Male Circumcision and HIV

50% of new HIV infections flow from primary infection, likely limits effectiveness of prevention technologies

A recent study out of Quebec appears to indicate that up to half of all new HIV infections flow from individuals with primary infection.

Primary infection is defined as the first few weeks and months after infection when viral loads are highest in the infected individual. Antiretroviral medications typically reduce viral load to an undetectable level. "Treatment experienced" individuals, those who are on medications and doing well, do not efficiently transmit the virus through sexual activity. (HIV is not an efficiently transmissible disease, anyway. In anal intercourse, which is generally considered more risky than vaginal intercourse, the transmission event occurs in 6 out of every 10,000 acts for insertive partners, i.e. men, and 82 out of every 10,000 acts for receptive partners, i.e. women or men. Source: Ask InSite, UCSF.)

The researchers conclude:

... that despite recent advances in prevention technologies, such as circumcision or treating sexually transmitted infections “these strategies may be of limited effectiveness if individuals at or near to [primary HIV infection] represent a major source of onward transmission, because many such interventions depend on an initial positive diagnosis.” 

Clearly, testing at or near the time of primary infection represents the best intervention in preventing transmission. Obviously, it is difficult to do. Hence, "normalizing" HIV testing in the health care system would likely answer the question of how to reach individuals early in their infection. A spotty health care system such as Africa has - and unfortunately among the poor in the United States - would seem to be one of the greatest obstacles to normalizing prevention efforts, especially testing.

Circumcision has been offered as an answer to "getting ahead of the curve" in transmission of this disease. However, it seems clear that getting ahead of the curve is far more dependent on knowing in whom and where infection is occurring rather than throwing a wide net over everyone, such as mass circumcision would seem to do. For the millions who are not at a high risk for HIV, circumcision offers nothing except known risks and physical, sexual, and financial costs.

Note: The article is not primarily about how this finding impacts on the debate over the implementation of male circumcision.

Aidsmap story after the jump.

New research complicates informed consent

New research published in the British Journal of Urology appears to demonstrate the damage to sexual function and sensitivity caused by circumcision. This new information will likely nix any idea of circumcision in the average consumer of cosmetic procedures. It undoubtedly will make it harder for a confused couple deciding by proxy, as is currently possible, whether to inflict the procedure on their newborn.

The study is available as a pdf file.

Download Sorrells_study_2007.pdf

THANK YOU to Norm UK for making this file available on their website.

Notebook: Circumcision, the West's answer to failure

Informed consent is a concept with a relatively recent history in Western medical practice. In the United States, it grew from a number of court  cases from the 1950s that dealt with consent in the context of medical mistakes. If a patient goes in for an appendectomy and comes out with a hysterectomy, the idea that she did not consent to the hysterectomy tipped the case in her favor despite the fact that she gave consent for something.

It continued to evolve over the decades in cases where consent was given for a procedure, but an unwanted outcome resulted in a deterioration in the patient's quality of life. But informed consent was tricky because the informed part presupposed a certain level of understanding and intelligence in the patient. Hence, proxy consent arose where a guardian could give consent, informed of course, in the place of the patient. Hence, parents could consent for children, caregivers for mentally incompetent charges, and children for elderly, perhaps unconscious parents, and so on.

But it didn't stop there. Informed consent can be given for medically unnecessary procedures. Assuming that the patient understood that a given procedure was unnecessary, this wasn't a problem except in the case of proxy consent. Since a procedure may have lifelong consequences, proxy consent became limited to immediate medical necessity due to the legal supposition that the patient could regain his competency either at any moment or in the future.

This development in the law of consent was oddly never applied in the context of neonatal circumcision. It is the great lacuna of medical law and ethics. Theories abound for why this is so. From religious origin to parental rights theory, many hopeful commentators have sought to explain this - never to my satisfaction, I might add.

So, what of Africa? If circumcision were deemed useful, how could you craft informed consent for a people who have not inherited this decidedly Western legal tradition? How could you explain the probable damage and likely loss of function resulting from circumcision that occurs over time? How could you possibly describe to an embattled, poorly educated population the so-called 'pros and cons' of a procedure that effectively has no consensus even among the educated Western masses?

I think it would be virtually impossible to do so. And it is the constant talk of involving the stakeholders by international policy makers that implicitly recognizes this virtual impossibility. Therefore, the only way of putting circumcision into practice is through proxy consent. The argument will be made by the proponents of circumcision that the high rates of HIV infection make this a medical emergency despite the alleged benefits not being evident for many years in some cases - and ultimately short-lived, indeed. In fact, this is exactly the argument being made by some for neonatal circumcision before so-called 'sexual debut,' that is first sexual experiences.

What is even more fascinating - and disturbing - is the knife's edge that international organizations will likely walk in any circumcision campaign. When does communication in the guise of informing the patient cross the line to advocacy towards a population ill-equipped - or unequipped - to understand and decide? Does advocacy of a procedure effectively become consent by proxy in these circumstances? How likely is it policy makers will overstate the case and ignore contradicting evidence to implement a policy - particularly one the given policy maker has a vested interest in? The potential for abuse is overwhelming.

Lost in the minutiae of this area of discussion is the big picture. Africa is suffering from massive HIV infection rates not because some African men have foreskins. They suffer because of poor development, ignorance, war, famine, environmental degradation, lack of medical care generally, and an endless list of maladies. The fact that circumcised and uncircumcised alike suffer from very similar rates of HIV in Africa contradicts in the macro sense the conclusions of the circumcision studies. The fact that foreskinned men in intact rich nations suffer much less from HIV infection than the circumcised in circumcised rich nations, i.e. The United States, underscores the contradiction. Proxy consent cannot apply where less invasive and more effective steps have been neglected or left unimplemented and untried. Male circumcision as public policy is implicitly an acknowledgment of failure to address root causes.

Notebook: The real targets of the linking of HIV/AIDS and circumcision

I have said in the past that the sudden upsurge in interest and research in male circumcision as a prophylactic tool in HIV prevention has everything to do with lack of real progress in the area of vaccine research and political failure in rolling out the gold standards of prevention in highly impacted areas, namely sub-Saharan Africa.

That's a long sentence. But it neatly encapsulates the reason that the international community has accepted this research now when it has rejected the idea for the two and half decades since this disease's worldwide debut. Nevertheless, every push for circumcision in the history of the procedure has had ulterior motives underlying it, i.e. someone's or some group's agenda is served by it.

A confluence of factors has emerged in the last half decade or so to create the current state of affairs. Apart from the aforementioned failures of political (and humanitarian) commitment, it is no coincidence that America and Americans are principally behind this push, as they are behind nearly every overt ideological rooted movement of today, excepting religious movements. It is also no small coincidental matter that Americans are circumcised in the majority. How else could world organizations dominated by the United States, endorse a procedure that:

1. Has shown to be ineffective in real world settings;
2. Likely leads to greater HIV infection in young people [pdf];
3. Puts women at greater risk for infection;
4. Fails to address the most vulnerable, i.e. women; and
5. Ignores contrary evidence of the prophylactic properties of the foreskin itself [pdf]?

The fact is the practical problems with circumcision in Africa will greatly slow its adoption and likely portend harmful unintended consequences where it is adopted. Hence, I don't see Africa as the probable intended "beneficiary." The more likely goal, as in all politics, is not what it would at first appear.

The American circumcision rate has been falling for nearly two decades now. Perhaps the better question to ask is, Who is likely to be on the receiving end of this new push? Africans without resources or infrastructure to carry it out? Or Americans who may be scared back into conformity? I don't know. I'm just asking.

"What works best in HIV prevention globally?"

If you were wondering where male circumcision is going to land in this grand experiment, the following downloadable pdf document gives you some idea. It was prepared in January of this year, prior to the Ugandan and Kenyan studies, but after the South African study. It is provided by the UCSF Center for AIDS Prevention Studies.

The money quote relative to "generalized high-level epidemics," such as is seen in "some countries in  Sub-Saharan Africa (Botswana and Zimbabwe)":

...
Prevention efforts should focus on broadly based, population-level interventions that can mobilize an entire society. Prevention should include:

...

• implementing individual-level approaches to innovative mass strategies with accompanying evaluations of effectiveness
  
• using the mass media as a tool for mobilizing society and changing social norms

Download InternationalFS.pdf

Update

This post was prepared prior to today's release of the recommendation that male circumcision be "urgently" rolled out to the masses by the group of world health NGOs, the WHO and UNAIDS that met recently in Montreaux, Switzerland. The world implicitly recognizes its failure today and calls it "victory."

India walks a tightrope

Sometimes, you can sense a palpable nervousness in media reports from places where circumcision is not routinely practiced. Part of it is a religious or historical aversion that goes to longstanding issues of communal identity. The best example of this would seem to be Hindus in India.

The article that follows walks a tightrope between acknowledging the difficulty of reconciling a longstanding denial of the practice and trying to be current (some would say, hip) with the world. The Western proponents of circumcision clearly have basked in the sunlight of this HIV prevention strategy du jour. However, India and all the world are right to be nervous when such mixing of science and advocacy occurs.

Article after the click-through.

A valuable critique of the Auvert study

The first study by Auvert et al. viz. HIV/AIDS and circumcision was roundly criticized for its overstated conclusions. A perhaps not widely circulated critique appeared in the same online journal that published the Auvert study. It is an enlightening and sobering read that brings the hype back down to Earth. It's provided in pdf format for download here.

Download the_Garenne_reply_2006.pdf

THANK YOU again to George Hill for providing the pdf file.

Maligned Langerhans cells may prove invaluable

The much maligned Langerhans cells, as noted in an earlier post, appear to act as a "natural barrier" to HIV. The study, downloadable below, flies in the face of much speculation without evidence that these same cells were the vector for HIV infection through the foreskin during sexual intercourse.

Does anyone else see the circumcision push as some grand experiment, akin to any other PR campaign, on a relatively powerless population? It is not implausible that as more studies come to the fore, the real explanation for a higher infection rate in intact men will turn out to be merely coincidental and the lower rate in circumcised men attributable to socio-cultural or other factors.

Download de_Witte_Study_2007.pdf

THANK YOU to George Hill for providing the pdf file.

Colonialism of circumcision?

In the following article, a skeptic lays down the controversy. We begin the fair-use article before the jump ...

Circumcision Fight: Profit, Pleasure, or Population Control?

If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy

“It is important that, while circumcision interventions are being planned, several points must be considered carefully. If the experiment fails, Africans are likely to feel abused and exploited by scientists who recommended the circumcision policy. In a region highly sensitive to previous colonial exploitation and suspicious of the biological warfare origin of the virus, failure of circumcision is likely to be a big issue. Those recommending it should know how to handle the political implications.” - James P.M. Ntozi.

Using circumcision to prevent HIV infection in sub-Saharan Africa

African people worldwide know about experimentation in the name of scientific advancement.  However, often-vital information goes without mention and the outcome devastates the victim as in the case with the Tuskegee Syphilis Experiment  in Alabama, USA.  This is precisely why suspicion remains around HIV\AIDS reduction experiments, but with little investigative attention by the corporate media groups.

Circumcision apparently spreads HIV/AIDS

This important article was published a few weeks back. Sorry I'm just now getting around to posting it.

The article speaks for itself and demonstrates the major obstacles in introducing circumcision in a developing country. As important is the issue it raises concerning circumcision in countries where the procedure is a cultural tradition.

IHT article after the break.