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Rolling Donut has a couple of excellent posts today on the UNAIDS most recent call to end female circumcision. Check out the first one, and then the second one.
His argument is not easy to summarize without quoting both entries in their entirety. I highly encourage readers to click on over.
In stark contradiction to the circumcision brigade's claims of "Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit [pdf warning]*," we have this just in from the San Francisco Department of Public Health:
In 2007, declines were noted for all reportable STDs in San Francisco. Reported gonorrhea declined 19% from 2006 to 2007 from 2469 cases to 2008. Rectal gonorrhea among men also declined from 557 cases to 489- a 12% decline. Declines in syphilis were also found. Primary and secondary syphilis declined 17% in 2007 from 243 cases to 202; all early syphilis also declined by 16% in 2007. Chlamydial infections also declined, but these declines were much more modest. Overall reported Chlamydia declined from 4050 to 3937 (3%) while rectal chlamydia increased in 2007 from 512 to 592 cases for a 16% annual increase. We are exploring why rectal Chlamydia increased in 2007 and rectal gonorrhea declined. For reported gonorrhea cases, all racial/ethnic groups had declines from 2006 to 2007; African-Americans saw a 22% decline, Hispanics 19%, Asian/Pacific Islanders 22%, and Whites 18%. For Chlamydia, there was a 9% increase among Asian/Pacifdic Islanders , all other racial/ethnic groups had declines; African American 12%, Hispanic 10% and Whites 1%. More comprehensive data will be available with the publication of the 2007 Annual Summary. Download STD012008.pdf
With apologies to Michael Petrelis over on The Petrelis Files, I lifted an additional bit of info not included in the SFDPH's report, but generously provided to his readers [link to specific post] at the aforementioned blog.
The monthly report omitted discussion about adult male shigellosis, which fell by 20%, from 99 to 78 cases; speed-related visits at SF General Hospital for males fell 17%, from 488 down to 402; for female visits there was a drop from 113 to 111.
The HIV figures from the primary STD testing site on Seventh Street, which are not the full numbers for the city but certainly represent a significant portion of the tests and results that comprise the city's overall HIV infection rate, increased by 12 percent, from 102 to 115.
However, the figure for number of antibody tests performed at this one clinic skyrocketed 58%; from 3,097 to 5,283. I think we can safely attribute the rise in HIV infections to the corresponding jump in tests.
For a county whose male population is experiencing a steady and persistent fall in rates of circumcision, this is startling news for circumcision junkies, but decidedly happy news for public health and the community at large.
*You will recall this was the opinion piece whose author's conclusions were in stark contrast with its headline and was written by that strange conglomeration of circumcision advocates in high places.
The Journal of Pediatrics is reporting in their March 2008 edition that "early childhood circumcision does not markedly reduce the risk of the common [sexually transmitted infections] in the general population in [developed] countries."
They are hedging a bit, as their conclusion sounds as if some reduction was observed. Just not enough. It may be the stilted nature of scientific language, but they are clearer in the abstract that "STIs were not statistically significantly different-23.4 and 24.4 per 1000 person-years for the uncircumcised and circumcised men, respectively." [Emphasis mine.]
Reference
Dickson NP, van Roode T, Herbison P, Paul C., J Pediatr. 2008 Mar;152(3):383-7. Epub 2007 Oct 22
The UNAIDS blog, HIV This Week, decided to repeat, perhaps for filler? to beat back lagging interest? a couple of studies that came out late last year.
The first one found after a lot of blather about more studies being needed, "In conclusion, after adjustment, male circumcision was not significantly associated with women’s HIV risk." [Emphasis theirs.]
Edit: Does this mean that the prevalence of HIV was equal as between the circumcised and intact groups? Or could it be that the act of heterosexual intercourse neutralizes the protective effect of circumcision? Or rather does this study call into question all the circumcision RCTs? Bet on the first and third possibilities.
Reference
Turner AN, Morrison CS, Padian NS, Kaufman JS, Salata RA, Chipato T, Mmiro FA, Mugerwa RD, Behets FM, Miller WC. Men’s circumcision status and women’s risk of HIV acquisition in Zimbabwe and Uganda. AIDS 2007;21:1779-89.
The second study was a systematic review of the literature that looked at other issues but recorded circumcision status. The authors talk shit and then admit the obvious. After noting a suggestion of "a strong association between male circumcision and lower HIV among men who have sex with men," they conclude,
"The observed effect might be due to confounding factors not measured
(and therefore not controlled for) in the studies, rather than being
the result of a biological effect of male circumcision."
Reference
Fankem SL, Wiysonge CS, Hankins CA. Male circumcision and the risk of HIV infection in men who have sex with men. Int J Epidemiol 2007 Oct 19; Epub ahead of print.
I couldn't find a way to easily link to this blog entry, so go here and good luck.
The HIV/AIDS research community has finally come to the conclusion that a vaccine will likely never come. More than one expert has said this in the last year. A few elder statesmen of long experience in the infectious disease research community have come out and said that HIV/AIDS is a disease easily avoided with a long period of incubation, usually past the years of child-bearing and most of those of child-rearing, that in most countries affects a small number of people engaging in very specific contagious behavior. Nature and evolution simply do not find this disease to be a major problem. Hence, it is less a threat to world humanity than a personal tragedy to individuals and those countries hardest hit.
We have entered a new period in the development of the HIV/AIDS era. The emphasis will now be on prevention. The HIV/AIDS research world is awash in money. If the donor community accepts that a vaccine is not possible, billions of dollars will flow elsewhere. Economics dictates that the recipients of donor largesse will have to shift their research and activities to continue receiving these huge sums of money, recipients being institutions rather then individuals. Hence, we saw the World Health Organization endorse male circumcision. Then we saw the United Nations add their voice as well.
More than a few people were perplexed at the apparently bizarre interest the vaccine activist community had in male circumcision. The AIDS Vaccine Advocacy Coalition and the International AIDS Vaccine Initiative both became positively giddy at the prospect of male circumcision. I now question whether they have concluded privately that the vaccine effort's days are numbered. Closer than anyone to the effort and more dependent on donors than even the research institutions, which usually have more than one focus, they perhaps see an opportunity for continued viability in the promotion of genital surgeries.
The evidence for male circumcision is weak. Its efficacy in a clinical setting is unclear. Its effectiveness in the general population is negligible. No one seems ready to acknowledge that all the players in the male circumcision push have vested interests. Yet, the United States Centers for Disease Control (CDC) appears ready to endorse it, falling in line with the United Nations and the World Health Organization. Given the condescending attitude of most US government institutions, I suspect the CDC is more than a little annoyed that they were beaten to the punch.
The CDC condemned the new Swiss
guidelines on HIV+ infectiousness almost immediately. More than eight
years of evidence went into the formulation of the new guideline. In prevention terms, why support male circumcision so quickly and condemn the proven prevention value of ARV therapy? The CDC will eventually come around to support the Swiss viewpoint.
Right now, the new guidelines are an uncomfortable, counterintuitive
change in direction. But it is fundamentally a technical question of prevention. Male circumcision on the other hand is an American cultural norm that evokes a fierce commitment to its continued practice in the United States. However, it is new to the HIV/AIDS scene. Hence it has attracted interest as it involves the creation or expansion of new organizational structures and materials, and provides a new opportunity for advocacy and the allocation of resources.
So where is the world now viz HIV/AIDS and male circumcision?
If the experts have concluded both that a vaccine is not possible and that HIV is little more than a personal tragedy for individuals in the developed world, I think we can expect a mad scramble for prevention funds. This will likely involve all sorts of new and innovative efforts, of which more than a few will involve genital mutilation. We can likely look forward to continued forced circumcisions of children and scaremongering to induce submission in adults. Much like the early period of HIV/AIDS, ethics and human rights will take a hit.
[This article has been reprinted as a news item on the European AIDS Treatment Group website.]
This post is coming a little late to the fore. Nevertheless, I still wanted to mention it briefly.
Swiss public health officials have issued new guidelines (original in French and German [pdf warning]) regarding the infectiousness of HIV+ individuals on effective anti-retroviral therapy. Basically, the new guidelines state that condoms are unnecessary in serodiscordant (one positive, the other not) couples under a narrow but widely applicable set of circumstances. These circumstances are:
Again, under these very narrow circumstances, serodiscordant couples needn't use condoms during sexual intercourse. Read the English translation here [pdf warning].
This is in accord with a study presented at the Fifteenth Conference on Retroviral and Opportunistic Infections. That study concluded that provision of ARV therapy to African nations could reduce HIV infection over all by 90%.
[This post was picked up by Reuters through Blogburst.]
UPDATE4: The information formerly in this post is now available on the The CDC/AAP Project page.
UPDATE3: I have reorganized the information below and put it on The AAP Project page, now rechristened The CDC/AAP Project.
UPDATE2: Some people have received form letters from the CDC regarding this issue. We still have time to press the point. I have added additional names, addresses and emails of individuals you may contact regarding the impending endorsement by the Federal Government of male circumcision. This is your government getting deeper into the business of genital mutilation and forced circumcision of children. Form letter added below.
UPDATE: At the end of this post is a list of key people to contact at the CDC and the AAP. Your voice is important. Please write the people speaking in your name.
"Mister, these Aids people have spoken for long about fighting the disease, but they had never come up with a practical solution as good as this one. Don’t have sex, don’t do this, don’t do that. Eh, man, how can a young man such as I forfeit sex, eh? And the condoms – where is the sense in putting on a condom when you are having sex? Sex is about feeling, and so no young person likes them!"
AIDS campaigners are fond of saying that this disease is "hydra-headed." Find one way to tamp it down and it will pop up somewhere else to wreak its havoc. In this case, circumcise them and they will forfeit condoms (carefree sex through circumcision?).
The attitudes and behavior of "young men" in the following story give us an inside view of what is driving this disease. Which has nothing to do with intact bodies. Despite some trepidation, the article's writer fatally embraces circumcision anyway, giving us a view of Africa's blind confidence in other people's solutions to their problems.
Fair use article after the break.
Continue reading "Rwandans look to West's "AIDS people" to save them [new headline]" »
The Times of South Africa quotes Auvert and perhaps unintentionally reveals his colonial intentions in the process.
French researcher Dr Bertran Auvert of Versailles University suggested this week that 40% to 50% of circumcisions in Southern Africa were only “ritual” or “partial” circumcisions — where the foreskin was not completely removed.
HIV trials conducted in South Africa, Kenya and Uganda showed that only clinical circumcision could reduce the risk of males getting HIV, said Auvert.
Let's start with the statement that "only clinical circumcisions c[an] reduce" HIV. Is the close observer to now understand that only clinical circumcisions were carried out in all the areas Auvert and colleagues have held up as proof that circumcision reduces risk, such as all of West Africa and the Muslim countries? That's of course absurd. Circumcision is ritualized everywhere it is found in Africa, and in fact clinical circumcision is rare.
This is just one more attempt by men from the developed world with a vested interest in the HIV/AIDS medical industrial complex to convince the world that only the West can look out for their interests (and garner huge sums of money from grants in the process).
The behavior and attitudes of men like Auvert bear a strong resemblance to the clinicians of a prior era that would bleed their patients to death in an effort to cure them of real and imagined illnesses. Unlike them, however, Auvert and colleagues have the means to know better, but refuse to acknowledge the vested interests that motivate them.
My wonder increases daily at who will call them on it besides an independently published blog.
Link: The Times - Article.
The Associated Press has issued an article dripping with ridicule in tone and use of selective quotes regarding South Africa's reluctance to "run roughshod" over the traditional values of certain ethnic groups that "frown" on circumcision by recommending the procedure.
Stephen Lewis, who is described as a former UN AIDS envoy, accused South Africa of being "addicted to folly" for refusing to jump on the bandwagon. Lewis repeats the lie that there is "overwhelming evidence" supporting circumcision as an AIDS "prevention."
The AP does not mention the numerous doubts expressed by AIDS organizations in Australia, Europe, and Canada over encouraging a genital surgery to deal with HIV/AIDS. It also fails to mention the cultural, economic and historical reasons that HIV has made such massive inroads in South Africa.
The article additionally makes no mention of the fact that circumcision likely increases HIV among women, disempowers women to negotiate condom use, and provides no protection for men who have sex with men.
The AP completely omits any mention that multiple, concurrent partnerships are the primary vector for HIV in sub-Saharan Africa, which has explained why countries such as Zimbabwe, Uganda, and South Africa suffer high rates of the disease compared to other parts of the continent.
The article does however tack on the obligatory line that "circumcision does not provide complete protection," thereby acknowledging the inherent problem of encouraging a procedure that harms many and may help some.
Contact the AP and Stephen Lewis.
AP Headquarters
450 W. 33rd St.
New York, NY 10001
info@ap.org
+1-212-621-1500
Attn. Stephen Lewis
Stephen Lewis Foundation
info@stephenlewisfoundation.org
Full fair use AP story after the fold.
Continue reading "AP ridicules South Africa for proceeding with caution on circumcision" »
[Dr. Susan Buchbinder] reported at the [15th CROI] conference today that further analysis of the Merck study results found that uncircumcised volunteers who received the vaccine ran nearly 4 times the risk of infection than those who were given a placebo.
Buchbinder said one possible explanation is that the vaccine somehow activated white blood cells near the surface of the foreskin - known HIV targets - making them more vulnerable to infection. She told reporters that she would not recommend at this time that study participants who are uncircumcised and received the vaccine, rather than a placebo, be circumcised as a precaution.
Follow-up research has also shown that the slight trend toward higher infection rates among all those who took the vaccine has not yet abated. But the number of infections involved is so low that there remains a possibility that the higher infection rates among uncircumcised men was purely the result of chance.
A vaccine trial that made volunteers more vulnerable to HIV that then would encourage circumcision is insult to injury for the unfortunates who received the ill-fated vaccine candidate.
A rethinking is in order, no doubt about it. But the rethink, at least in the developed world, is that HIV/AIDS is 100% avoidable. This virus may be beyond us, but it is infinitely containable. We know more than enough to shift some of the burden that researchers are feeling onto the shoulders of the community. We all have to take responsibility for avoiding this virus.
If some ADULTS want circumcision as part of this process, they should have it. The challenge then is how to maintain the responsibility on the adult individual, the only place where it can work. The danger is that the temptation will be to shift the decision from the individual to someone else, such as doctors and parents. Ethically, that is the wrong path to take, and ultimately another ill-effect of the virus, but which is within the power of humans to avoid.
Link: Failure to find AIDS vaccine has researchers seeking new directions.
Aidsmap, the best source of information on HIV/AIDS in the English language, has a better analysis of the Merck vaccine failure. Their article includes details of a discussion that the failed vaccine may have deactivated the protective mechanism in the mucosal tissue of the foreskin.
I think it is important to realize what the difference between the intact and circumcised seroconverters was in real numbers: 49 versus 33, respectively, out of 930 male volunteers. That's a tiny group, conclusions from which would seem ill-advised.
UPDATE: Forty-nine people in the vaccine trial group seroconverted. Thirty-three in the control group also seroconverted. Therefore, the difference between the circumcised and intact group who seroconverted is even smaller than the difference between the trial and control group. The numbers here are miniscule with no statistical significance. That wasn't made clear in the earlier reports. And it was glossed over by the largely circumcision positive press.
Link: Aidsmap | CROI: AIDS vaccine: additional [increased] infection risk restricted to uncircumcised men.
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