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ANGOLA: The pros and cons of snipping

[This report does not necessarily reflect the views of the United Nations]

LUANDA, 21 February (PLUSNEWS) - Friends Paula and Marta giggle at the suggestion of having sex with an uncircumcised man; both say they have only tried it once.

"That little piece of skin, it hurts," said Marta, 28, a domestic worker in the Angolan capital, Luanda. "No-one warned me that it was painful for the woman - I wouldn't want to do it again."

PlusNews spoke to about a dozen Angolan women, most of whom said they would prefer a circumcised man as a sexual partner. Their reasons included perceptions of greater hygiene, virility and a more pleasing aesthetic.

The small casual survey reflects a reality in Angola, where around 90 percent of men are circumcised, according to Americo Kwononoka, director of the country's National Museum of Anthropology.

In most ethnic groups, especially in rural areas, the removal of some or all of the foreskin is a procedure associated with entering manhood, and normally takes place when a boy is aged between 12 and 14.

"The process usually starts with a party, then the candidates are taken away from the community to a camp," Kwononoka explained. "The prepuce is cut in cold blood, without anaesthetic." Circumcision is also widely practiced in urban areas, although it not steeped in as much ritual and symbolism.

Low HIV, high male circumcision

Recent data indicates that circumcision correlates with a significantly reduced risk of HIV transmission during heterosexual intercourse, but this is still the subject of ongoing research and debate in the medical community.

Official 2004 statistics, based on tests conducted on 12,440 pregnant women in Angola, put the overall HIV prevalence at 2.8 percent - low in a region where several countries have infection levels above 20 percent.

"If it is true that almost all men are circumcised in Angola, it would suggest that circumcision acts as a buffer against infection and slows down the spread of the epidemic," said Daniel Halperin, an AIDS researcher.

"However, if this pattern of nearly universal male circumcision were to change, given the level of risky sexual behaviour in Angola, the epidemic could explode," he commented.

Having multiple partners is the norm in Angola. Marta's boyfriend of five years also has another girlfriend, with whom he lives and has a child. Marta, who also has a child from a previous relationship, wants to move out of her mother's home so that she and her boyfriend can live together.

Her colleague, Paula, 34, and the mother of five, has been seeing her boyfriend, who is also married, for four months. "It's normal here for a man to have several wives. Sometimes they have three or four wives and they usually split their time between each home," she said. "But I always use a condom with my boyfriend."

Not the full story?

Ana Leitao, of the World Bank's HIV/AIDS, Malaria and TB Control project (HAMSET), said it was too soon to assess the impact of widespread circumcision on HIV prevalence in Angola; national statistics have been heavily contested and many believe the rate is significantly higher than the figures portray.

Even if they are correct, other factors could also have contributed to lower rates: the country's borders were largely closed during the 27-year civil war that finally ended in 2002.

But in southern Cunene Province, where the majority ethnic group in the area, the Kwanyama, do not traditionally practice circumcision, statistics show HIV prevalence at 9.1 percent, significantly higher than the national average.

This could be one reason for the higher rate, but it may not be the full story. "Remember that Cunene shares a border with Namibia, where the rate is very high, and there is a lot of movement between the two countries," said Leitao. "There may also be specific reasons why HIV is so much more prevalent in Namibia than in Cunene, or maybe we don't know the real rate of infection in Cunene - it could be a lot higher."

There are also fears that some might mistakenly believe circumcision alone will protect them against HIV, and could see it as an alternative to condom use.

Experts say the introduction of any policy encouraging circumcision would have to be included as part of a broader package to help slow down the spread of the virus. "Angola has an opportunity not to make the same mistakes as other countries [by controlling the epidemic]," said Halperin. "Angola should concentrate on prevention among sex workers, truck drivers and other high-risk groups, and on sexual partner reduction among youth."

Other risks besides HIV

There are risks associated with traditional male circumcision: complications resulting from poorly conducted procedures, post-operative bleeding and infection can have catastrophic and sometimes fatal consequences because circumcisions are not always carried out in bona fide hospitals or clinics.

The health structure is still in tatters five years after the war's end and many circumcisions are carried out by a traditional doctor or elder rather than a qualified medical practitioner. "In most cases, instruments aren't sterilised, people don't necessarily have the training to carry out the procedure, and sometimes several people are circumcised in one session," said Leitao.

While other countries in the region are seriously weighing a national policy on circumcision, in view of Angola's pressing need to improve basic public health services, such a decision could be premature.

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