Male Circumcision and HIV

Male circumcision as subjugation of women

Cultural beliefs that women are inferior to men are spurring the rapid spread of HIV in Swaziland and Botswana, the countries most affected by AIDS, according to a report released Monday.

...

Women subsequently ha[ve] no control over sexual decisions, including using a condom, and fear testing positive w[ill] jeapordise their relationships and lead to them being stigmatised and shunned by society.

African women have it hard enough. Do we really want to put more power in the hands of men than they already have? By circumcising men, Westerners, in colonial fashion, will empower and embolden them to make unjustifiable claims in the safer sex negotiating process. Male circumcision will make women more vulnerable by undermining what little negotiating leverage they are struggling to hang onto.

Read the fair use AFP story, next page.

Male circumcision first, doctors and nurses second (or not at all): talk about the cart before the horse!

While the press is running around in circles trumpeting male circumcision as the breakthrough we've been waiting for, Africa goes on bleeding. Mark Dybul, the Global AIDS Coordinator for the US Department of State, has remarked that it takes some 200 circumcisions before a practitioner can be let loose to perform them unsupervised with reliable results. Meanwhile, the WHO and UNAIDS have endorsed the procedure and suggested affected high HIV prevalence countries take it up. And now we get further reports that Africa is "hemorrhaging" doctors and nurses and thereby exacerbating the HIV/AIDS epidemic. Talk about putting the cart before the horse!

The unspeakable truth that nobody wants to discuss is that the circumcision trials were all about American researchers justifying their existence and perpetuating male circumcision in the United States at a time of its decline here rather than about Africa's fight against HIV/AIDS. Given the choice between lifesaving condoms and male circumcision from inexperienced, overworked, sick medical staff who may not be doctors PLUS lifesaving condoms, any sane person (which Africans are implicitly not so considered) would choose the condoms and forgo the circumcision.

It's politics as usual.

Download the Healthcare_Worker_Report_05-2007.pdf. Read the IRIN story, next page.

Zimbabwe in meltdown

As far as I know Zimbabwe has not embraced male circumcision or the findings of the WHO and UNAIDS on the procedure to prevent reduce the risk of HIV/AIDS infection. If events in that country continue along the current path, it is unlikely it will do so anytime soon. Good news for the men of that country, bad news for the country as a whole because other proven and effective prevention measures will also be ignored.

Zimbabwe is in crisis. Its gay-baiting and confiscatory leadership has mishandled problem after problem. In a climate like this, HIV/AIDS has slid far down the list of priorities behind feeding one's family and maintaining a steady supply of fuel, which is now necessary due to electricity rationing. Even before, President Mugabe paid little attention to the epidemic, blaming the disease variously on the West, "degenerates," and drug abusers. In such a climate, the only hope from the West is to concentrate the focus firmly on ensuring a supply of condoms (at an affordable current price of 3 cents a piece) and providing information.

The Economist reports after the jump ...

Rewriting Ask InSite's answers to take out the anti-foreskin bias

[Ask InSite is a feature of the University of California San Francisco's HIV InSite. The site touts itself as  providing "Comprehensive, up-to-date information on HIV/AIDS treatment, prevention, and policy from the University of California San Francisco." And in nearly every sense, it does just that. I have a lot of respect for HIV InSite's tireless work in the HIV/AIDS research and public information arena. But sometimes the site gets it wrong. The authors have a lot of ground to cover and sometimes they go with the flow instead of critically reviewing the evidence. So with that, here's my rewrite of a recent question to Ask InSite.]

Blood on My Penis: Was I exposed to HIV?

May 11, 2007

Answered by Mark Vogel, MA, HIV InSite Prevention Editor, anti-foreskin bias corrected by David Wilton, Blog Editor, Male Circumcision and HIV

Question

One month ago, I had protected sex with my girlfriend, who has some experience as a sex worker. When removing the condom, I must have touched my penis rim accidentally. I saw stains of blood on my penis. I wiped off the blood with a tissue immediately. I had no bruise at all. I was disturbed, but my girlfriend told me that she has not had sex without a condom for the past 4 years and she always carries condoms whenever she is working. She has also taken several tests before and after our encounter because of the nature of her work. She has always tested negative. She is ready to take another test. My worry is whether I was exposed to HIV. I am really worried because I have a wife.

Answer

This sounds low risk: you used a condom during the encounter, and your girlfriend sounds as though she is very careful to use condoms during her other sexual encounters. Theoretically, if your penis came into contact with blood, it is possible that you were exposed to HIV. Blood can enter the penis in one of two several ways: through the foreskin a cut or abrasion on your penis or through the urethra. Intact Uncircumcised men have an abundance of Langerhans cells in their foreskins that are known to "eat up" HIV. Where there are no cuts or abrasions, this may provide greater protection than if you are circumcised because circumcised men lack the abundance of Langerhans cells that intact men have and, it is believed, are prone to greater epithelial trauma due to the lack of movable skin. are more at risk because HIV can enter the body through cells on the foreskin. The reports of circumcised men being at greater risk for HIV were limited to a specific set of circumstances in Africa and are probably limited to that setting. Blood can also enter through the urethra, but that’s a less likely entry point more difficult for HIV to enter the body this way. Having a sexually transmitted disease (STD) increases your risk of acquiring HIV as well. Nevertheless, from what you describe, it doesn’t sound like there was contact between her blood and the inside of your foreskin or urethra, where asymtomatic STDs can hide and provide a non-obvious opening or sore. Washing immediately after sex also greatly decreases your chances of being exposed. You stated you wiped the blood off immediately, which likely provided similar protection to washing.

If you are still concerned, the best thing to do is get tested. Get tested now to rule out possible existing HIV infection, then again after 1 month (by which point many people produce the antibodies that HIV tests detect) and again at 3 months (the point at which nearly everyone produces antibodies to HIV). You might find some comfort if your girlfriend’s test result comes back negative. If she is, indeed, negative there is no chance of HIV transmission from her to you. That said, it’s generally a bad idea to determine your own HIV status based on that of your sexual partners.

[Editor's Note: Strike-throughs and italics are editor's corrections.]

AVAC goes off the rails (and off message)

It is now clear that normally sober public policy organizations are vulnerable to veering into the area of propaganda and thoughtless advocacy usually only seen in the ideologically driven arena of abstinence and "be faithful" schools of HIV/AIDS prevention. One such group, among several, is the AIDS Vaccine Advocacy Coalition. It has gone off the rails (and off message) with its uncritical embrace of male circumcision. They have accepted it as the vaccine they have been hoping for. More reasonable researchers know it is no such thing.

I was intending to do a critical report on their advocacy sheets. However, I have decided that the time and effort would be better spent in focusing on broader policy issues that have a real chance of affecting the epidemic in a reasonable amount of time rather than in two or three decades (if at all). I will come back to them if the need arises. However, I believe that the only way to counter the nonsense such orgs spout is to  join those orgs and work to get another point of view incorporated into their message. Any volunteers?

One interesting article on the broader policy issues I have come across recently was a review on the recent book, The Invisible Cure: Africa, The West, and the Fight Against AIDS. Helen Epstein has been a researcher, activist, and reporter on the AIDS story in Africa since she first visited the continent in 1993. Her sober assessment is that western aid organizations have made things worse by assuming they know better than the societies they have rushed in to "rescue." Her overriding theme is that the hardest hit communities have come up with strategies and approaches to combat HIV only to find themselves undermined by western aid agencies who have placed conditions on funding, introduced ideas that work against the native cultures, and frankly made African misery a vehicle for careerism.

Unfortunately, she gets the circumcision issue utterly wrong, saying that west east Africa practiced circumcision until colonialism was introduced. Her point is that native circumcision practices were a barrier to HIV that was destroyed by early western intervention. She's wrong. In fact, west east Africa did not circumcise prior to colonialism. It is colonialism that is about to introduce it. AIDS activist colonialism, which she opposes.

Americans just can't help themselves. Ms. Epstein is no exception in this regard. We are imbued with the abusive practice of circumcision and cannot separate ourselves from our cultural clinging to hurtful acts. It is a cultural legacy much like racism is a cultural legacy. Americans suffer from tertiary stage hubris in so many areas. It should not be surprising we suffer it in this most personal of areas. The abused carry on the habit they have inherited, ever finding excuses to ignore the harm by insisting on its necessity or benefit. Ms. Epstein's treatment is short, but it mars an otherwise interesting book.

My own full review will be forthcoming. Meanwhile, Salon.com's review after the break.

Council on Foreign Relations Takes Up Male Circumcision and HIV

It's not often two areas of great interest to me come together. It happened on May 7, 2007, when the Council on Foreign Relations took up the issue of male circumcision and HIV. The Council presented a program entitled, "Is Male Circumcision the Key to Stopping the AIDS Epidemic?" that primarily focused on Africa with Dr. Thomas Friedan of the New York Health Department and Mark Dybul, the Global AIDS Coordinator for the US Department of State.

This was a fascinating presentation for several reasons.

First, the panel discussion showcased the confusion that the dual, contradictory messages that 1) circumcision protects and 2) safe(r) sex practices must still be adhered to, presents even to an educated audience. The discussion clearly had a few essential take-away points, which I will get to in a minute, but let me talk about the second reason it was fascinating.

Mark Dybul gave the impression to the audience, as evidenced by the questions that followed, that male circumcision was not a "silver bullet" by any means -- or even very much worth the probable confusion and message dilution it could produce. But he then proceeds to ... what's the word? Reassure the audience that the US government (PEPFAR) and the HIV/AIDS community are on board with it. Dr. Frieden was late (stuck in traffic) and didn't add much worthwhile to the over all discussion. When he did speak, he focused on New York City's situation, and the controversy viz. application to gay sex.

These are the points that made Dybul sound skeptical.

1. This is not a vaccine and will not provide the prevention of a vaccine. Hence, there will be nowhere near the widely disseminated 50-60% protective effect that the studies' authors claimed. Rather, perhaps a 20-30% effect over 20-30 years could be expected.

2. Other prevention technologies believed to possess great promise have disappointed. Dybul said that the herpes suppression medication Acyclovir hasn't changed the transmission rates "much at all" in ongoing clinical trials. Genital herpes and other ulcerative diseases and conditions greatly increase the level of HIV transmission. The implications for male circumcision are huge, particularly since the trials were stopped short of completion -- which he mentioned -- and the foreskin has been blamed for harboring ulcerative conditions to explain the protective effect of circumcision.

3. Disinhibiting behavior can overcome any protective effect. An increase in sexual partners can overcome any protective effect as well. There is some evidence that men who are coming in for circumcision are doing so because they think "they can't get infected." He went to great pains to stress this and spent considerable time talking about the other methods and their importance. He even discussed the successes of the proven prevention techniques in the absence of male circumcision. Most importantly along these lines, he said that male circumcision could undo progress in the area of gender equality, which is an area that has helped in reducing HIV transmission. One could be forgiven for wondering why circumcision is even being considered as it would appear to muddy the waters both in terms of delivering the over all prevention message and in getting men to adhere to it.

4. Convincing men to get circumcised is proving more difficult than anticipated. Apparently, male circumcision is not proving to be as popular as the proponents believed it would be. And the positive numbers depend a great deal on its reach. And this is where the audience questions prompted a discussion on the encouragement and introduction of infant circumcision as a more "acceptable" method of introduction, which is a very disturbing and possible direction this thing could take if men don't take it up in great enough numbers.

Mark Dybul mentioned something else that I have so far not heard yet in the mainstream discussions: numbers needed to treat. He mentioned that the procedure has to be targeted to be most effective. He didn't quite say "cost effective." But that message was implicit.

I would conclude that much of the world will have these concerns, and more, if (likely) circumcised American officials are having them. I was disappointed in the failure to address (truly) informed consent in light of the recent studies on the effects of male circumcision, and especially that the issue of infant circumcision reared its ugly head.

A small confession is in order here. I read the transcript and have not listened to the complete presentation. Time constraints ... If readers detect something in the video that comes across at odds with my assessment, please note it in the comments. Thank you.

Here is a link to the transcript.

See the presentation on the Council for Foreign Relations' website.

You can also listen to the audio in mp3 format.

Or see it below:

Early, consistent treatment followed by a new class of drug could cure HIV

I used to think a series of three shots to the abdomen to treat rabies after a wild animal bite was extreme. But this treatment, if it works, would be rabies treatment hell-on-wheels.

Dr. Anthony Fauci, Director of the NIH, recently co-authored a paper published in the Journal of Infectious Disease that appeared to show eight years of treatment when begun early followed by a new class of drug at very high levels could result in a cure. That's right. A cure.

So much focus has been on prevention by way of a vaccine that it has hardly occurred to most in the last 10 to 15 years that a cure would ever be possible. Still, eight years followed by what is likely to be an unpleasant level of dosing is not an easy way out. Moreover, the treatment only contemplates a narrow class of individuals.

Yet, this is better for the narrow group it might work for than a lifetime of drugs, but less preferred than preventing infection altogether. Therefore, don't expect the hoped for results from the coming trials to take male circumcision off the table.

Bloomberg News article, next page.

Notebook: Influencing the Discussion on Male Circumcision and HIV

In order to effectively slow down the roll out of male circumcision, it will be necessary to determine a set of crucial points of discussion. The damage that male circumcision causes is gaining a wider audience [see posts from 4/30, 5/2, and 5/3]. Also, Its relation to female circumcision has been widely discussed and compared. These two points are the key offsets to the gain or perceived gain from its implementation in communities that do not accept or practice it.

Policies are being formulated for male circumcision to take its place among the prophylactic tools currently available. It is essential that the skeptical members of the HIV/AIDS activist community offer a well thought out policy alternative. One way of doing this is to look at the proposed policies and build from them to incorporate the concerns of individuals concerned about the ethics and wisdom of removing tissue as a prophylactic measure.

A couple of crucial first points

1. The advocate HIV/AIDS organizations and individuals have been careful to state that male circumcision must not replace or displace current prevention tools. From a practical standpoint, the existing tools have not been fully implemented anywhere, except in the most developed countries. Therefore, it is inevitable that from a limited source of funding and human capital, resources will be taken away from testing, education, condoms, and even advocacy to get these highly effective existing tools in place.

2. The advocate HIV/AIDS organizations and individuals have been careful to repeat their stated belief that female circumcision bears no relation to male circumcision. They make the implicit assumption that male circumcision entails no physical cost to the individual either in sexual function or feedback of erogenous stimuli. This has been proven incorrect in two recent studies without question and in a third whose proper interpretation does not contradict and in fact supports from a different direction the conclusions of the first two. The repeated need to stress and point out the belief that female circumcision is qualitatively different rather than different only in degree demonstrates that a natural comparison inevitably flows from any discussion of surgery on human genitals.

The advocates of circumcision know that a skeptical constituency is out there. They are aware of the long-term opposition that male circumcision has enjoyed in the United States. Their likely (and stated) response will be to move quickly with the resources available to the HIV/AIDS community to put male circumcision in place before significant opposition can develop.

Once in place, male circumcision will take on a meaning independent of its original rationale. Overturning it then will be significantly more difficult than preventing it now. Whether the advocate organizations or individuals know this is unclear. That it is true is borne out by a century of gratuitous circumcision in the United States, half a century of it in South Korea, and the persistent myths of the benefits of the practice in countries where it is not in widespread practice.

The AIDS Vaccine Advocacy Coalition has put out a "special publication" entitled A New Way to Protect Against HIV? Understanding the Results of Male Circumcision Studies for HIV Prevention. It is an advocacy publication (propagandistic) aimed directly at convincing policy makers to begin pushing male circumcision. The next post on Male Circumcision and HIV will be a critique of this pamphlet with suggestions for inserting the ethical concerns that the proponents disregard.

Notebook: Circumcision will be implemented, what now?

The debate over circumcision is moving, indeed has moved, towards how, not whether, to implement the procedure. The HIV/AIDS research and advocacy community is a powerful force when it comes to rolling out mandates, particularly mandates it sets for itself.

Activists concerned with male circumcision, particularly it's use and misuse in the United States and other English-speaking countries, cannot afford to work as before, in virtual isolation, through self-organized, single issue groups and organizations. If said activists choose to continue in the old way, their views will be marginalized and ultimately fail to have a vital influence in how this is going to happen.

I urge the leaders in the so-called "intactivist" community to formulate a plan to join the major HIV/AIDS organizations and give voice within these groups to their ethical and scientific concerns. I would suggest that activists go local and put their time, effort, and money into these groups to gain a voice. It won't be enough to simply show up at functions, fund-raisers, and gatherings with pamphlets, signs, and slogans.

Rather it will be necessary to show a genuine interest in abating the HIV/AIDS threat. This means understanding the bigger picture, the developing epidemic, and the desperation that has allowed male circumcision to gain a toehold now after 25 years of this disease. Most importantly, activists will have to offer an alternative to this approach. This means formulating a policy regarding HIV/AIDS, which is now more than a mere disease. It is a social phenomenon as much as a scientific and medical problem, with its own momentum, logic, and mores.

Male circumcision's decline in the United States has largely been a development of increased awareness of children's rights, a greater skepticism towards all professionals', not least doctors', unsubstantiated opinions, and a cultural phenomenon of looking askance at unquestioning conformity of all kinds. No countervailing force has existed to any degree except inertia.

Activists now have the full force and funding of the HIV/AIDS community against them -- or at least moving against them at an angle -- whose power was borne of a rebellion against prejudice, indifference, and outright disdain for those most affected by the disease. To oppose male circumcision outside the context of HIV/AIDS organizations could easily be seen as embracing these quite rightly rejected social realities.

No one knows how this will play out. There are many, many social and scientific problems in the world with the power to impact the course of the disease and "male genital mutilation." From climate change to economic problems, peak oil to unpredictable wars of choice: all have the power to send events in unpredictable directions. However, when the vaccine initiatives get involved in male circumcision instead of vaccines, you know where we're headed. I'll have a post on that issue later this week.

Notebook: The Military Industrial Complex School of Development

In the waning days of the cold war when the Berlin Wall was about to fall and the "velvet revolutions" of eastern Europe were confounding Western predictions of a continued multi-generational stand off between the communists block and the Western world, defense contractors were in a panic. Talk about a "peace dividend" was beginning to percolate up in the public discourse. The idea bouncing around the dizzy heads of academics, politicians, and the punditry of the day, was that massive defense budgets and far-flung outposts and the fear that another Vietnam could be foisted upon us at a time or place not of our choosing could all fall by the wayside and make way for investments in neglected inner city schools, health care, and infrastructure of all types.

The defense contractors may have been in a panic, but they were not back on their heels for long. They came up with an argument. The argument depended on an old idea, dating from the age of rapid technological innovation of the 1950s and before. The nutshell version of the argument went like this: a billion dollars spent on weapons research will produce untold and as-yet unimagined gadgets and technologies for civilian use, and thereby justifies otherwise unjustifiable expenditures. Basically, they said to the US government, "You must fund weapons systems because they advance research and development that would not otherwise advance." In essence, their argument was a pitch for socialism. Private industry won't do the research. "So we must. And along the way, we'll come up with some pretty fantastic new guns and aircraft, too."

In a system where conflicts of interest are rife and making guns pays better than making butter, the  counter-argument never had a chance: whatever civilian gadget the military spun off would cost a fraction of that billion dollars to develop alone.

Circumcision is just like that. This article, which I will not reproduce here, tries to convince that circumcision is a good thing, not solely because it will allegedly save people from HIV infection, but also because it will drive development of infrastructure. And said infrastructure will yield dividends in strengthening health systems and disseminating education on the epidemic. In essence, the greater the demand for circumcisions, the more clinics and trained personnel there will be. And hence, the myriad other services clinics and trained personnel can provide, will be provided. Circumcision is the vehicle for development.

The disturbing part of all this is that the new infrastructure will be used to provide prevention strategies that actually work, raising the general healthfulness of all. But the circumcision campaign will get all the credit and perpetuate on cultural grounds. And here's the problem: there is no way that once the cultural meme for circumcision gets rooted in society that any discussion of ethical issues will be able to control it. Ethical violations in the form of uninformed consent, enforced conformity, and social pressure to submit, will beget further ethical violations.

And so it goes, long into the future without regard to the trend of HIV/AIDS. The end of the epidemic will leave this destruction in its wake as well.