Male Circumcision and HIV

Notebook: Rising food costs, the tanking dollar, sexual behavior in multiples, and PrEP, like condoms, may be a true pillar of AIDS prevention

The New York Times reports that American food aid to Africa is in a pinch due to rising costs. The reasons are varied. However, the primary reasons are a higher demand for food stocks for ethanol and higher transportation and logistical costs. Food aid purchases (as opposed to total allocations) fell from $105 million to $70 million between 2002 and 2006.

Implicitly, the tanking US dollar, which hit a record low against the Euro this week at $1.41 plus, can't be helping. And the dollar's problems are in some ways related to the energy issues, tying this all up in a nice little bow.

The article makes the observation that food aid has never been as altruistic an endeavor as one would hope. A solution to higher demand for US corn crops for ethanol production could be buying these same crops elsewhere where production costs are less. However, the article quotes an American ship owner representative, Gloria Tosi,  who suggested "buying commodities abroad would erode domestic political support for the program and lead to lower food aid budgets from Congress. She said it was 'politically naïve' to think the food commodity groups and ship owners that have for decades supported food aid in Congress would favor buying commodities abroad."

Clearly, one lesson seems to be that acts of charity don't happen on their own. They happen when interests coalesce and business or careers advance. This obviously implicates the bit of luck necessary in just about everything. Still, individual efforts are valuable and necessary if anyone feels like throwing up his or her hands on the circumcision issue.

The dollar

In the last few weeks, the US dollar has hit parity with the Canadian dollar for the first time since the 1960s and reached a new low against the Euro, having lost fully 69% of its value against that currency since 2001. This is extraordinary on a number of levels. First for the issues this blog is concerned with, the dollar's buying power is clearly being eroded across all currencies, although not at the same rate. For example, the Thai baht is fetching 25% more now than it did a few years ago. Circumcisions are therefore escalating in cost, for what it's worth.

Never underestimate the power of unexpected forces to change the calculus in this game.

Gay Sex: three times more potent than straight sex

A recent study has demonstrated that heterosexuals require up to three times more unprotected sexual encounters to reach the levels of infection of gay men. Not sure of the implications here, but it seems this is not so difficult to explain. Gay men may adopt both passive and insertive roles in intercourse. Heterosexual vaginal intercourse is logically believed to be less conducive to HIV infection. As a percentage, more gay men than heterosexual pairings combine drug use and sexual encounters in the major urban centers of HIV prevalence, which has been identified as a risk factor.

Maybe the researchers that be should conduct some studies in sub-Saharan Africa to determine whether heterosexuals exhibit any extraordinary risk factors similar to that of gay men in the West, particularly the US, and that are decidedly absent in Western heterosexual pairings. That would explain super low rates of infection among the intact Europeans.

Condoms and a pill: a death blow to new HIV infection

In the last post, I talked a bit about a study that suggested that risk reduction strategies were much less effective on an individual basis than had been hoped for. Well, how about a new strategy with an effectiveness rate approaching that of condoms.

Animal studies have shown a 100% prophylactic effectiveness rate with two drugs, tenofovir and FTC (emtricitabine, Emtriva). Taken daily by HIV negative monkeys, not necessarily together, repeated exposure to HIV resulted in no new infections. That's pretty amazing. It would be the first and only female controlled method of prevention. Combined with the inevitable incomplete use of condoms and we may have a winner.

"Risk reduction" strategies no substitute for consistent condom use, study shows

Ok. Admittedly, condoms are themselves a form of risk reduction. But in my view, at a high 90% effectiveness rate, condoms function more like a vaccine. Ok. That's a bad comparison, too. But the point is that so-called risk reduction strategies, such as sero-sorting, only engaging in the insertive role, and choosing partners according to undetectable viral load, are hardly any protection at all in comparison.

So what of circumcision?

It seems more likely than not that circumcision falls in there with strategies most similar to choosing to engage in only the insertive role. A rather pure form of gambling.

While the message has been that risk reduction strategies (including male circumcision) may have some importance across populations, the researchers conclude that "risk reduction strategies seem to fail to prevent HIV infection on an individual level."

Why is this an important point? Because this is precisely the opposite message delivered by Bailey, Halperin and others concerning implementation of circumcision in the United States and other developed countries. How often have they said to the media that mass circumcision may not have value for low prevalence countries, but individually it could save your life?

It is becoming clearer that it has no value in developed countries as a risk reduction strategy either for whole societies or individuals.

Edit: And I might add this study reinforces an emerging picture supported by the Sydney study that showed circumcision was of no value in halting the spread of HIV among gay men.

Aidsmap article after the jump.

Quickpost: Rwanda, desperate and vulnerable, succumbs to circumcision hysteria; US promotes genital mutilation

Rwanda is the latest country to succumb to circumcision hysteria in the face of failed efforts at behavior modification, condom distribution, and international indifference to the poor implementation of ARV therapies.

The United States will provide funds to promote the genital mutilation even as its own rates fall.

Quickpost: Zambia, unprepared and undeterred

Hugh over on the Intactivism Pages provides a glimpse into an African debacle in the making in a critique of a news piece. The salient points are ham-fisted implementation that utterly misses the "in addition to" caveat of the UNAIDS and WHO recommendation on circumcision and the usual meddling in and muddling up by western NGOs.

Thanks to Joe in CA for a heads-up in the comments.

Notebook: Fade to brown, white boy

Salon.com has a curious article on the US elections entitled, "So long, white boy". The basic premise is that the candidates, particularly the Democratic candidates, haven't really depended on the quintessential white male voter to swing elections for two election cycles already. So why are they concerned with playing to a demographic that isn't in the driver's seat anymore? After all, one in five people in the United States doesn't even speak English in the home. And nobody believes that's because the United States has become a top destination for Germans and Swedes seeking economic advantage. As Thomas F. Schaller writes, with the white male demographic declining at about one percent a year, "Bubba is no longer a kingmaker."

Still, the white man has in recent history been a trend-setter where the loins are concerned. Or as sociologists who like to mix it up would put it, the white guy has occupied a master status by virtue of a history of domination that for various reasons, mostly happenstance, has become identified with skin color. Newer immigrants and non-whites have, not individually, but as a whole, followed his lead in circumcising their young, particularly after the first couple of generations in the white man's vernacular, "on these shores." This applies to Latino immigrants north of LA county and to Asians all over, but much sooner, like in many unfortunate cases, the moment they disembark.

I don't presume to know how the white man's decline will influence what junk guys carry around in their pants two decades from now. But I suspect that as varying groups take their place at the forefront of American culture, those who aren't, won't. Cut their young that is. Or at least we can hope if only to get through the night.

In all of my many conversations with Asian and Mexican men, I have never heard a circumcision aspirant convincingly tell me they wanted to be circumcised because it was "healthier." To a man, it was because there was some perceived social advantage to it. In a few cases, I hope I was successful in dissuasion by openly ridiculing such perceptions. "No matter how cut your dick is, you still won't be white." And fuck it, you shouldn't want to be. I happily relinquish whatever status I have if it means men keep it whole and wouldn't have it any other way.

More evidence that condom use a primary source of stable HIV incidence

HIV negative men who engage in high risk sexual behavior but who also engage in sero-sorting, or the practice of choosing partners of the same HIV status, sero-convert at much greater rates than men who use condoms as their primary method of prevention, so reports a new study from The Netherlands.

When I read this article, it occurred to me that both sero-sorting and condom use would provide much greater protection than either alone. But then I realized that if you are using condoms, at an effectiveness rate of around 99%, sero-sorting would yield a negligible gain. So ultimately, condoms are the answer and everything else is a distant second.

An echo of this phenomenon can easily be imagined in the case of circumcision. HIV negative men who depend on circumcision as a method of prevention will sero-convert at much greater rates than condom users. Obviously. Give them condoms and circumcision simply has no effect at all on sero-conversion rates. Wasn't this the problem with the circumcision/HIV studies?

At any rate, the point here is, given condoms or discussing and choosing partners based on HIV status or in many cases perceived status, condoms win the effectiveness race every time. Given condoms or circumcision, the choice is equally obvious. Circumcision posits a hopelessly confused and confusing message that will not work and sets the stage for "prevention" based on wishful thinking and denial, and ultimately a worse epidemic.

Aidsmap fair use article after the jump.

Obsessive Monitors, Rigorous Analysts, Gonzo Writers Needed

The interesting ideas are not always in the stories specifically about circumcision and HIV. Much can be gleaned at the crossroads between the prevailing currents and the backlash. That's what I have always believed.

People concerned with children's rights, human rights, bad science, personal agendas, and puritan pressures on freedom have much to contribute to this debate. Never again will circumcision blanket the educated masses. The cat is out of the bag. However, there will be battles won, skirmishes lost, and  a tugging to and fro.

That's where good ideas come in. Monitoring and analysis followed by compelling writing will keep the debate fresh. Humor and biting sarcasm wouldn't hurt either. Ranting is ok as long as it doesn't become just another tiresome diatribe.

Posting here once a day keeps us in the search engines, near the top of Digg and Technorati. Not posting regularly causes the stats to fall and our influence to wane. Not that we've got a lot of influence -- yet. The goal of this site is a post a day. Two if possible. And 100 RSS subscribers by the end of the year. To do that, we need more than one guy sitting in a SoMa apartment nights, after a long day roaming the San Francisco Hall of Justice, dreading checking the usual sites or email for fear of more bad news.

Nope. We need brave souls. A team of them actually. There is no blog out there covering this story with regularity. We are it. For now. So let's keep it going.

What You Need To Write Here

A broad curiosity about culture, sexuality, world events, public policy, human rights, children's rights, immigrant rights, yourself and others. An interest in HIV, first and foremost. This site is about circumcision, but it is first and foremost about HIV. HIV is the enemy. Circumcision is the bad policy, the weapon of the people who care less about HIV than they do about promoting their deep attachment to cutting. A literate but punchy writing style. A unique vocabulary. A unique viewpoint.

There are a number of people who have commented regularly here. You would be good candidates. If you want to post regularly, then let me know. We can set you up. I may contact you eventually. But it would be easier if you made your interest known. Intact and of parenting age are encouraged to apply.

Thanks and Ciao for Now.

Notebook: AIDS and The Shock Doctrine

Alfonso Cuarón, the Mexican director of such films as Children of Men and one of the Harry Potter movies, brings us this short film on Naomi Klein's Shock Doctrine. Politics aside, put the idea of circumcision in the context of a terrified Africa in the grip of what is to them a still mysterious and puzzling disease, and you'll have an understanding, for example, of how Luo tribesmen of Kenya in urgent need of an education in condom use could be tricked into accepting the chicanery of circumcision. The Shock Doctrine, indeed. [Yes, I like long  sentences.]

Is there anything condoms can't do? or, Condoms: Still number one prevention technology

From every direction, the scientific and social sciences communities have tried to explain how HIV has gotten such a death grip on sub-Saharan Africa. The most promising theories have been those of multiple concurrent sexual relationships and culturally tolerated cross or inter-generational sexual encounters. Of course, the theory of choice in the last year has been poisonous foreskins.

Double digit percentages of infection have so confounded the scientific (and largely closed) NGOs and social and health policy advocates that nearly anything has the potential to gain traction -- hence the current rage against poisonous foreskins. However, sober voices do percolate up from time to time.

One of the ideas that has gotten some testing has been the disruption of the above-mentioned concurrent partnerships. So-called "zero grazing" campaigns and discouraging the practice of taking "sugar daddies" among other outreach activities have been launched to convince people to reduce multiple sexual pairings. Such campaigns have had some success in Uganda -- despite the obvious economic necessity that has engendered such widespread practices.

Now a study has come out that shows that as much as the outreach activities appear promising, simple widespread distribution of condoms and information and encouragement of their proper use is more effective. Loosely translated, people are going to do what they have to do with whomever they have to do it. Condoms are the best intervention. At 3 cents a piece, a dollar a day per sexually active male provides well over 1,000 condoms per month. That's an ample supply by any measure.

Changing behavior? Circumcision? Providing people with condoms and knowledge? Condoms and knowledge arrested the epidemic among Western gay men. It can do the same in African countries, too. Sometimes the simplest answers are the most effective.

Fair use Aidsmap story below the fold.

Australian AIDS org says circumcision "has no role" in Australian context

The Australian Federation of AIDS Organisations has issued a briefing paper [html] with the telling headline, "Male circumcision has no role in the Australian AIDS epidemic."

Among the key points are:

• There is no demonstrated benefit of circumcision in men who have sex with men.
• Correct and consistent condom use, not circumcision, is the most effective means of reducing female-to-male transmission, and vice-versa.
• African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way.

The first point is a reiteration of a recent study from Sydney that showed circumcision provided no protection for gay men. The second point is clear from the statements and caveats issued from the circumcision studies organizers themselves. The third point is clear from the key contextual attribute of all three studies, that the protective effect is in heterosexual couples in only one direction.

A high impact, succinctly written poster presentation given at this years's International AIDS Society Conference is available here [large pdf] and is worth printing in color for outreach activities.

Download Circumcision07.pdf