

My major sources of uncertainty were:

• What is the impact of Voluntary male circumcision amongst heterosexual males in sexual relationships with HIV-infected female partners infected with HIV? Men in these kinds of relationships who choose to be circumcised ought to be provided with sufficient HIV risk –reduction information.
• My other concerns were the impact of VMC on men who culturally had multiple female partners either out of customary wife inheritance and other traditional practices. In my view wife inheritance especially amongst the Luo communities has in fact increased the prevalence of HIV persons in the community. Data on female infected persons is available but most men infected with HIV amongst the Luo community is scanty owing to the fact that men avoid being tested.
• I was also very uncertain about males who have undergone Voluntary male circumcision who are in relationships with women at high-risks of contracting HIV. And these women who fall under the category of commercial sex workers, drug injecting females and females in distinct populations with HIV dominance of one per cent or elevated.

Summary 

What is the problem?

About 1.5 million people are in Kenya are HIV positive while about 1 million people are receiving antiretroviral therapy in the country according to the Ministry of Health. There are approximately 35,000 new cases every year that puts huge cost on the current health systems.

The median economic unit cost per patient-year is $249.91 for an adult antiretroviral patient; or $120.72 when the cost of ARVs is excluded. Newly diagnosed ART (Antiretroviral Therapy) patients are associated with higher costs at $274.95 for adults. ARVS is the largest single cost of component, cost of median of $123.03 per year for ART, (Cost of comprehensive HIV treatment in Kenya, 2013) 

The direct cost of HIV is about 1.5 million DALYs per annum.HIV in Kenya causes about 1/3 DALYS per year as compared to malaria and cholera. The cost of treating these 35,000 patients for one year is estimated to be 3.42 billion shillings and this is anticipated to rise to 3.8 billion shillings in 2030.

In view of the urgency in curbing the spread of HIV infected populations, Voluntary Male Circumcision has been described as key strategy to curb the spread of the pandemic.

Eventually the extent to which Voluntary male circumcision will help avert the spread of HIV will depend on several factors.

 A number of factors will comprise the percentage of heterosexual men at high risk who choose to be circumcised and whether the approach can be successfully included with other established HIV prevention strategies.

From my findings it is apparent that data on the cost-effectiveness of Voluntary Male Circumcision to prevent the spread of HIV transmission is quite inadequate. Findings in the field show that circumcision of new borns would present long term investments by sinking the existence of risks of HIV infection. 

Sources of uncertainty

Financial costs.

The existence of HIV/AIDS tends to draw scarce resources away from alternative investments or other socio-economic benefits within an economy for instance treatment of other very acute conditions such as cholera, malaria, tuberculosis, Covid 19 interventions(testing and prevention) and malnutrition but also investments in very critical infrastructure and critical sectors such energy, transportation, education, health service facilities and critical skills such as doctors, data scientists, nurses and engineers.

Uncertain short run costs of HIV-mortality

It is expected that the deaths caused by non-communicable disease account for about 27% of all deaths suffered by Kenyans which is significantly higher than the deaths accounted for by HIV which is 4.9%.

Morbidity and mortality of HIV prevalence results in low levels of economic growth due to low production, low incomes, low savings leading to low investments in the country

Slow economic growth tends to lower production as a result of the HIV disease burden which has implications in low exports and high imports of both medicines and other health care service interventions.

Mortality rates have direct cost on critical health care training for doctors, nurses and other health care professionals that would otherwise not be there. Again the impact on caregivers has huge implications to both work, productivity and business, the country also becomes unattractive to foreign direct investments that provide much needed jobs and income.

Neglectedness

As per the no. deaths due to HIV, Voluntary Male circumcision is not particularly neglected.

This is evidenced by the decline of the no. of deaths in Kenya since 2005.About 28,200 people died of HIV in 2017 compared to approximately 53,900 in 210, a decrease of about 48% deaths annually for the study period.

The decline is particularly due to availability of antiretroviral therapy and better information for patients provide through the National Aids Control Programe.

Cost per patient with ART intervention is approximately $274.95 which is lower compared to non communicable disease of $ 987 per patient per annum.

Tractability

Voluntary male circumcision to prevent HIV transmission is not very manageable and its control varies.

One cultural beliefs and practices play a huge part in informing men’s lifestyles in Luo Nyanza Region. Men in these region have for a very long time practiced wife inheritance These practice has shown its incidence of raising HIV transmission. Again fishing as a means of livelihood has forced women to engage in sex for fish, fishermen who are particularly men exchange fish for sex.

Two a lack of trained human resources to is a major constraint.

Thirdly ritual sex as part of the communities’ norms hinders the need for Voluntary Male circumcision.

Fourthly most Luo men are unwilling to undergo voluntary male circumcision due to religion/cultural, notions of manhood and social disapproval.

Fifth, fear of pain from the procedure, perception of low HIV risk, lack of partner support, fear of HIV testing, reluctance to abstain from sex and myths and misconceptions are commonly reported barriers

Six, cultural practices orchestrated by local leaders and women, as well as the involvement of female health workers during medical male circumcision. 

(Key challenges to voluntary medical male circumcision uptake in traditionally circumcising settings of Machinga district in Malawi, Oct 2021)

Possible Interventions

To address interventions for VMC it is imperative that the interventions must address the barriers that exist in VMC. These barriers include:

• Fear of pain and its consequences
• Periods of sexual abstinence
• Threats to masculinity
• Opportunity cost of procedure and in the form of lost wages
• Religious and cultural norms

Interventions addressing the above factors will be the following:

Interventions that are basically economic that tends to influence behavioral change to include compensation for wages lost.

Financial incentives were used to promote desirable health outcomes for voluntary male circumcision in the region. Financial incentives (FI) are a potential strategy for increasing demand for health services by compensating users’ direct (e.g. transport) and indirect costs (e.g. opportunity cost of time)

Table 1 - Some financial incentives and their definitions

Using influencers to provide much needed information such as intimate partners to convey encouragements, peers and male sports personalities to convey information.

Using already circumcised role models like sports coaches has been seen as effective means to encourage the uptake of Voluntary male circumcision among men and boys. Organizing sports events in schools and colleges also has been very effective in carrying out the communication process. Again the use of celebrities to pass out messages in advertising channels has been a very effective method.

Messages delivered through cell phones, social; media platforms and other internet based services.

Mobile messages using cell phones and other mobile communication techniques has proved very effective in VMC. Social platforms like twitter, Instargram, face book have been very pivotal in giving positive outcomes. Very important is follow up phone calls by health providers on status of treatments.

Entertainment platforms

Music events, poetry drama and cinema giving out positive messages on VMC. Use of local content, music and film celebrities to encourage men.

Opportunities for Philanthropy

• Philanthropist can intervene by building health facilities to perform VMC, HIV Counseling, ART provision and training of health providers in combating disease prevalence in the region including malaria,cholera,tuberculosis,Covid-19 and other non- communicable diseases like diabetes, blood pressure etc.
• Identification and sharing of best practices and support for regional learning exchange.
• Continuous quality improvement supported by External Quality Assessments (EQAs)
• Technical assistance for policy, strategic, and operational plan development.
• Commodity procurement and logistics management including quality assurance on commodities and distribution

Conclusion

Qualitative information from a Kenya study suggests that men who are already interested in circumcision are more likely to be persuaded or nudged into action by these short-term interventions. Further research can help identify mechanisms to reach men who have not yet considered circumcision, or are still uncertain as to whether it is right for them.

References

• Male Circumcision and HIV: the here and now (Part 1)-UNAIDS
• How does male circumcision protect against HIV infection? Robert Szabo 2000
• Are There Advantages to Male Circumcision for HIV Prevention? Eleesha Lockett, MS September 30, 2021
• www.cdc.gov/hiv.
• UN Aids
• Health In Kenya
• Cost effectiveness and survival analysis of HIV and aids treatment in Kenya, Elizabeth Anyango Owiti, 2013
• Leading causes of death and high mortality rates in an HIV endemic setting (Kisumu County, Kenya, 2019)
• Kenya: HIV positive patients hopeful after trials for injectable drugs begin,2022
• The cost of comprehensive HIV treatment in Kenya, August 2013
• The Institute for Health Metrics and Evaluation (IHME)
• The global health observatory, WHO
• High HIV prevalence among decedents received by two high-volume mortuaries in Kisumu, western Kenya, 2019
• Identification of fast-spreading HIV variant provides evidence of urgency to halt the pandemic and reach all with testing and treatment, Feb 2019
• Key challenges to voluntary medical male circumcision uptake in traditionally circumcising settings of Machinga district in Malawi, Oct 2021
• Interventions to Drive Uptake of Voluntary Medical Male Circumcision—a Collection of Impact Evaluation Evidence, Oct 2016
• Changing health behaviors using financial incentives: a review from behavioral economics, August 2019The effect of demand-side financial incentives for increasing linkage into HIV treatment and voluntary medical male circumcision: A systematic review and meta-analysis of randomized controlled trials in low- and middle-income countries, Nov 208
• Voluntary medical male circumcision, US AIDS
• Can influencers and peers increase male voluntary circumcision uptake? 3ie Dec 2016