Male Circumcision and HIV

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'.

Will a falling dollar and soaring food prices undo circumcision policy in Africa?

A falling US dollar, a soaring world population, climate change, food shortages ... will this be the undoing of circumcision policy? Change and history rarely turn out as expected. If food becomes an issue worldwide, as it frequently has in Africa, and the donor dollar, which is at historic lows against other world currencies, continues to lose its place in the world trading order, who knows how priorities will change ...

Follow the link for an article detailing this emerging problem and game-changing development.

Link: Focus: Hunger. Strikes. Riots. The food crisis bites | Environment | The Observer.

The AAP/CDC policy makers speak

The LA Times has published an article in the usual circumcision news story style. You have quotes from the parents who will and the ones who won't and the fence-sitters. Inevitably, the fence-sitters always do by the end of the story. And this piece is no different. However, there were some choice quotes in there that are perhaps revealing of what the American people can expect to see soon from policy makers on circumcision.

Peter Kilmarx, chief of epidemiology in the CDC's division of HIV/AIDS prevention, is quoted as basically advocating two things. That the United States shouldn't look to the rest of the world for a consensus on this issue and that universal health care should be extended, if only for this one procedure. Rather than question why the rest of the developed world finds routine circumcision on medical grounds a little absurd, he simply says we have the science and not the cultural handicaps to prevent us from engaging in circumcision. His major emphasis is, of course, on HIV.

Interestingly, he states that "The early opinion from the consultants -- and not the position of the CDC, which involves a peer review process and public comment -- is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted."

In other words, the consultants are that cabal of close-knit individuals to include Halperin, Bailey, Auvert, Morris (maybe, not sure on this one), Wiswell, Schoen, and a few others who have been well-known long prior to  the HIV/circumcision studies to advocate (and even write poems on) circumcision. They are all members of The Gilgal Society, a UK-based organization dedicated to the romanticization and sexualization of the act of circumcision.

Dr. Doug Diekema, on the other hand, is not entirely in agreement with Kilmarx. He also sits on the AAP Task Force on Circumcision and will take part in the revision of that organization's policy statement, due out this year. "The fact that circumcision is an even split these days is not a bad thing," he says. "If there are not religious beliefs, then parents really are left with the primary question of whether circumcision offers another benefit. The data are not compelling in either direction.

"The social pressure parents faced before to circumcise their sons was not the best reason to do it," Diekema continued.

Dr. Andrew Freedman is another member of the AAP Task Force. He seems less critical of the position Kilmarx takes on the data. Yet he states, "While [the circumcision studies are] important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant."

It's hard to know whether Kilmarx is simply close-minded on the issue of circumcision for reasons all his own, or whether he just doesn't respect the opinions of doctors and medical public policy makers in Europe and much of Asia, when he says, "The procedure is so ancient, and steeped in cultures, I'm not surprised that the rate of adult circumcision in civilized countries doesn't track with medical evidence. But as scientists, we don't solely rely on what other countries do as a guideline."

As a scientist, he would should be more open-minded. As an American policy advocate, he's staking out territory.

Edit: And you have to love the occasional slip that spotlights the prejudices and bias of people like Kilmarx. If by "civilized countries" he means rich, developed countries, you can imagine his regressive views on poor, developing countries that have managed to hold onto their foreskins. And this guy is making policy. Lord, help us!

Full fair use LA Times article below the fold with a few of my comments interlineated in red.

Falling Rates of STIs at a Time of Decreasing Rates of Circumcision in San Francisco

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.

Notebook: What happens when we realize a vaccine isn't possible?

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.]

Rwandans look to West's "AIDS people" to save them [new headline]

"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.

Link: The New Times - Rwandas First Daily :: Issue 13440 :: Nothing can fight HIV/Aids better than discipline.

Fair use article after the break.

S.F. General researchers follow strain of drug-resistant bacteria

A killer responsible for more deaths than HIV/AIDS. A strain that takes days to kill instead of years. The epicenter localized in San Francisco's gay community. Where have we seen this before?

Oh wait. In San Francisco's gay community.

When AIDS was first identified, people were dead within weeks or months of diagnosis. Today we know the disease incubates for years before causing the opportune infections that result in death. Still, the comparison bears making, however imperfect it may be. Today we have a new formerly harmless infection in the form of a bacteria that is taking shape as a frightening reprise of HIV/AIDS albeit in a very different form.

It's possibly not the best comparison. However, when the HIV/AIDS community is starting to turn to drastic measures such as removal of sexual tissue to deal with HIV infection, we should all be worried about how that might provide an opportunity for another deadly infection to step in.

The unintended consequences of circumcision may come from a direction no one anticipated.

[This article has been reprinted by Reuters.]

Full fair use story below the fold.

Notebook: Circumcision as Lucky Charm

A very long time ago in my search for validation of my growing belief that God was a rather implausible and fanciful idea, I remember coming across a piece in some foreign journal that expressed astonishment at the disconnect between the professional lives and religious lives of Los Alamos nuclear scientists. Apparently some Godless European was incredulous at this greater insolvable problem than the mystery of splitting the atom. How could Ph.Ds spend their days dissecting the toughest theoretical and practical problems of the molecular world and their nights believing in mythological tales of creation and some sentient, eternal being in the sky and not suffer some mental break?

Richard Dawkins expressed this paradox by way of explanation. He said in his book, The God Delusion, that religion must have served some purpose for uniting mutually dependent bands of people in allegiance, identity and hope that ensured the survival of the species -- or at least the bands that took up such beliefs. His conclusion in light of the great suffering and destruction done in the name of religion, particularly Abrahamic religions, is that it is time to retire the meme of religious belief. Perhaps he is correct. But surely some other destructive force will fill the void as people in the main still need some tie to bind them to one another -- and means with an element of destruction and sacrifice seem to be the most effective so far.

To many, male circumcision represents a great hope to humanity. It is a hope that correlates with the great hope that crystallized in the coincidence of some animal or human sacrifice and the lucky salvation of the people who practiced it. (Think Pavlov ...) In those rituals, nothing real was achieved outside of the minds of the practitioners. In reality, a net loss was realized in the loss of the person or the animal. But the sacrifices lasted many multiples of time longer than people have enjoyed the modern era.

The data is pretty clear that circumcision damages the sexual lives of the men who suffer it. This is a truism that has been poorly studied, but amply anecdotally expressed in the internet age. It is done largely without consent, imposed by cultural authority on subordinates, and varies widely in its physical and destructive form. Yet its value remains in the minds of those who have suffered it, and in those who see salvation in it because they are so desperate or so forsaken.

The following article makes the case that HIV/AIDS is a "Darwinian event." A vaccine may never come. The virus works its destruction too slowly to ever "burn itself out" of existence. Except for the rare "elite controllers" and individuals with some mysterious immunity, no biological adaptation is possible for the great majority of individuals. Instead, it will be cultural adaptation that contains HIV.**

In the developed world, people will defeat the disease by learning to avoid and prevent it. Condoms used in more and more intimate settings are an adaptation. Serial monogamy is an existing adaptation in most of the world and one that will be adopted in sub-Saharan Africa where it is rare. Rapid and frequent testing is an adaptation. The article lumps male circumcision in with the others as an adaptation. Of course, male circumcision is not a protection. But it fills the human need for lucky sacrifice to ensure success.

Therefore, as condoms and monogamy take hold, education and testing seeps into the consciousness and routine of individuals, and as some populations are persuaded to embrace male circumcision, the poorer African communities that have been targeted won't really know what's containing the virus. But they will leave nothing to chance and continue to embrace it all.

Meanwhile, people outside Africa will likely use their own adaptations, condoms and testing, to contain the virus. They won't need male circumcision because they already know success without it -- and they aren't dependent on the United States or as dominated by it. The levels of infection have leveled off long ago and begun to decline in most of the world. The great epidemics in China, Southeast Asia, Latin America, and Eastern Europe, predicted in the first decades of the disease will likely remain predictions. But the reality will be something different. America and Africa will be alone in their dogma of destructive sacrifice for success.

**This is probably not true. However, in our fortunate age of advanced medicine and instantaneous communication, the biological processes required over generations to develop an innate immunity will likely never get the chance to occur.

Enjoy the Globe & Mail article below the fold.

Circumcised men experience more pain and have greater difficulty penetrating, study shows; authors, BBC wish it were otherwise

A recent study conducted in Uganda confirms an earlier Korean study that circumcised men experience greater sexual difficulties than their intact brethren. This information is important as the procedure could face a hard sell in Africa with no remedy for buyer's remorse.

According to the BBC article, quoting from the study published in the British Journal of Urology - International, the same journal that reported last year that four out of the five most erogenous zones of the penis are located on the foreskin:

Some 98.4% of the circumcised men reported satisfaction, compared to 99.9% in the control group.

In terms of ability to penetrate, 98.6% of the circumcised group reported no problem, compared with 99.4 of the non-circumcised group.

One Ronald Gray of Johns Hopkins University, another statistician member of the HIV/AIDS industrial complex, led the study, drawing opposite conclusions than from what the data showed.

Deborah Jack, chief executive of the National Aids Trust (UK), said:

There is a fear that people that have been circumcised will feel they are protected from HIV when they are not.

Condoms remain the best way of preventing HIV through sexual intercourse.

It should be noted that research into HIV and circumcision has been very limited in its scope.

Ms. Jack is not entirely accurate. Three studies have now shown that gay men receive no benefit from circumcision viz protection from HIV infection. One study was conducted by the proponents of circumcision, cutting into their eroding credibility even as they again concluded the opposite of what their data showed.

Clearly, the most difficult part of the study was adjusting for the problems associated with self-reporting. The circumcised men, with no effective way to turn back the clock, may not have felt comfortable admitting that they no longer had the same level of satisfaction and comfort as they had before sexual tissue was removed.

Additionally, unlike a survey of men who use or refrain from using condoms, once circumcised, comparisons are limited to fading memories and wishful thinking. The study did not apparently look at satisfaction longitudinally, which would better measure the well-known problems reported by circumcised men in North America, namely declining sexual sensation and response over time.

Reference

Staff reports. Circumcision 'does not curb sex'. BBC Online. January 7, 2008.

http://news.bbc.co.uk/2/hi/health/7174929.stm

CDC Expected To Raise Estimates Of New HIV Infections In US

One wonders if this rather complex maelstrom of information and reports is also making the decision makers nervous, since they touch on politically sensitive issues, and any suggestion that the big organizations don't know what they are doing will shake confidence and perhaps make until now generous aid donors tighten their purse strings.

Large international and national monitoring organizations frequently raise and lower estimates of all sorts of incidence in many different fields. Why are the CDC, UNAIDS, and other organizations is the media making such a fuss out of this process? They say that the "real" figures are the same, but their methodology has improved. Yet, one gets the distinct feeling that something more is happening under the surface. It's a kind of frenzy that is reminiscent of economic shocks.

I don't know what to make of this. But I think it bears mentioning ... and watching.

Link: CDC Expected To Raise Estimates Of New HIV Infections In US.