Male Circumcision and HIV

Morals in Medicine: beliefs dictate care

This one needs very little introductory comment. It's something we all know about. But here is a study to shore up our personal anecdotes.

The moral is: Question your doctor with the critical thinking skills you possess.

Nevertheless, what's not discussed is what if your doctor doesn't know all the options or drawbacks, as is frequently the case with medical circumcision?

Fair use story and link to original source, next page.

Politics plays a part in research

An object lesson, perhaps first pioneered in the case of infant circumcision and largely still unrecognized in that area, has recently gotten some attention in the media. Advocates for research funds in any disease obviously play politics to get it, as would be expected and obvious. However, the effectiveness of such advocacy has little to do with the seriousness of the disease and a lot to do with the skills and connections of the people advocating for its research funding.

The article, after the break, details how Chronic Fatigue Syndrome garnered first a lot of attention and then a lot of money far above the relative levels that it affects people either in numbers or in health outcomes. Not surprisingly HIV/AIDS is mentioned as a case where "hard-nosed" politicking came above ground and shocked the public health sector into action.

I guess the point here is that no matter the issue we mustn't be naive about the forces pushing for one agenda or another. This goes doubly so in the case of circumcision in the HIV/AIDS context, where not only are the (probably circumcised) American researchers mentally and emotionally invested in the practice, but the formidable HIV/AIDS funding apparatus, seeking to showcase progress against the disease, is becoming so as well.

The article at the click-through.

Notebook: Strategies for influencing the use of male circumcision in HIV prevention

The time has come (perhaps has been here a while) to look at influencing the debate viz. the use of male circumcision in HIV prevention.

Obviously, this blog has held a skeptical view of male circumcision from the beginning. This practice has had a very long history of abuse and implementation in an ethical vacuum. The infant variety is in violation of every human rights tenet espoused in universally recognized fora, particularly that of the United Nations.

Today, it is clear the HIV/AIDS problem is likely to take on vector status in spreading the urge to mutilate. As has been noted below, the Stallings et al. study is no less supportive of female circumcision in HIV prevention. It has gotten less press in the US, but it has not gone unnoticed in Africa. Viewing male and female circumcision as one problem instead of two, HIV/AIDS is driving a ruinous path through communities in more ways than one.

Hence, the question must be asked, do we outright oppose circumcision in all its varieties as a prophylactic measure on human rights grounds? Or do we seek to contain it by arguing it has a severely limited (but) appropriate place of implementation?

The Forum for Collaborative HIV Research has called for an independent body to oversee HIV prevention strategies to "reach out to stakeholders; facilitate the design and testing of combination products; share information; establish links between donors and stakeholders; fill gaps in knowledge; reduce research duplication; and make recommendations regarding use of resources."

This could be a positive development if the public could mobilize to lobby this body in favor of ethical approaches to the use of circumcision. To draw on Margaret Mead's observation of societal change, the public may end up being a small but dedicated group of human rights activists.

More on the call for an independent body for HIV prevention research oversight after the break.

Notebook: "Three trials now proof that circumcision prevents AIDS infection: scientists"

And the misinformation and confusion begins full force ...

Already headlines like the one above are making their appearance, sure to lead many an unsuspecting circumcised young man down the path to infection.

Mankind has a serious sexual mutilation pathology. Americans are the worst.

- The Editors

The Lancet lends its imprimature to circumcision

Perhaps sensing the unstoppable tide of misinterpreted science and careless attention to human rights and ethics, The Lancet published today two recent studies said to validate surgical modification of male genitals in reducing female-to-male HIV infection.

The recent mood in the HIV/AIDS community has been gloomy. This research is an acknowledgment of a generalized failure in the face of an entirely preventable "social" disease.

HIV infection rates are a tiny fraction of over all disease in developed countries for very good reasons. Even the most basic improvements in health care systems render the heterosexual HIV transmission risk non-threatening to the vast majority of the populace. Basic hygiene (from running water), testing, and education have quarantined the virus into "concentrated" high risk groups, such as intravenous drug users, sex workers, and highly sexually-active (and incautious) gay males.

Despite years of observational data that showed a lower HIV risk to the owners of surgically modified male genitals, research scientists were hardly taken seriously when suggesting an irreversible, ethically fraught procedure with unknown and unacknowledged long-term detrimental effects.

Their message has now gained traction and threatens to leave a swath across Africa of misunderstanding, medical mishaps, and diverted resources.

Yet, no one has asked, if HIV/AIDS rates were at .3% with a yearly death rate of under a 100 as in Belgium, or .1% with yearly deaths under a 1000 as in Germany, would there be calls to mass-circumcise the male populace? The answer is, of course not.

Instead of committing to improved health care for Africa and beyond, the world has said to them, "Go circumcise."

This is shameful, indeed.

-The Editors

Great debate may slow circumcisionists push

Cautious voices have said all along that trumpeting male circumcision as a prevention strategy against HIV infection mixes messages and feeds confusion. Such confusion therefore threatens gains made by the unified message of safer sexual practices, abstention from or rehabilitation for intravenous drug use, drug use harm reduction (needle exchange) and knowing your HIV status.

Now leaders in Africa are getting in on the debate and echoing this stance. President Yoweri Museveni recently joined the "heated" Ugandan national debate, arguing that the findings could hurt the fight against the pandemic.

Dr Godfrey Kigozi, one of the researchers in the Ugandan study, has said, "When you say circumcision reduces acquisition ... it does not mean it eliminates HIV/AIDS. It is just one component in our arm of prevention. If you are circumcised, then it is fine, but if you practice safe sex or abstain [that is] better."

The essential message is that you cannot depend on circumcision to protect you. Therefore, don't circumcise solely for the purpose of reducing your risk. Anything more nuanced, such as, "if you occasionally engage in unsafe sexual practices, get circumcised to reduce the one-off chance you will be infected," is hopelessly confusing and unhelpful. In any event, opponents argue that the disadvantages and longterm damage to sexual function obviously would detract from such an approach, nuanced or not, as it could lead to more frequent unsafe sexual activity.

Uganda continues to mull over the findings of the studies promoting circumcision as a risk reduction procedure.

Click through for the full text of the article.

Geese get equal treatment in Africa at Dr. Piot's urging

When the Kenyan and Ugandan studies were announced linking lower HIV infection risk with male circumcision, many sober voices immediately called for safe and consensual procedures by trained clinicians instead of in the wild by witch doctors, if a given country decided to implement a mass circumcision campaign.

It was rather shocking then when Dr. Peter Piot, head of UNAIDS, called for infant circumcision to be implemented as a first step. After all, outside of the North American and Jewish experience, infant circumcision is widely seen as non-consensual and cruel with often unforeseen and unrecognized complications. But give Dr. Piot credit. For he must have known that there would be widespread resistence among people old enough to understand the pain and damage the procedure entails.

We reported right here on this blog what Dr. Piot must have been thinking. One Ms. Thoko Tsabedze, an HIV-positive mother from Macatjeni district south-east of the Swaziland capital, was quoted as saying, "It is difficult even when you try to talk to your son about circumcision. He says, 'How am I going to take a bath publicly with my friends, I will be ridiculed'."

So, is it true or not that what is good for the gander is good for the goose?

If so, Dr. Piot must be getting goose bumps to hear from a competing UN agency, the UN Population Fund, about clinics now being spotted "in Egypt, Kenya, Somalia, Djibouti and Yemen" offering female circumcisions to increasingly younger girls because of "increased awareness of the health risks associated with the practice" in non-clinical settings, i.e. by witch doctors, and "to avoid refusals to participate," i.e. give consent.

Imagine how these "clinics" will pick up steam when they learn of the Stallings study, echoing loudly the prophylactic effect of male circumcision, but in females who have undergone female circumcision!

Full fair use text of the Reuters article and the Stallings abstract after the hop.

Spain reports falling heterosexual HIV prevalence

Testing centers in Valencia report a falling incidence of HIV infection among members of all risk groups with the most precipitous fall among heterosexuals. The highest rate remains among injecting drug users.

The researchers conclude the lower incidence and prevalence over time could be from greater testing or prevention messages. It is widely believed that knowing one's HIV status is a major contributor to the reduction of the spread of the disease because people who know their status are less likely to expose others.

Spain presents an example of a non-circumcising country with a low and falling incidence and prevalence of heterosexually transmitted HIV/AIDS.

Complete text of the article after the jump.

Zimbabwe editorial explains doubts over circumcision and HIV link

Independent researcher Laurie Milner, citing a number of studies, explained that malaria and so-called "dry sex" are greater threats to public health and the spread of HIV in Africa than the presence of the human foreskin.

Milner echoed Dr. Joseph Matare's conclusions in a previous article that other already proven methods of HIV prevention are less costly, less invasive, and far more eficacious than circumcision.

Complete text of the article after the jump.

Swaziland falls victim to mass HIV infection, shortage of medical personnel, and now false hope

In a nation where the HIV infection rate is said to be nearing 50%, people are desperate. Getting sick with wholly curable diseases can be life-threatening. Getting HIV is a short-order yet slowly unfolding death sentence. It may take 10 years for HIV to begin to cause opportunistic diseases, but when it begins, it is a slow and inexorable descent into illness and agony.

Swazi men have latched onto circumcision as their silver bullet. Yet, the question remains, in a country where half of all people have HIV already, will a procedure with marginal prevention value and no curative effect mean much?

Many say no. And yet, what else is there when condoms and other methods of prevention have gone largely unused and unimplemented? The real question perhaps should be, is circumcision providing a hope that is largely absent otherwise? Is its value not in the alleged medical benefit, but rather in the hope it provides? Is it a talisman, a kind of national amulet to be carried in the loins of Swazi men?

Even the article referenced below misstates and misunderstands circumcision, repeating speculation as to its alleged protective mechanism and making the astounding claim that condoms are only of limited effect. When the national media doesn't understand or know the facts, how can the poorly educated masses have any hope of implementing defensive measures against the disease?

Swaziland, like many poor African nations, has a massive shortage of medical personnel. Therefore, the chances of obtaining a safe circumcision are low. It is entirely possible that circumcision may result in many sub-standard procedures. It will therefore likely spawn a new pathology of its own, if it takes hold in numbers. As Thoko Tsabedze, an HIV-positive mother from Macatjeni district south-east of the capital, explains, "It is difficult even when you try to talk to your son about circumcision. He says, 'How am I going to take a bath publicly with my friends, I will be ridiculed'."

At a 50% infection rate, it must be asked whether those who would contract the disease haven't already fallen victim. Even if circumcision had some protective effect, it likely would not benefit those who are now negative. The numbers needed to treat would be so high as to make it a worthless effort. In a country with so few resources, the latest national tragedy to befall Swaziland would be implementation of a superfluous surgery in place of whatever else is medically lacking.

Complete text of the article after the jump.