Male Circumcision and HIV

Gay men's HIV prevention 'falter[s]', JAMA misleads and ignores evidence viz male circumcision

A JAMA article highlighting the newly rising rates of HIV seroconversion in gay men ignored studies that rule out circumcision as an effective intervention, claiming the effectiveness is unknown. Aidsmap has caught it and pointed out Jaffe et al.'s ignorance. Inevitable conclusion: American researchers and commentators simply can't be trusted anymore require heightened vigilance to determine biases on issues of prevention, particularly the weight given to the relative value of new prevention technologies.

Link: Aidsmap | Gay men's HIV prevention in the US and Europe is 'faltering'.

Edit: And this just in, a cross sectional survey of black and Latino men in three US cities presented "no evidence that being circumcised was protective against HIV infection among black MSM* or Latino MSM. ... Further, circumcision was not associated with a reduced likelihood of HIV infection among men who had engaged in unprotected insertive and not unprotected receptive anal sex." Link is to the abstract. If anyone has a pdf copy for the pdf library, please forward it to me. Thanks.

Hat tip to Hugh on the Intactivist Pages for the heads up.

*Men who have sex with men.

And now this contradiction from China: Health Minister Chen Zhu says HIV slowing, China may consider circumcision in HIV fight

I have always thought that East Asia with its strong emphasis on modernizing and catching up with the West, primarily the United States, would be vulnerable to circumcision campaigns. Witness South Korea, for instance. Now with HIV/AIDS as an excuse (and a vector) for cultural practices, it could take off there. It's a rather confounding development because sexual mutilation intuitively should find resistance where it has been absent. The biggest irony? The spread of HIV is slowing, and yet the health minister cites this as a reason to consider circumcision.

Link: China AIDS rate slows, main transmission now sex - Yahoo! News.

Fair use Reuters article after the break.

China reports sharp drop in HIV cases - Yahoo! News

Experts have said the figures are probably accurate because they are in line with a change in the way data are collected.
...
Previous estimates were largely inflated and the new numbers are the result of a different methodology, which show that the AIDS pandemic is losing momentum.

It is hard to internalize the meaning of this development. The numbers have come down from nearly a million estimated HIV infected individuals to 223,501 individuals in a country of nearly a billion and a half. How do we reconcile the theories and beliefs of the circumcisionists with the reality of this intact nation? I don't think that we can. The reality is that HIV and its spread is a socially derived problem rather than one of biology. We don't breathe it in. Nor do we pick it up from unwashed food or unsterile surfaces. We get it from the most intimate contact, whether that be through sex or sharing objects that commingle our blood. It's sociology and the way we arrange our societies that will determine the course of this disease.

Edit: More detailed reports say that the suspected number of HIV infections probably stand around 700,000 rather than the number quoted above. The 223,501 are the confirmed cases.

Link: China reports sharp drop in HIV cases - Yahoo! News.

Full AP story below the fold.

Study finds no protective effect in gay men from circumcision, so why are the authors still promoting it?

The stock response in the last two decades to the realization that circumcision has little to no value in public health and can be demonstrated to harm newborn males as well as adult sexuality has been to repeat old saws that it's cleaner, all the kids are circumcised, and that it's "healthier" in some as yet undiscovered way. And so Zohar Mor, Charlotte K. Kent, Robert P. Kohn, and Jeffrey D. Klausner have dressed up nothing to look like something to reinforce the point in the misleadingly entitled article Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit. The only thing to recommend their nothing-new-to-report [pdf] article is that they conclude:

Our findings, showing no significant differences between circumcision status and the risk of HIV or syphilis infection, are consistent with the importance of non-penile, rectal acquisition of those infections (or oral infection in syphilis) among gay men in the U.S. [22], rather than penile acquisition as in heterosexual intercourse, during which the foreskin may be exposed to HIV infection. Because large proportions of gay men practice both insertive and receptive anal intercourse [23], the ability to differentiate between different risks for HIV infection associated with sexual practices versus circumcision status is limited.

So there you have the real take home point: penile acquisition of HIV is but one method of acquisition among the highest risk group in the United States that cannot be separated out from other methods of acquisition. And hence, no value is realized from circumcision due to the diversity of sexual behaviors among men who have sex with men. This is wholly consistent with the study presented in Sydney, Australia at the International AIDS Society conference earlier this year. Due to the low prevalence of HIV among American heterosexuals this conclusion effectively pulls the rug out from under the prime justification remaining for routine circumcision in the United States, i.e. disease control.

So why do these authors dress up truths as lies by continuing to advocate circumcision? Only they know for sure. But the public needs to be aware of these junk scientists' intentions, which may be neatly summarized in their own words:

In conclusion, while a majority of men attending the San Francisco STD clinic were circumcised, there were large and steady declines in circumcision across all racial/ethnic groups since 1960. There were significant differences by racial/ethnic groups suggesting important socio-cultural factors related to decisions to circumcise newborn males. Given the recent evidence demonstrating the substantial potential public health benefit of male circumcision [refuted a few short paragraphs before] and our observed declines in circumcision rates, national organizations that promote circumcision policy should review current practice guidelines in responding to those trends.

Direct your comments to: Jeff.Klausner@sfdph.org; zmor@sph.emory.edu

Zimbabwe nothwithstanding 'voluntary testing and counseling' does have an effect

Aidsmap | Study finally backs up conventional wisdom: VCT does reduce risky sex

A study out of Zimbabwe recently provided much fodder for the proponents of circumcision who have staked the value of circumcision on the ineffectiveness of voluntary testing and counseling (VCT) in lowering HIV infection rates. But as is often the case with the claims used to support circumcision as prophylactic, contrary evidence is showing up to blunt their argument.

Link: Aidsmap | Study finally backs up conventional wisdom: VCT does reduce risky sex.

Notebook: Dallas Edition

Once again, getting out of town has provided me with the chance to jot down some ideas on recent news. This time, we're in Dallas, Texas.

The Numbers

In the early days of the AIDS epidemic in the United States gay men were emerging from not years or decades, but centuries of discrimination and persecution. AIDS was often cited by scary religious types  as devine retribution, or in the secular understanding, as a "natural" outcome of "unnatural" sexual behavior. In this environment, it's not hard to understand the urge to exaggerate the numbers. The argument that this isn't just us (gay men), but could in short order be you (heterosexuals) has a certain power.

Today, however, this tactic has resulted in the long established and accepted belief, largely supported by the obvious truth it carries in Africa, that the disease is biding its time before it races through the general population. But Africa is a very special case where multiple concurrent partnerships are responsible for the widespread dissimination of the virus. Yet still better data and a greater understanding of the whys and wherefores of dissimination at the population level is only now working its way into the popular understanding of HIV/AIDS.

And so once again, after first being noted in India, the numbers are being revised downward [Yahoo! link may expire] worldwide by the large AIDS organizations. What does it mean to revise downward the number of people living with this disease? First and foremost, it means a re-prioritization of health needs and the resources allocated thereto. In the pantheon of preventable diseases, cancer and heart disease kill more people than HIV. And emerging threats, such as MRSA, are proliferating in the United States and abroad, and also apparently kill more people than AIDS.

[Edit: Hugh over on the Intactivism Pages points out the very important fact that lower numbers throw the circumcision/HIV mathematical models into very grave doubt.]

"Territorial Jealousy"

In a related AFP article, a global lung health conference taking place in South Africa reports that  organizations working on different diseases compete -- and not in a good way. The astounding idea that two groups working on public health issues would exhibit "a lack of mutual trust and territorial jealousy" is really hard for me to take in. But a quick reflection on the driver of any public health campaign, i.e. resources aka money, in a place of dire poverty doesn't seem so astounding after all. Enter the circumcisers.

Within a given disease, differing approaches clearly compete for the available resources. The mad scram for money exists wherever there's ... well, money. That is to say, also in healthcare, public health policy making and implementation, wherever ... . Circumcision without regard to its appropriateness or effectiveness may be developing into just one more offering in the school cafeteria of HIV/AIDS.

Stem cell from foreskins

Yesterday, National Public Radio in the Untied States reported that stem cells can be created by introducing only four specific genes into a skin cell using a virus as a vehicle. The scientists tell us  that this is extraordinary because "from the foreskin of a newborn child" we can make limitless numbers of stem cells for actual practical applications for disease control and cures. Yes, they said that. Let it be known that another market may be developing to continue driving gratuitous circumcisions of unconsenting infants. From one speculative ethical issue, i.e. embryonic stem cells, to a well-established ethical issue, i.e. circumcisions without consent, a morally confused America meanders.

Now, the inevitable question is: Can they take a skin cell from an infant foreskin, make a stem cell, and then grow a new foreskin for restorers? And would conscientious restorers accept such a restoration in light of the ethical problems? Fortunately, the skin cell likely can come from other areas of the body.

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Is female circumcision really a risk factor for HIV?

Opponents of female circumcision make the case that it is a risk factor for contracting HIV. But is it? In fact, at least some research draws the opposite conclusion. But is that a reason to tolerate it? The answer is absolutely not.

It is hard to quibble with any arguments that cast female circumcision in the worst possible light. Yet it is also hard to take statements that do not acknowledge the parallels between female and male circumcision [pdf]. The article below the fold asserts some unfortunate claims that aren't likely to help the cause to wipe out the practice of either mutilation.

Full critique in red below the fold.

US STIs at all time high

Wow! You wouldn't expect this in a majority circumcised society ... or would you?

Real world versus theory? The real world isn't conforming to the theory of the proponents of circumcision, and is unlikely to do so in Africa, either.

Fair use AP article below the fold.

A word about fundraising on MC & HIV

In the last two months, I have received three contributions to the Tip Jar. First, thanks guys. Now for an important word on fundraising.

As of this post, no money has been withdrawn from the Paypal account in which all funds contributed are deposited. I have taken the step of enrolling in Paypal's money market fund in order to maximize the value of each person's contribution. I do not intend on withdrawing any of the money for the expenses of running this blog. I will continue to pay Typepad subscription fees, Google Adword fees, and any other expenses out of my own pocket. Any tax consequences of my collecting this money and retaining custody of the funds will be borne entirely by me.

This site can serve as both a point of dissemination and a flatform for fundraising. Of course, contributions are not tax deductible and I have taken no steps in that direction yet. Some who read this blog may remember that pledges were asked for at the Ninth International Symposium on Circumcision and Genital Integrity in Seattle, in August of 2006. If that effort ever gets off the ground, I will consider channeling the funds collected here to that fund. Meanwhile, I will be exploring the possibility of setting up an independent non-profit charity.

If and when such a charity is set up, I will let everyone know and encourage everyone to give what each can afford. Rest assured that any org set up for the purposes of doing the work we do will be transparent and governed by a board of directors with oversight capacity and the power to choose suitable projects and individuals to support.

Thanks again for reading, supporting, and taking a stand.