Male Circumcision and HIV

Needle exchange best method to prevent heterosexual HIV infection

In a November 29, 2006 presentation to a UCSF epidemiology class, Dr. Willi McFarland of San Francisco General Hospital said that the North American prevalence of heterosexual HIV transmission is almost exclusively concentrated in the intravenous drug user population. The rapid decrease to near extinction of HIV infection among heterosexual groups in San Francisco has been the city's policy of providing needle exchange to this high risk group.

These insights virtually rule out circumcision as a cost effective measure against HIV infection in the North American context, not only because needle exchange is inexpensive and avoids the numbers-needed-to-treat conundrum, but also because intravenous drug users are small in number and reachable. [See this excellent discussion on the numbers needed to treat in the circumcision/HIV context.]

In response to a question viz. the falling rates of infection among intravenous drug users being due to needle exchange, Dr. McFarland said:

San Francisco was more progressive than most of the country in this regard. [Needle exchange] was implemented early despite the laws [that] didn't change, but San Francisco does this, supports it, ongoing. We can't use federal money, so it is a very proactive effort to sustain needle exchange. I think it was a case of doing the right thing at the right time. And it isn't just among injectors. The heterosexual epidemic in North America follows the injection epidemic. [Heterosexual transmission] really isn't much from bisexual men. So by preventing it among injection drug users, we prevent it among heterosexuals, we prevent it among women, we prevent it among children. ... If we want to prevent it among women and children, this is the way to do it.

Dr. McFarland's talk was presented as part of the San Francisco General Hospital Positive Health Program Grand Rounds.

Reference

McFarland, Willli, MD, Ph.D. HIV/AIDS Epi-Update for San Francisco. HIVinSite Featured Content. November 29, 2006.

http://hivinsite.ucsf.edu/InSite?page=cfphp-mcfarland

Notebook: Is male circumcision an acknowledgment of failure?

Opponents of circumcision claim its use to combat HIV infection is a pessimistic approach. Proponents say it is a hopeful one. Ironically, the proponents' hope stands in stark juxtaposition with its assumption of past and future failure.

For 25 years, the world has battled HIV/AIDS with the hope, and even assumption, that a vaccine was right around the corner. The astounding success in battling world diseases from polio to cancer in the last century has conditioned humanity to expect no disease, save old age, to be beyond our ability to contain and roll back. AIDS was a rude awakening that the world is only now coming to grips with.

Yet, HIV/AIDS is a disease with more resources thrown at it than almost any other disease in the modern world. It victimizes fewer people on a yearly basis than heart disease, cancer, drug abuse, and auto accidents. More people die every year of malaria and even starvation than HIV/AIDS. Yet, this disease is relentless in its march across the world. It is slow. But it moves with a fierce power.

It isn't hard to understand why the world fears it. What is astounding and almost beyond understanding is why the world is so reluctant to roll out proven prevention methods. Culture and inertia have conspired to stop the prevention agenda from moving forward ahead of the pandemic. The West, particularly NGOs of the West, never tires of lamenting this state of affairs in places like Africa and India.

So, why is male circumcision considered hopeful by its proponents?

Clearly, circumcision, like all efforts, competes in a marketplace of acceptance. Talking about prevention methods, such as correct condom usage, empowerment of women, and curtailing wide sexual networks, presents greater ongoing obstacles than even submitting one's genitalia to a disfiguring and experientially altering surgery, if said surgery works every time, which we know is unfortunately not the case. And this is doubly true when we are talking about doing it to those unable to consent.

It is therefore hopeful because it avoids these emotional and destabilizing subjects. It also does an end run around the ethical considerations because when parents submit their boys to genital surgeries, it is considered a personal choice for the parents, as the boy does not exist apart from his parents. It is a way of achieving what can't be achieved in the adult population. It assumes we have failed with strategies aimed at adults and entire societies where methodologies can't be rammed down people's throats. It assumes past and future failure in overcoming culture, indifference, and politics. And hence, many have noticed the recent encouragement of the adoption of infant or childhood circumcision as a starting point.

Opponents of circumcision in contrast find the procedure pessimistic because it seems to be a kind of surrender to the perceived futility in the realm of human affairs. They haven't yet given up on rational decision-making despite all the apparent evidence to the contrary. Africa and India, they say, lack resources of all kinds, i.e. education, political power, adequate emphasis on wealth generating infrastructure and cultural values, in short, development, and opponents say this is the real reason HIV/AIDS is on the march. Opponents point out that development goes far beyond containing disease. It raises living standards, more equitably redistributes power, and gives hope through health. In other words, the holistic approach should be preferred to piecemeal, "arsenal" type prevention strategies.

Opponents are optimistic despite all the evidence to the contrary. Proponents have given up and perhaps see profit in doing so, whether professionally or in prestige. Opponents see pessimism in circumcision because they are optimistic in the proven methodologies and in a holistic approach. Proponents see optimism in the procedure because they are pessimistic as to the alternatives.

More sober voices have expressed doubt as to the effectiveness of male circumcision, noting that within countries, over time, the HIV rates are about even between the circumcised and intact. It seems not just pessimistic but wholly wishful that male circumcision will somehow change the rate of infection.

The proven methods of female empowerment, correct condom usage, and over all development remain our only effective means of stemming the disease so far. Who wins the circumcision argument may not matter in the long run viz. HIV rates. It will matter viz. quality of life for the men and in maintaining pressure on the world to push what works.

-Editors

Medical Apartheid goes to Africa (oh, the irony!)

The recently published book, Medical Apartheid, details a fascinating story of forced medical experimentation by establishment doctors of the 19th and 20th centuries on young black men and women.

While the subject matter is not directly related to the issues addressed here, the author, Harriet Washington, draws a strong connection with the spreading of these practices from the United States of the last two centuries to Africa of the 21st century.

While she does not speak specifically of circumcision, she talks a great deal about the drafting of economically disadvantaged populations into medical studies with the promises of payment and other favors, which she postulates is a form of coercion. Clearly, an impoverished populace is far less equipped to resist the temptation to risk one's health for some alleged betterment of medicine when he's poorly informed and in material need.

The horrific studies of which she speaks are reminiscent of the Nazi doctors. Obviously, such experimentation has dissipated in North America. But she reminds us in vivid detail that it continues elsewhere under the cover of Western aid and medical missions.

Critics of the HIV/circumcision studies have frequently spoken of the apparent racism in promoting circumcision primarily in Africa where HIV rates are out of control. The primary point is that the West promises much and delivers little in the way of established HIV prevention strategies. So, it has no business getting into the messy business of promoting a difficult and culturally sensitive procedure supported only by controversial studies that are flawed with unaccounted for confounding factors.

On circumcision, the rhetoric treats the problem as a colonial endeavor to assist the natives who allegedly can't help themselves. Harriet Washington shines a spotlight on the broader issue from the perspective of African Americans to that of Sub-Saharan Africans.

She was interviewed on Democracy Now! on Friday.

Harriet Washington is a medical writer and editor. She is a visiting Scholar at DePaul University School of Law. Previously she was a Fellow in Medical Ethics at Harvard Medical School and at Stanford University.

Reference

Goodman, Amy and Gonzalez, Juan. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present [segment title]. Democracy Now! January 19, 2007.

http://www.democracynow.org/article.pl?sid=07/01/19/1432231

Belizeans not sold on circumcision as HIV/AIDS prevention effort

Residents of the tiny former British colony of Belize are not sold on circumcision in the efforts against HIV infection. Belize is on the east coast of Central America.

Dr. Marvin Manzanero was asked whether he thought circumcision would catch on in Belize. “Knowing the way we go here in Belize, I don’t think even if you give out that males would be more circumcised than before, I don’t think so.”

Dr. Lisa Johnson of Belize's Universal Health Services stated, "For every study that has supported circumcision there is an equally good study that takes away support, that does not support circumcision and actually the position of the American Academy of Paediatrics is that they neither recommend circumcision nor do they say that it is a bad thing.”

In a Channel 5 news report, four out of six people on the street informally polled against the procedure. 

Dr. Manzanero stated, "The fact that you are circumcised does not mean that you can go ahead and engage in high risky sexual behaviour. That is not the case. You might have one risk factor less, but still you have to still use a condom, still practice safe sex every time you have a partner. We go back to the same issues, the abstinence, the be faithful, the condom usage, and we have to wait for further studies for us to give conclusive evidence [before we] try to start promoting male circumcision as another means of preventing HIV/AIDS.”

Verbatim transcript from the boradcast after the jump.

China rejects circumcision in fight against HIV/AIDS

Ru Xiaomei, deputy director general of China's National Population and Family Planning Commission, told Reuters in an interview that China is not currently considering a campaign to implement circumcision in the battle against HIV/AIDS.

Reuters quotes Ru: "I'm not yet totally certain about the evidence for circumcision. We should exercise caution."

China joins South Africa in setting forth a cautious position vis-a-vis the controversial studies coming out of Africa. The studies in question were conducted in Uganda, Kenya and South Africa. They have been funded and conducted by researchers from circumcising nations and by individuals with longstanding positions in favor of circumcision unrelated to HIV/AIDS. The non-circumcising world has so far been far less enthusiastic and more skeptical regarding the announced results.

"[In a country with the world's largest population - 1.3 billion people,] there's a problem with cost too," Reuters quotes the senior health minister. "It would be a big deal. It's much more reasonable to get people to use condoms."

The US based groups, Doctors Opposing Circumcision and MGMbill.org, have also noted the more reasonable approach of using condoms in countries outside of Africa.

Other approaches to combat HIV/AIDS with many knock-on benefits that have gotten far less attention are greater emphasis on empowering women, provision of clean water resources, food security, economic development, and encouraging the reduction of sexual partners among the sexually active young adult population.

The article incorrectly states that Japan practices infant circumcision. Likewise, it gets the facts wrong concerning circumcision in South Korea, where it is practiced around puberty.

The article also restates unproven speculation on the reasons why circumcision may reduce the risk of HIV infection without citation or attribution.

Complete fair use text of the article after the jump.

Kenyan men who choose to undergo circumcision have a history of unsafe sexual behavior over men who choose to remain intact

Aidsmap reports on a study released this month showing that Kenyan men who choose to undergo circumcision have a history of engaging in unsafe sexual behavior at a higher rate than men who choose to remain intact.

Significantly, this finding mirrors at the psychological level if not the physical level Laumann et al's findings that circumcised men are more likely to engage or continue to engage in riskier sexual behaviors:

The investigators found that men who chose to be circumcised were significantly more likely than men who chose to remain uncircumcised to have had risky sex in the three months before entry to the study (p = 0.025) and to have had unprotected risky sex during this period (p = 0.03).*

Interestingly, this study touched upon an issue not accounted for in the widely reported studies purportedly showing a prophylactic effect against HIV infection from circumcision, namely a period of "disinhibition" following the procedure:

In the month following circumcision, men undergoing the procedure were 60% less likely to report risky sex than men remaining uncircumcised, and 87% less likely than uncircumcised men to report unprotected risky sex. The investigators attribute this to sexual disinhibition due to healing of the penis following the circumcision operation and counselling about safer sex.

These prior studies have been criticized for failing to factor in the time that the circumcised control group were not sexually active due to healing from the reductive procedure. Failure to factor in the inactive period would necessarily skew the results towards a greater protective effect against HIV infection than would actually be the case.

The researchers make a confusing and inconclusive observation regarding the year following the procedure. They say that the circumcised control group did not report "any appreciable [ ... ] excess of risky sex or unprotected risky sex" over the group who chose to remain intact.

Yet the question remains, Were the men less likely to engage in risky sex because they were counseled appropriately? Had the men already decided to reduce risky sexual behaviors prior to opting for the procedure and thus the procedure was itself merely evidence of self-initiated behavior change?  Or was something about the procedure permanently "disinhibiting?"**

* “Risky sex” was defined as sexual intercourse with an individual other than the man’s wife or regular partner, and “unprotected risky sex” was sex without a condom with an individual other than a wife or regular partner. Clearly, this further confuses any conclusions from the study due to the fact that the two categories are not comparable. Sexual intercourse with a condom provides a level of protection unrelated to whether the partner is one's wife or regular partner.

** These observations, though inscrutable, echo previous rationales for circumcision, i.e. its "disinhibiting" effects on sexuality and sexual activity. Of course judging by context, the authors probably mean inhibiting rather than "disinhibiting" as a century ago the purpose was to reinforce inhibitions regarding such activity.

Complete text of the article after the jump.

BBC: Men in Uganda seek circumcisions despite HIV rate parity

Men in Uganda have begun seeking circumcisions in numbers after media coverage of two US-sponsored as-yet unpublished studies purportedly showed a reduced risk of contracting HIV in unprotected heterosexual intercourse, according to the BBC.

Despite HIV rates in circumcised and intact populations being about the same, approximately 2500 men sought circumcisions in 2006, according to the same report. About 400 men sought the procedure in 2005.

The two studies, one in Uganda and one in Kenya, were sponsored by the National Institutes of Health and the Bill and Melinda Gates Foundation. Both organizations are based in the United States, a country that circumcises a majority of its infants without apparent effect on the HIV pandemic.

The BBC article noted:

Few cultural groups in Uganda circumcise boys before they are accepted as men in the society, but researchers say the HIV infection patterns in the country appear to be similar in both circumcising and non-circumcising groups.

Complete text of the article after the jump.