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HIV loosens tribe's resistance to circumcision

Understanding link between HIV, circumcision is essential to reversing disease's course in Africa.
Craig Timberg
Erick Onyango Otieno, shown in Mbita, Kenya, is willing to defy tradition and undergo circumcision. "I do not want to die at this early age," the 21-year-old says.Craig Timberg / The Washington Post
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Family gatherings for Collins Omondi once were boisterous affairs here on the verdant shores of Lake Victoria. But in just 11 years, AIDS has killed seven of his uncles, six aunts, five cousins and both his parents. His extended family now consists of one surviving uncle, an aunt and their 2-year-old child -- all of whom have AIDS.

Omondi, 28, a tall, broad-shouldered fish trader, has come to believe that a quirk of culture contributed to the decimation of his family. They were Luos, members of the only major tribe in Kenya that does not routinely circumcise boys. The absence of this ritual, Omondi said, helps explain why Luos are dying from AIDS at a rate unheard of among other Kenyans and rare in East Africa.

Twenty years after the first reports of a connection between HIV rates and circumcision, scientists are saying it is essential to understanding the path of the disease through Africa and possibly to reversing its course. President Bush's $15 billion anti-AIDS program is pledging millions of dollars to Kenya and other countries so they can offer circumcision services in communities long defined, in part, by their reluctance to perform the procedure.

The unprecedented effort already has provoked a backlash from the Council of Luo Tribal Elders, which decided last year to officially oppose it. But along the beaches of Lake Victoria, where fishermen push their colorful sailboats into the waves before dawn each day, many express a willingness to leave this tradition behind if it means surviving an epidemic that seems to have no end.

"We are the people who are sick," said Omondi, who recalled the haunting feeling of walking through his father's empty home on a nearby beach. "We are the ones who lose people every day."

Most African tribes traditionally circumcise boys in rituals marking the onset of manhood. But the Luos and some other Nilotic tribes, whose ancestors migrated south from Sudan, used to mark the end of childhood in a different but also painful way -- removing six bottom front teeth.

'The most proven, effective HIV prevention'
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. Within Kenya, roughly one in 17 adults has HIV. Yet among Luo adults, the virus has infected one in five.

Scientists say the cells in a man's foreskin are unusually easy for HIV to penetrate. Removing it through circumcision also makes the skin on the penis head grow thicker and more resistant to infection. Trials in Kenya, Uganda and South Africa have shown that circumcised men are 60 percent less likely to contract HIV. The World Health Organization endorsed it as a key prevention strategy in March.

"It's now the most proven, effective HIV prevention strategy we have for male heterosexuals, so it's really important that we make this widely available," said Robert C. Bailey, an epidemiologist at the University of Illinois at Chicago who oversaw the Kenyan trial in nearby Kisumu.

Bailey has calculated that a well-run program could lower the HIV rate among Luo men from 18 percent to 8 percent over 20 years, averting tens of thousands of infections. Women would also be less vulnerable to HIV because of the decreasing infection rates of their sexual partners. Across Africa, widespread circumcision programs could save 5.7 million lives -- far more than any prevention strategy yet tried, U.N. officials have estimated.

Several countries, including Zambia and Swaziland, are exploring how to expand circumcision services, but none is further along than Kenya. Peter Cherutich, a top health official overseeing the issue, said a policy on making circumcision "available in a safe and voluntary manner" probably will be completed in the next month or two.

Officials for the Bill and Melinda Gates Foundation have expressed interest in helping expand circumcision services in Africa but said no final decisions have been made. Several Kenyan health experts said a multimillion-dollar grant from the foundation supporting the effort is expected to be announced soon after Kenya's policy is adopted. The U.S. contribution, worth $5 million to Kenya this year, also is due after the government policy is released.

The program initially would focus here in western Kenya's Luoland. Existing clinics and youth centers could begin offering services as soon as early next year, and mobile teams would use vans to visit churches, markets and beaches where fishermen work, offering free circumcisions with sterile surgical kits they would bring along.

Kawango Agot, a circumcision researcher and herself a Luo, said the effort is likely to be popular. In a survey she and Bailey conducted, 60 percent of Luo men said they would like to be circumcised because they believed it was cleaner and healthier. The percentage was highest among those younger than 25. She called the cultural concerns overblown.

"Sincerely, I just don't care," Agot said. "What I care about is people are dying."

Fear and education

Luos long have faced discrimination for not circumcising their sons. Members of other Kenyan tribes sometimes refused to vote for Luo politicians on the grounds that they had not become adults. Luos who traveled far from their homeland were mocked with a variety of cruel nicknames, such as "Kehe," which translates literally as "uncircumcised" but to Kenyan ears means "boy."

Meshack Riaga Ogalo, the 73-year-old leader of the Council of Luo Tribal Elders, said the true source of high rates of HIV in the tribe, which is one of Kenya's largest with a population of about 4.5 million, is not the lack of circumcision but the abandonment of traditional culture, especially by fishing communities.

"Nowadays, because of Christianity and all kinds of civilization, you introduce something like love affairs. The world is now horrible," said Ogalo, who favors a walking stick and black cowboy hat. "We don't want foreigners to interfere with our culture. It is absolutely wrong."

Lake Victoria's fishermen, following the winds, often kept girlfriends at several different beaches. The men generally were among the few in villages with steady supplies of cash, arriving home each day with $10 or $20 -- sometimes much more -- in areas where many earn less than $1 a day.

"With the fishermen, you can't trust them," said Mary Achieng Bunde, 41, a former fish trader and an AIDS activist whose husband died of the disease.

Of the women who trade in fish, she said, sexual favors were expected and generally granted. "Most of them, they are ready to do because maybe your husband has died, your children have school fees. . . . What can you do?"

She said attitudes are changing on the beaches because of fear and aggressive education programs. More fishermen are living in family houses, with their wives and children, rather than in communal dorms. The carousing has quieted as the toll of AIDS has grown.

Yet she suspected that circumcision would require a degree of change beyond what most fishermen would accept. "It will not be easy for them, because it is not our culture," she said.

Abandoning tradition
Less than a mile away, down on the soggy, grass-covered beach where Bunde once bought fish, a new generation of fishermen has taken over. Erick Onyango Otieno, 21, called circumcision "a good idea" and said younger fishermen did not want to make the mistakes of the previous generation.

"The older ones are almost all dead," he said. "I do not want to die at this early age."

Otieno and other fishermen expressed concern about the procedure itself, the amount of pain involved and the possibility of side effects. They worried about losing profits during the days -- and in some cases weeks -- that men may miss work while healing from the procedure.

A few, including some women who worked the beach, echoed the concerns of tribal elders about abandoning culture. Yet more said a Luo man who is circumcised is no less a Luo.

A substantial minority of Luos, especially those who have lived in other parts of Kenya, already have been circumcised. That includes Omondi, whose father had him circumcised when he was a child to prevent him from being teased when he bathed with boys from other tribes.

On another nearby beach, Erick Okoth, 31, a fisherman and father of two, said he has grown weary of the shifting AIDS-prevention strategies -- condoms, abstinence, monogamy, testing -- brought to Luoland. He would rather see the Luos solve their problems themselves.

"Removing the skin is like taking my rights away," Okoth said. "If you are telling me to get circumcised at this age, it's like telling another tribe to remove the teeth."

Some also wondered whether circumcision would affect their fertility, though scientists say it does not. Luos traditionally have large families, and pressures to have several children have grown along with the death toll of AIDS.

"We are going to lose our strength," warned George Okoyo Mawere, 48, a part-time fisherman, politician and local tribal elder. "When you are circumcised, the hormones are lower. That's why within the Luos, we have a very small area, but we have a very big population."

Yet Mawere said that despite his misgivings, he would support making the procedure available if it curbs AIDS. "Obviously we shall, because it's a disaster," he said.

On the beaches closer to the town center of Mbita, where lifestyles are less traditional, few fishermen expressed opposition to circumcision. On the beach worked by Omondi, there was wide consensus about the need for expanding services.

"I'll do it, plus my three sons," said Arthur Odipo, 33, a lean but fit-looking fisherman. "If circumcision can reduce the risk, we will do it."

Fishermen have been dying in Luoland so quickly and for so long that several said they were eager for any solution, regardless of culture.

One respected fisherman died just last month, and his wife appears sick as well, other fishermen said. His picture hangs on the wall of the fishermen's association office, and they were preparing to go, as a group, to the funeral.