Whose culture hurts the HIV/AIDS cause more? Ours or theirs?

Let's be realistic and brutally honest about Swaziland.

According to the Globe and Mail, a "toxic mix" of factors has fueled the country's HIV epidemic, including a highly virulent strain of the disease circulating among residents; a culture that "condones, even encourages" promiscuity and polygamy among men and denies women the right to negotiate condom use; a "limited economy" that relies on sending men to work in South Africa for long periods of time; and a "playboy" king with an "ever-expanding stable" of wives who has denied the magnitude of the problem, according to the Globe and Mail. In addition, the country's understaffed and underfunded health system could not treat people when the epidemic hit in the 1990s and, as a result, "achingly slow progress" has been achieved in delivering antiretroviral drugs to those in need, the Globe and Mail reports. The rates of new HIV cases have begun to decrease minimally among young people, but the rates remain stable or are increasing among people in their 30s. About one-third of people who need antiretrovirals are getting the drugs (Nolen, Globe and Mail, 12/22/07).

The fact is foreskins are the least of the country's problems and the pushers of circumcision in lieu of dealing with the real issues do nothing but displace the focus from where it should be and put lives at risk thereby.

Link: Global Challenges | HIV/AIDS Epidemic Affecting Swaziland's Population, Experts Say - Kaisernetwork.org.

Another country whose problems are so severe that they overwhelm efforts to provide relief in the short term is Zimbabwe.

Zimbabwe's health system is collapsing after a financial crisis in the country, causing an increase in AIDS-related deaths since the government in October 2006 stopped providing treatment to people newly diagnosed with HIV/AIDS, the Los Angeles Times reports (Dixon, Los Angeles Times, 12/30/07).

The country's efforts to increase access to antiretroviral drugs have been delayed by a shortage of foreign currency, which has increased poverty levels and raised inflation by 3,700%. More than 3,000 people die of AIDS-related illnesses weekly in the country, and 70% of hospital admissions in Zimbabwe are HIV/AIDS-related (Kaiser Daily HIV/AIDS Report, 10/29/07).

Link: Global Challenges | AIDS-Related Deaths in Zimbabwe Increasing as Health System Collapses, Los Angeles Times Reports - Kaisernetwork.org.

Development is the only solution to these countries' HIV crisis. And development realistically will only come from within when/if the underlying causes of corruption and cultural issues acting as a platform from which the disease spreads unchecked are addressed.

If you think for a moment about the above realities, you will eventually want to ask why anyone would focus on circumcision at all -- at least until these severe barriers preliminary to any prevention campaign are addressed.

The answer is probably a cultural one. American culture, the place from which this campaign originates, has more to do with it than any three problematic studies do. As usual, and in accordance with the observations of by now many, the West, particularly the United States, is following its own well-worn path in the crusade to save Africa from itself without understanding a thing about the place it seeks to help. Never mind that places like Lesotho and Swaziland, as just one example, share similar rates of HIV and economic pain while one is largely circumcised and the other is not.

The target here bears the appearance of being not just Africa, but America's own slipping rates of neonatal circumcision. Whether this is true or not is another matter, but the possibility cannot be discounted after the recent discussions at the CDC and among the vaccine initiatives' leadership.

The future is more chilling than ever and the politicization of HIV/AIDS has never been so far advanced and confused as it is at the beginning of 2008.

Comments

[SunkenShip]

Great post and as usual you're right on about the American circumcision campaigners ignoring the facts. As you point out, Lesotho and Swaziland both have rampant rates of HIV infection and yet, Lesotho is no stranger to circumcision.

Foreskins aren't the problem in terms of HIV infection, dangerous behavior is.

[anon]

Yes, there are myriad problems underlying the HIV epidemic but this just highlights the importance of using all proven methods possible to address the epidemic. And male circumcision is now a proven method - whether you like this or not.

By the way, only about 5% of men in Lesotho are circumcised (the self-reported circumcision prevalence of 48% in the DHS survey refers to the proportion of men who attend an initiation school, of whom only a minority are circumcised). In southern Africa, only Madagascar & Angola have high rates of circumcision - and these are the only two countries with relatively low HIV prevalence.

[Joe in CA]

"And male circumcision is now a proven method - whether you like this or not."

I'm sorry? Did I miss something?

For a moment there I could have sworn someone said that circumcision has been proven to prevent HIV.

If this is the case, then someone needs to inform the HIV virus that is causing the current epidemic in the United States, that scientists have proven that circumcised men cannot contract the virus, and that it must leave immediately.

Maybe the circumcised men that died of AIDS still had a little bit of foreskin left...

[Joe in CA]

The only proven method of HIV prevention is education in safe sex and the use of condoms.

This is where any money needs to be channelled, not a program to provide men and children with a needless and ineffective cosmetic surgery.

It is having promiscous, unprotected sex that has been proven to spread HIV. Telling men the lie that circumcision prevents HIV isn't too helpful.

Those countries are screwed.

[David]

Circumcision is not a prevention for HIV. Not even a "partial" prevention. That mischaracterizes even the African studies' own conclusions. It doesn't matter what I like.

At best, it may delay infection by reducing risk in high prevalence populations. It can do nothing to predict individual likelihood of infection in each case of unprotected heterosexual intercourse.

And of course, recent reports of the underreporting of MSM activity in Africa further undermines any prospective predictions. Again a lesson that being hasty because you are desperate is no solution to this problem. (By the way, the Lesotho circumcision number is reportedly closer to 80%. Halperin has claimed a 45% rate of circumcision for that country in the comments on this website. Seems to just keep falling ...)

It is convenient if you "like" the idea of circumcision to prevent HIV, owing to its "silver bullet" appearance, to claim different numbers in conflicting evidence, but you can't just change the numbers in Lesotho for circumcision status to fix the problem.

A study presented around the same time the three African studies were released showed the parity between circumcised and intact men viz HIV status. A later study showed men choosing circumcision also had a higher rate of risky behaviors over all. While this has been hailed as further proof of the miracle of circumcision, the same study also showed high rates of HIV and begged the question whether a low risk-taking individual would benefit from circumcision even if it had value.

Btw, to the anonymous commenter above: You come to this site from a very prestigious academic institution with real international clout and credibility. Why post anonymously? Why not put your public face out there in this debate? You published a statistical argument for circumcision (Curr Opin Infect Dis. 2007 Feb;20(1):66-72) in Feb 2007. It appears to have repeated all the speculation where the evidence is lacking and drawn the same poor conclusions from the same data, judging by the abstract. This site would be honored to host just such a debate.

David

(Every study mentioned herein has been detailed and/or hosted on this site. See Download pdf files in the right sidebar.)

[Hugh7]

Whatever the actual circumcision rate in Lesotho, the same DHS study found the HIV rate to be 22.8% in circumcised men and only 15.2% in intact men.

[Hugh7]

"a culture that ... denies women the right to negotiate condom use"

That's the killer. Circumcision "to prevent HIV" is going to make it even harder for women to insist on condoms.

[Joe]

anon - From the sound of it you plan on relying on circumcision to protect you while having sex with someone whose HIV status is positive or unknown. That doesn't sound like a good idea to me.

[Helen Weiss]

David asked me not to be anonymous.

Yes, I should have said male circumcision is 'partially protective' i.e. reduces risk of heterosexual (female-male) transmission by around 60% - but does not completely eliminate it. This partial protection is proven by the three randomised controlled trials and numerous observational studies. The results have consensus in the scientific community - e.g. see the WHO recommendations.

Every recommendation about male circumcision for HIV prevention stresses that this must be implemented in addition to existing HIV prevention strategies. If everyone used condoms correctly and consistently we would not need other strategies, but as you know, the unfortunate fact is that, over 25 years into the epidemic, condom use is still very low in many settings - including, for example, within marriage, where much HIV transmission occurs. We really can't afford to dismiss other additional methods of prevention.

[David]

(This comment is in response to Helen Weiss, who is a lecturer at the London School of Hygiene and Tropical Medicine, University of London.)

The fact is the studies had many problems that have never been adequately addressed by the authors who have all had long standing track records for promoting circumcision prior to linking the procedure to HIV. Proof could not have been more evident than when the authors began promoting the procedure in settings that they themselves had previously said were not appropriate.

Among just some of the problems in the research were:

1. Self-selection of the participants and exclusion of certain would-be participants without adequate explanation.
2. Problematic and unverifiable self-reporting of sexual activity.
3. Monetary inducements to report a desired outcome the participants were aware the researchers were seeking; failure to follow up on participants that dropped out.
2. Failure to follow the groups long enough.
3. Under-reporting of MSM among the group, greatly compromising any findings of efficacy, much less prospective predictions of effectiveness.

Analysis of the data in mathematical models greatly exaggerated the cost and life-saving value of the procedure as was born out by other studies showing HIV parity between circumcised and intact men within countries (as opposed to across borders). This very fact throws into question whether the variables controlled for were really controlled for.

The question of ethics was discussed entirely on the basis of voluntariness and inadequately or not at all on the equally important basis of informed consent. Moreover, any purported concern for voluntariness was entirely made absurd by the subsequent suggestion that circumcision be introduced neonatally. The fact is the researchers and those promoting circumcision do not know or understand or seem very much interested in the losses and harm associated with the removal of healthy, functional tissue. And hence, they could not possibly talk with authority about the contraindications associated with the procedure.

The fact is all of the issues, outcomes, and problems of circumcision in the HIV context have not been synthesized to the point of consensus. A self-selected group who has been active in publishing and promoting a procedure does not make for a "scientific consensus."

To say that "[w]e really can't afford to dismiss other additional methods of prevention" repeats the lie that circumcision is a prevention rather than possibly a risk reduction measure. Moreover, it cast a very broad net that would not exclude the forced testing and banishment along the lines of uncooperative TB patients or lepers of a former time, overreaching and unwarranted criminal prosecutions for passing the virus, and all sorts of potentially effective but society-damaging measures. Most disturbing and entirely unremarked is the potential for introducing or maintaining female circumcision because it too has been shown to correlate with a lower incidence of HIV (See Stallings et al.).

A civilized approach to public health does not implement a measure at any cost just because it is believed to be effective -- or for that matter IS effective.

[Joe]

While echoing most of David's concerns I would like to heap on some of my own. Helen said: "If everyone used condoms correctly and consistently we would not need other strategies, but as you know, the unfortunate fact is that, over 25 years into the epidemic, condom use is still very low in many settings."

This to me implies that you are treating circumcision as some sort of fail safe. Meaning if you can't get a condom or if you don't like to use condoms at least you'll be circumcised. That is the message that is going to get 'heard' that or the more succinct 'prevents'. On more than one occasion the study authors themselves have used terms similar to or stronger than these; which in my opinion is not only dangerously misleading but boarders on fraud. People in their position, and yours, should be much more careful about how you describe such things because it is clearly far to easy to misinterpret and exaggerate.

The message is really this: either you don't need a circumcision but you must always wear a condom, limit and be choosy about your sex partners or if you get circumcision you must always wear a condom, limit and be choosy about your sex partners. Since no matter what I do I still always need to wear a condom, limit and be choosy about my sex partners how is it even logical to consider circumcision? The only way I can see it is if I believe that circumcision will be the quick-fix silver bullet and intend to disregard the rest of the instructions.

Efficiency is a key component here too; there is, of course, a finite pot of money. To spend money on an invasive intervention that can't stand on its own but instead still needs support of less invasive, safer, cheaper, more efficient, and far more effective measures is simply ludicrous. For the cost of a circumcision you could provide somewhere in the neighborhood of 1500 - 1600 condoms (about five years worth if they are used once a day). Considering the fact that it seems there is likely a deficit of condoms and drugs it doesn't seem wise or logical to dump the precious little money that they have into something that won't really fix the problem.

There also seems to be a bit of a shell game going on. We started out with voluntary adult which was soon changed to involuntary infant. This is particularly troubling. In addition to the problems with implementing circumcision using voluntary adults (illogical and a resource sink) it becomes wholly unethical as the child does not immediately need this protection and could instead be a voluntary adult, if he wanted to.

In addition to implying prevention, as David pointed out, I think the sentence of yours I quoted presents another interesting component. It sounds to me like you're characterizing the HIV fight in Africa as a battle that is being lost. And now like an Army facing imminent defeat, the world is turning to less logical and less rational strategies all this despite the fact that it appears that things are slowly turning.

If it is the case that our backs are to the wall perhaps we should consider the Stallings study. As Dr. Jon Myers, Professor of Public Health at the University of Cape Town, said in this recent article discussing the Stallings study. “A Tanzanian study had found that female circumcision reduced HIV transmission. Biologically, the explanation for this was probably the same as for male circumcision. ... “If female circumcision was medicalised in a similar way to male circumcision, it could be made safer and less damaging.” As Dr. Myers' goes on to say it is only the fact that male circumcision is still tolerated in the west that allows us to lower our ethical barriers to the point where this can be considered acceptable. Don't boys deserve the same respect as girls?

[SunkenShip]

Bravo Joe and David. Great responses.