Male Circumcision and HIV

The Guardian: 'People do stupid things - that's what spreads HIV'

A few years ago, I commented to an HIV-positive friend of mine that I had just received the results of my own HIV test. I was negative and not particularly surprised by it. He made some comment about how it isn't a good idea to be too smug, and how could I be so sure I wasn't going to test positive. My reply surprised even me.

I have a number of friends living with the virus. Until I moved to San Francisco six years ago, all of my HIV-positive friends had been infected in the first 10 years of the epidemic. In short, prevention efforts and education had a very long way to go during that time. Since living here, I have met a few people who have become positive after we became friends. Shock doesn't begin to describe how it feels to learn a friend has become positive.

I think a lot of people would find it ironic that rather than pity or sadness (those emotions came later), I felt disappointed and angry. HIV is no mystery to a young man living in San Francisco. The ways you get it are intimately familiar to anyone who has even a modest awareness of his community.

After relating my results to my friend, and receiving his caution about being smug, I said to him that if I got infected at this stage I would be deeply embarrassed and ashamed because I have lived alongside the virus for 25 years and I have seen it take the legs through severe neuropathy of my dearest friend. I have seen his body deform before my very eyes from the toxic drugs he has to take to stay alive. For me to become infected would be shameful and no one's fault but my own. To that my friend replied, " Well, HIV is really no one's fault."

To that I held my tongue. But of course, I knew that it is the fault of the person who does "stupid things" and gets infected because of it.

Elisabeth Pisani's new book, Wisdom of Whores, is to be published next week and the Guardian of London has a nice write up about it. Her book would appear to neatly encapsulate my conversation with my friend. The whole world is saying AIDS is nobody's fault when in fact it is somebody's fault. Prevention rests with the individual. And to the extent that prevention fails, the fault rests there.

What is difficult about Pisani's position as she postulates it on her website WisdomofWhores.com is that she seems to think circumcision is ok. No big deal. Not at all major. Of course, the opposite is true. Yet her broader position is in fact supportive of skipping the circumcision and going straight to the condoms and needle exchange. It's a disconnect probably influenced from not thinking about it too much with so many other things on her plate. (I'm trying to be generous here to a promising philosophical fellow traveler, much like I feel for Helen Epstein's work.)

Among the interesting quotes in the Guardian article:

"We could knock this epidemic in the rest of the world on the head - just like we've knocked so many things on the head in the rest of the world - but we're not doing it, largely because of the paradigm that we're developing in Africa. The Aids industry has become an island unto itself, in a sea of common sense. That's the tragedy of it. It's unsayable."
...
Even the 20 cents in every US dollar allowed to be spent on prevention is wasted, Pisani argues. A third of the prevention budget has to be allocated to faith-based organisations, which refuse to distribute condoms and will promote only abstinence before marriage. The failure rate of "virginity pledge" programmes among young Americans in the US is about 75%; condoms' failure rate is roughly 2%. Yet Pepfar, Pisani laughs, "claims its policy decisions are 'evidence based'".
...
"You know, it's one of the difficult things about arguing for a more targeted response. You're basically saying, 'Look, people are getting infected now because they're doing dumb things.' But people do dumb things all the time. I do. We all do. Why is it OK to be judgmental about people who smoke? But not to be judgmental about people who take crystal meth and fuck 16 guys in a weekend without condoms?"

Yet, she also says on her website that where people don't wear condoms anyway, why not circumcision? But how is this different from abstinence only programs that she doesn't like? Circumcision may slow down the virus, but it doesn't stop it. No study has even come close to making that absurd claim. And no study has adequately addressed the longitudinal outcomes of circumcision. So how is it that where men aren't wearing condoms anyway, the solution is a massive, messy, complication-prone, and expensive campaign to get them circumcised rather than to get them to wear a condom? It's internally inconsistent and of course more doomed-to-fail policy trickery.

While Pisani's thesis seems allied with the reality we espouse on this website, she has slipped into name calling, as we do here as well from time to time, by referring to skeptics of the circumcise-them-all school of thought prevention as "denialist" -- with a link to NOCIRC.org. And it's a pity that she does so.

[Minor edits for clarity and context in last two paragraphs.]

Link: 'People do stupid things - that's what spreads HIV' | World news | The Guardian.

Kenyan Muslim clerics declare war on condoms, Aidsmap reviews Halperin's call to abandon ABC

"We know the condoms are not safe ... if you want to contract the virus that causes AIDS, then use [a condom]," he said. "After all, we have heard in the past that the Western world is using the condom to eliminate Africans, and Muslims in particular." - Abdi Welli, a taxi driver in Garissa, who told IRIN/PlusNews that he agreed with the clerics that condoms should be banned.

Is this a war on HIV or a war on sex? Or simply a war on common sense? The obvious reason "HIV prevalence rates are still among the lowest in the country [among the Muslims of the region] - 1.4 percent compared to the national average of 5.1 percent" is because sexual activity is carefully contained and deeply repressed. It is also possible that circumcision of both sexes has reduced the level of sexual incentive.

Link: Reuters AlertNet - KENYA: Muslim clerics declare war on condoms.

Aidsmap also has a careful review of the article urging the dropping of ABC and adopting circumcision in African countries with a generalized epidemic. The take-away lesson that Halperin and Potts deliver is that condoms can't be consistently used for practical reasons, voluntary testing and delaying sexual debut are of limited value, treating sexually transmitted infections have not proved efficacious in reducing HIV infection, and antiretrovirals are unaffordable in the longer term. Basically, they reject all efforts except male circumcision -- a one size fits all approach. They also contend that prevention programs shouldn't consider in their implementation evidence demonstrating male circumcision has no value for women.

Edit: Curiously, the Halperin/Potts article does spend some time on the issue of reducing sexual partners. However, the de-emphasis on adolescent sexual behavior and condom use along with the lack of belief in the AB (abstinence, be faithful) in the ABC approach renders partner reduction a bit muted.

Joint Harvard/Berkeley policy paper says drop ABC, adopt male circumcision

The points made in this paper to be published in the journal Science, are simply incorrect. In short, they are the opposite of the truth in HIV prevention. The authors urge dropping the ABC approach in Africa and focusing on male circumcision and campaigns to encourage the reduction of sexual partners.

If anything, this academically dishonest diatribe on what the authors say doesn't work, particularly viz condoms, is evidence of the authors' own agenda to promote circumcision for its own sake. Their reasons can only be explained as a personal infatuation with the act itself.

It is amazing to me that leading schools such as UC-Berkeley and Harvard have been the locus of this activity. It makes a mockery of academic freedom when biased, dangerous, and scientifically unsupported agendas rise to the top of such institutions' efforts.

At what point do people like Halperin, Potts, and their cohorts cross the line into the camp of deniers of HIV as the cause of AIDS, 9/11 government conspiracy theorists, and other assorted circus clowns? The level to which these people are capturing the attention and imagination of real policy makers is reminiscent of the beet juice and vitamin policies of South Africa's health ministers during the 90s.

[Note: I've done some minor editing and adding throughout for clarity.]

And the media obsession with circumcision continues in the Times of London.

The BBC has picked up the story as well, adding this sensible quote, "Roger England, chair of small Grenada-based think tank, Health Systems Workshop, said too much is being spent on HIV compared with other diseases which kill more people.

"He said globally HIV causes 3.7% of mortality but received 25% of health aid."

Where is the coverage of the antidote to Halperin's hysteria as demonstrated in Future Medicine?

Link: 05.08.2008 - More focus needed for effective HIV prevention strategies in Africa, says new policy paper.

Future Medicine: Male Circumcision is not the HIV vaccine we have been waiting for!

The May issue of Future Medicine carries an editorial authored by Lawrence W. Green of UCSF's Department of Epidemiology & Biostatistics, Ryan G. McAllister of Georgetown University, Kent W. Peterson of Virginia-based Occupational Health Strategies, and John W. Travis of North Carolina-based Wellness Associates.

The abstract to the aptly entitled article Male circumcision is not the HIV 'vaccine' we have been waiting for!:

Over the past several months, some researchers and health organizations [101] have proclaimed circumcision to be a compelling and important new HIV tool. A recent commentary claims that circumcision is “at least as good as the HIV vaccine we have been waiting for, praying for and hoping to see in our lifetimes” [1]. Thousands of African men now line up to get circumcised in the mistaken belief that it will save them from HIV, as some developing nations – lacking even rudimentary medical care and clean drinking water – rush to implement mass circumcision programs with encouragement and millions of pledged dollars from the US government [2, 102, 103]. In addition, there are calls for implementing mass neonatal circumcision [104].

The push to institute mass circumcision in Africa, following the three randomized clinical trials (RCTs) conducted in Africa [3-5] , is based on an incomplete evaluation of real-world preventive effects over the long-term – effects that may be quite different outside the research setting and circumstances, with their access to resources, sanitary standards and intensive counseling. Moreover, proposals for mass circumcision lack a thorough and objective consideration of costs in relation to hoped-for benefits. No field-test has been performed to evaluate the effectiveness, complications, personnel requirements, costs and practicality of proposed approaches in real-life conditions. These are the classic distinctions between efficacy and effectiveness trials, and between internal validity and external validity [6].

Campaigns to promote safe-sex behaviors have been shown to accomplish a high rate of infection reduction [7], without the surgical risks and complications of circumcision, and at a much lower cost. For the health community to rush to recommend a program based on incomplete evidence is both premature and ill-advised. It misleads the public by promoting false hope from uncertain conclusions and might ultimately aggravate the problem by altering people’s behavioral patterns and exposing them and their partners to new or expanded risks [8] . Given these problems, circumcision of adults, and especially of children, by coercion or by false hope, raises human rights concerns.

You can read the article online here. You can download it here: Download mcnotavaccine.pdf.

This article states the case very well. Among the bullet points presented:

• All three of the studies were halted early
• The durations of the experiments were short
• No long-term follow-up has been or can be done
• A large number of participants were lost to follow-up
• Many infections appear to be from nonsexual sources

Other important confounding factors considered:

• Condom use and safe-sex practices were repeatedly reinforced
• Participants were provided 2 years of free medical care
• Participants were paid to participate
• Participants were solicited who wanted to be circumcised, and who may, therefore, not be representative of the general population
• The trials were conducted in atypically sanitary and well-resourced settings that are unlikely to be replicated in mass African circumcision campaigns   

The authors conclude:

Regardless of whether circumcision might offer some heterosexual males a partial degree of protection from HIV, numerous other issues need to be thoroughly considered before instituting mass circumcision campaigns.

In short, given the large number of unknowns, confounding factors and lack of long-term follow-up in the three RCTs, it is premature to recommend circumcision as an HIV-prevention strategy. Much more evidence must be gathered on real-world efficacy of male circumcision as a prevention tool before mass surgeries are implemented.

An objective scientific assessment must be conducted to determine if the three RCTs are applicable in real-world settings. And, to determine the true cost of a circumcision campaign, there must be a comprehensive resource analysis of the plan. These mass circumcision costs also must be compared with the opportunity costs of funding ABC campaigns.

As part of these assessments, the very real risks of circumcision surgery, including directly increasing HIV transmission to men as well as indirectly increasing transmission to women, surgical risks such as hemorrhage, other infections, meatal stenosis, need for repeat surgery and even death, must be considered.

Finally, the value and function of the foreskin as an integral part of the male sexual organ [31] and the ethical issues surrounding such surgery, including informed consent, the possibility of coercion and the dangerous implications of conveying erroneous messages of HIV immunity, must also be carefully considered in any analysis.

ABC programs offer nearly full protection from HIV infection, yet even if circumcision’s effectiveness matches the 50–60% effectiveness the RCTs reported, it only partially protects men, does not protect women at all, and leaves women more vulnerable to unsafe sex practices being forced upon them.

Those promoting circumcision argue that circumcision is an additional tool that will ultimately reduce infections more than just relying on condoms, monogamy and abstinence. However, African males are already lining up to be circumcised, thinking they will no longer need to use condoms. Rather than complementing ABC programs, promoting circumcision will undermine the ABC approach by diverting funds and encouraging risk compensation behavior, ultimately leading to an increase in HIV infections.

The world community must cautiously review and carefully consider the long-term consequences of mass circumcision campaigns, from the risk of increasing deaths and infections to human rights violations. In the rush to save lives, many may instead be lost and human rights trampled in the stampede. Circumcision is not the panacea the world has been waiting for in the battle to stem the HIV crisis.

At long last, members of the academic and health policy community, a sector from which much of this is emanating, have stepped forward with a systematic analysis of the problems and issues associated with the widespread promotion of circumcision for the purposes of addressing the HIV epidemic. We need more like this one.

Wired Magazine: Why Medicine Should Care Less About 'Sick,' More About 'Normal'

Have you ever known an elderly person who fell ill and decided to live out their final days without treatment? The idea behind refusing treatment by the elderly would seem to be that no intervention, particularly costly and uncomfortable invention, is necessary where the final outcome is predetermined by normal parameters, such as life-expectancy. How much pain and discomfort, not to mention inconvenience, are "worth it" to gain an extra year or two of life?

Similar questions are starting to be asked in younger people. A seemingly classic example might be UTIs in infants. For example, instead of asking whether a UTI in the first year of life is cause for long term concern, doctors tend to think in terms of pre-emptive treatment to reduce the risk - at least in the case of neonatal circumcision. But is the prevention of a single UTI in one child out of a 100 + children worth 100 circumcisions if one UTI in a 100 is within normal parameters? Most would say no, especially given easy treatment with a weak antibiotic.

Similar questions should be asked of HIV infection. How many new infections can be expected with a normal level of fully deployed proven prevention efforts? This number may be hard to come by and even more controversial to assert, given the level of funding at stake. Unlike UTIs, HIV occupies a center-of-gravity in the funding universe.

This very state of affairs may explain the irrational rush to promote circumcision in sub-Saharan Africa. Wherever there are doubt and confusion about what is normal and expected given the circumstances, there will be those who rush in to fill the void with whatever they can. However, what would be different if we knew the expected rate of infection with clean water? Better neonatal care? Regular STD screening? Regular HIV testing? Adequate nutrition? Full employment? Greater empowerment of women? The list is really endless.

In the absence of all these things, I suspect the circumcisionists would say their solution is the best stop-gap. But is it? I rather believe that stop-gaps are excuses to fail in the provision of these other important improvements whose benefits extend much further beyond merely reducing HIV infection.

And with that, the following article talks about the idea behind "distinguishing between a condition within normal parameters — which doesn't require intervention — and an anomaly, which demands it."

Link: Why Medicine Should Care Less About 'Sick,' More About 'Normal'.

Swaziland rolls out the billboards ...

[Click on image to enlarge.]

Link: Circumcision. Billboard is in Swaziland, photo source: joe-ks.com (presumably pronounced "jokes"), "Largest Source of Internet Humour, eh!"

Thanks to Frank McGuinness and David Loewen.

Report: Global warming set to fan the HIV fire

My conclusion is of course a bit different than Professor Cooper's in the story linked below. Climate change towards a warmer environment dictates that we move away from coercive practices such as male circumcision rather than towards them. Circumcision soaks up resources and introduces conflict where cooperation and careful deployment of aid are called for. In fact, resources devoted carelessly rather than carefully to HIV prevention activities could potentially put more people at risk from dangers other than HIV, such as avian flu and related epidemics that are not preventable by condoms and common sense.

Link: Global warming set to fan the HIV fire - Breaking News - National - Breaking News.