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.

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'.

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.

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.

Picking up on SFAF's Statement on Circumcision and HIV

The San Francisco AIDS Foundation, an organization for whom I have raised money, came out with a policy statement on male circumcision and HIV in March of last year. This escaped my attention even though I knew they were formulating a policy. Better addressed late than never ...

Here are the important points made.

• Being circumcised is not HIV protection. Circumcision may reduce, but does not eliminate risk of HIV infection. Sexually active men, whether or not they are circumcised, should use condoms to protect against acquiring and transmitting HIV and other sexually transmitted infections.

• There is a potential for men who have been circumcised to believe they are fully protected and to lapse in condom use and other modes of risk reduction, which could have the effect of increasing HIV transmission rather than decreasing it.

• The studies in sub-Saharan Africa took place in highly controlled medical settings and were conducted by medical experts on previously uncircumcised men who have vaginal sex with women. These men were given counseling about sexual risk and were provided with condoms. Their health was regularly monitored for any adverse outcomes from the circumcision, which were treated upon detection. [Statements that would seem to validate the lack of similar real world outcomes.]

• There  is no comparable evidence about the effect of male circumcision for gay and other men who have sex with men. [In fact, the evidence is in, and it is that circumcision provides NO protection for gay men.]

• There is no comparable evidence about the effect of male circumcision for anal intercourse.

• There is insufficient evidence about whether circumcision in HIV-positive men protects their male or female sexual partners. [In fact, there is some evidence that male and female partners of circumcised men are at greater risk.]

• There is no evidence about the effect of male circumcision on reducing acquisition of HIV among women. Another study in Rakai, Uganda is currently looking at this, but it is not yet completed. [Preliminary data from this last trial suggested women were at greater risk; see last bullet point above.]

• The evidence from the trials in sub-Saharan Africa applies to adult men. It cannot tell us specifically about the potential HIV risk reduction benefits of circumcision conducted on newborns or children. [Good as far as it goes. However, any reference to informed consent and voluntariness must recognize that these principles extend to all human life. Decision-making shifting due to age on care not intended to address an immediate health need, like say a polio vaccine shot, leads to lack of consent and involunatary procedures.]

• Male circumcision has cultural and religious significance in many settings, which may affect its acceptability among different communities.

With the foregoing in mind, the Foundation goes on to state:

• Circumcision is an invasive medical procedure that must be conducted by trained individuals under sterile conditions with appropriate monitoring and an adequate healing period to eliminate the risk of bacterial infection. Community and health care provider education will be essential for the implementation of male circumcision as an HIV prevention strategy.

• Payment for the procedure should not be an obstacle to any man who chooses to undergo it; public and private health care programs and insurers should cover male circumcision as part of preventive medicine.

• Adult male circumcision should always be voluntary, with appropriate informed consent. ["Should" is too weak. It must always be voluntary and with complete informed consent. No overreaching or undue persuasion should be permitted. The loss of sexual function must also be addressed.]

• The public health community should understand and respect religious and cultural meanings of male circumcision in formulating implementation strategies. [Statements like these require clarification. What about cultural aversion to the procedure? Wouldn't such aversion require the same level or a greater level of respect? The Luo seem to have lost out on this particular principle.]

• Circumcision is a personal decision that should be made in consultation with providers, pediatricians and others. The Foundation does not make recommendations about individual health choices. [Reference to pediatricians is telling as to where the Foundation lies in its conventionality viz. infant circumcision.]

The SF AIDS Foundation is a non-governmental political body trying to maximize its fundraising potential. It has some obligation to kowtow to have its greatest success. And so in this particular case, it has gone along to a certain extent while trying to make obviously valid points. It fails in the end by pointing to sources, such as the AIDS Vaccine Clearinghouse, which is an egregious choice for information on this issue. Which brings me to a point that needs to be made.

I think it is a stunning success for the proponents of circumcision that they have sold the lie that circumcision prevents HIV with such alacrity. Today whole nations are purportly willing to force their populations under the knife with scant proof that it will do anything in their fight against HIV/AIDS. This is just stunning.

I think anyone with an interest in public health policy would do well to learn from this development. One important message to be drawn (I write here somewhat sarcastically) is that one should start with a plausible proposition that is essentially unverifiable, do your experimenting in and make your weightiest pitches to the most desperate nations far, far away, and publish, publish, publish. It also helps to have an acquiescent media and be employed by prestigious medical and educational institutions who are familiar with and favorable to circumcision as a cultural artifact.

I would recommend everyone who wishes to weigh in on SFAF's policy to write to them. Put the "public" back in health policy.

Contact SFAF:

policy@sfaf.org
415/487-3080

Public Policy Dept.
San Francisco AIDS Foundation
995 Market St, Ste 200
San Francisco CA 94103

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.

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.

LA Times: AIDS displaces the basics thanks to the billions of the Gates Foundation

Balance. Or is it prioritization?

How does one criticize a lack of balance in priorities without appearing to take a cheap shot at the very generous donors to HIV/AIDS causes? The first step is to accept that very pointed interests are at stake: those of the program directors, managers, and allocators (among many sometimes unapparent others). And the second step is to understand that ranking of relative need is in no one's interest except, of course, the patient, although ostensibly there are rules to deal with this problem, i.e. rules of professionalism and ethical canons, etc. Thirdly, the patients' needs nominally have first priority as noted, but in a competitive system of allocation, the better financed, organized and pitched program, disease or organization wins the day.

The Los Angeles Times reports on the Gates Foundation and the unintended consequences of large donors to the fight against HIV/AIDS, a very high profile disease. The obvious import of this issue viz male circumcision and the almost glamorous presentation of it by the media and some AIDS organizations, including most puzzlingly those concerned with vaccine research, should be obvious to readers of this weblog.

" Dr. Peter Poore, a pediatrician who has worked in Africa for three decades, is a former Global Fund board member and consultant to GAVI (formerly the Global Alliance for Vaccines and Immunization). He says they and other donors provide crucial help but overstate the impact of their programs. 'They can also do dangerous things,' he said. 'They can be very disruptive to health systems -- the very things they claim they are trying to improve.' "

...

"Who chose the human right of universal treatment of AIDS over other human rights?" asked economist William Easterly, co-director of the New York University Development Research Institute, in his book "The White Man's Burden." He added: "A nonutopian approach would make the tough choices to spend foreign aid resources in a way that reached the most people with their most urgent needs."

However, to be explicit AIDS prevention and research efforts span many areas of concern. Male circumcision, despite its complex and uncertain real world impact, is one more offering competing for funding, attention, and the spotlight. The likes of its promoters are simply filling the natural but often harmful role of the careerists, such as those discussed in Helen Epstein's book, The Invisible Cure.

This is why a grassroots effort such as that which this weblog is concerned with eventually requires formal institutions and networks. And for that, one typically needs first and foremost funds. Funds then buy paid staff, professionalization, and well, more funds frankly. To counter careerists who have adopted male circumcision and HIV as a vehicle, you gotta pay to play (or rather to effectively organize and advocate).

Fair use LA Times story below the fold. Note: Follow the link at the end of the article for a richer read with photos, boxes, and links.

Observations on Sansom cost-effectiveness analysis of circumcision against HIV infection in males

The following is a revised [12/11/2007] rebuttal analysis prepared by several observers of the recent presentation to the CDC viz recommendations on circumcision and HIV and STDs. It is extraordinarily distressing that the US government is contemplating promotion of genital surgeries not just on the poor evidence viz. public health benefit, but also given that the US pretends to be a leader on human rights issues. A country gaining a reputation for torture and blatant disregard for the well-being of the rest of the world can ill-afford to now have non-consensual genital surgery added to the list of American questionable practices.

Samson et al. analyzed whether circumcision is cost-effective in preventing HIV infection in males in:

EFFECT OF CIRCUMCISION ON U.S. MALES' EXPECTED LIFETIME COST OF HIV, Stephanie Sansom, PhD, Angela Hutchinson, PhD, MPH, Q An, I Hall, A Lasry, and A Taylor. Centers for Disease Control and Prevention, Atlanta, GA

Their results are summarized in Table 1.

Tablle 1. Expected lifetime cost of HIV for uncircumcised v. circumcised US males by race/ethnicity, 2003-2004 ($US 2006)

	Uncircumcised	Circumcised	Difference
All males	$2381	$2041	-$340 (14.3%)
Black	$8050	$6916	-$1134 (14.1%)
Hispanic	$3515	$3175	-$340(9.7%)
White	$1168	$1066	-$102 (8.7%)

Costs used in calculations:

Circumcision cost $678;
HIV treatment cost $113,381.

It is anomalous for the relative benefit for all males (14.3%) to be higher than the highest relative benefit for any of the ethnic groups. This suggests that the difference for all males ($340) is incorrect. If the differences for each group are correct, the difference for all males, based on the distribution of births by race/ethnicity in 2004, is approximately $310, and the relative benefit is 11.5%.

Although Table 1 makes it appear that circumcision has the greatest relative benefit among Blacks, it is, in fact, among Whites that the greatest proportional reduction in the incidence of HIV due to circumcision would take place to produce the figures in the table. The table implies that circumcision would reduce the number of infections among Whites by 66%, among Hispanics by 29% and among Blacks by 23%.

According to Sansom, "We assumed lifetime HIV risk from heterosexual behavior only reflected a 50% reduced risk among circumcised males." Does that imply that the assumption was made of no reduction in risk from MSM behavior and IDU, which, between them, were responsible for 85% of all infections? That would be a reasonable assumption because, recent studies have shown no protection by circumcision in MSM while, clearly, being circumcised offers no protection from infection by IDU. If the analysis makes the assumption that circumcision reduces risk of heterosexual transmission, which currently accounts for only 15% of all transmissions, by 50%, and has no effect on the risk of transmission by other modes, it is hard to see how circumcision could reduce the number of infections among Whites by 66%.

" An analysis which does not take into account all costs and benefits of a measure is useless and even if a measure has a net financial benefit it does not necessarily follow that it should be adopted."

The benefit for all males according to Table 1 implies that that circumcising all of the approximately 2.12 million boys born annually in the US would result in a reduction in the number of boys in an annual cohort from being infected during their lifetimes of about 19,000. Even using the lower benefit of $310, the implied reduction would be about 18,500.

These figures seem extraordinarily high compared with the current number of annual infections in the US. According to the 2005 HIV/AIDS Surveillance Report published by the CDC, 4,255 males were infected by heterosexual mode in 33 states which it is estimated account for 63% of nationwide infections. Taking into account the different distributions of mode of transmission by race/ethnicity and the different prevalences of circumcision by race/ethnicity, if circumcision reduces a man’s risk of infection by 50% then approximately 10,400 males would have been infected nationally if none was circumcised and approximately 5,200 if all were circumcised. In other words, if circumcision reduces a man’s risk of infection by 50% then if 100% of the males in the US were circumcised, there would have been about 5,200 fewer infections than if zero were circumcised.

It is difficult to reconcile this relatively low number with the almost four times higher number in Sansom's analysis. Could this mean that Sansom is assuming a much higher prevalence of HIV or risk of infection in the future, which would cause a rise in the incidence (and boost the cost-effectiveness of circumcision if circumcision is assumed to halve the risk)?

In Sansom's analysis, if the reduction in the number of lifetime infections in an annual cohort was less than about 12,500, the net financial value of circumcision to prevent HIV would be negative, i.e., the immediate cost of circumcision would exceed the expected future savings in HIV treatment costs. Again, comparing the required reduction in the number of infections with the current annual number of infections by heterosexual mode, it is difficult to see how circumcision could prevent a large enough number of infections in the future for the net financial value to be positive.

Apart from these arithmetical issues, there are other more serious and less easily remedied problems in Sansom's attempt to establish whether circumcision is justifiable.

The analysis appears to consider only the financial benefits of circumcision in preventing HIV infection against the cost of circumcision.

A true financial analysis must include all costs and benefits, and even that would be inadequate. A comprehensive financial analysis might provide "compelling" evidence that radical female mastectomy at birth or adolescence or after child-bearing is financially advantageous, yet it would not persuade the CDC to assert that the "benefits of prophylactic mastectomy outweigh the risks." It does not follow that something should be done simply because it is financially advantageous. Life is more than financial advantage.

Ignoring other financial costs and benefits renders Sansom's analysis useless because the net present cost of all other financially calculable costs and benefits might exceed the net benefit in respect of HIV and, even if a comprehensive financial analysis showed a net financial benefit of circumcision, it would not necessarily follow that boys should be circumcised.

Another major weakness, perhaps a fatal flaw, is that the analysis makes predictions about highly uncertain events in the future. Computer projections are too often treated as if they were crystal balls enabling people to see the future clearly and with certainty, when the future they reveal is dependent on assumptions that may be way off the mark. The future course of HIV is wildly uncertain. The average age of infection in the Sansom model is 36, i.e., for boys born in 2008, that would be the year 2044. Does Sansom's model assume that the incidence of HIV infection will be the same in 2044 as now?

That no progress will have been made in preventing or curbing the disease in the next 36 years? It's possible, but it's just one possibility in a range of possibilities that includes the possibility that a vaccine will have been developed well before then. Any analysis that relies on the assumption that HIV incidences will not change in the next 75 years or, more broadly, relies on any assumptions whatsoever about the incidence of HIV in the distant future, is inherently unreliable.

To sum up:

1. There appear to be flaws in the conduct of the analysis.
2. An analysis which does not take into account all costs and benefits of a measure is useless and even if a measure has a net financial benefit it does not necessarily follow that it should be adopted. It is difficult to incorporate all advantages and disadvantages of a measure into a financial analysis because many are not reducible to or expressible in dollar values. Beyond that, moral and ethical considerations can easily outweigh financial considerations.
3. No reliance can be placed on an analysis based on assumptions about such uncertain values as the future incidence of HIV.

Sansom's analysis is a paltry one upon which to base a recommendation concerning the circumcision of 20 million US-born boys in the next decade.

Download sansomobservationrevised.pdf

Editor's note: Yet another variable is relative cost of the two controls. Circumcision surely won't be getting any cheaper given the longstanding practice in the United States at government expense. But HIV treatment may in fact get substantially cheaper, for example, if the US turned to universal healthcare.

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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