Male Circumcision and HIV

UGANDA: New HIV/Aids Messages [re male circumcision] Worsening HIV Situation

Objective minds predicted this outcome long before any on-the-ground examination was carried out. The reality is male circumcision is making things worse.

New HIV/Aids Messages Worsening HIV Situation

A new report by PANOS Eastern Africa has shown that new HIV/Aids messages meant to reduce the prevalence of the disease are instead facilitating its spread as they have created false impressions, especially with regard to multiple concurrent partnerships and male circumcision. PANOS is a network of institutions world over that carries out research and documentation of development information in marginalised communities.

image / flickr / genvessel / constant gardener

The report, titled "Communication challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision", shows that majority of rural population believed that male circumcision gives a complete protection to HIV/Aids, while more than 88 per cent did not exactly know what the sexual network was.

Download "Communication Challenges in HIV Prevention"

JOURNAL OF PUBLIC HEALTH IN AFRICA: How the circumcision solution in Africa will increase HIV infections

Congratulations to Dr. Van Howe and Dr. Storms on publishing the following paper. Full article available at the link below.

How the circumcision solution in Africa will increase HIV infections

Abstract

The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.

IRIN PlusNews: Stupid Talk with Stephen "Orgy of Male Bonding" Lewis

Five minutes online and you will discover that there is a very vocal opposition to infant male circumcision for profoundly important ethical and practical reasons. While Canadian Stephen "Orgy of Male Bonding" Lewis may not like it, he can hardly claim shock and dismay at the fact that male circumcision is not a popular choice in the HIV/AIDS prevention community except in places where money-driven NGOs dominate areas where the public sector is weak and ineffectual.

image / flickr / makeroadssafe / Stephen Lewis, Hypnotist (Stephen Lewis, Former UN Special Envoy for HIV/AIDS)

Lewis, whose son, Avi Lewis, is married to noted Leftist activist and author, Naomi Klein, is not an advocate without a conflict of interest in this push. He operates a charity, AIDS Free World, which is active in pushing the circumcisionists agenda and espouses an AIDS exceptionalism much decried in the last few years. He's also on record stating he has shared moments of emotional bonding with other men over his being circumcised himself.

In the article excerpted below, he claims that we knew circumcision reduced HIV infection in the 1990s and laments that the world waited for some evidence, however scanty and unclear, before doling out millions of US taxpayer dollars to bum rush millions of panicked and gullible Africans into submitting to the procedure. Lewis demonstrates a brazen certitude underlying the gusto with which several East African countries have embraced one more spigot of AIDS funding pouring into the region.

HIV/AIDS: Straight Talk with Stephen Lewis

...

Q: What is the hardest truth about the fight against HIV that we are not facing?

A: The recognition that there are HIV prevention interventions that would work if only the world would galvanize around them.

...

Look how long it took us to implement male circumcision. We knew in the 1990s that male circumcision was a way of reducing HIV infection for men. We waited until we had a plethora of studies and didn't get going until 2005. Paula [Donovan, AIDS-Free World co-director], in the year 2000, suggested circumcision [should] coincide with immunization for babies. If that had been done, we would soon be receiving the benefits of that but everybody laughed it off.

AMERICAN JOURNAL OF PREVENTIVE MEDICINE: Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity

The American Journal of Preventive Medicine has recently published a discussion on the "external validity" of the three African randomized control trials that examined circumcision as a preventive measure for HIV infection. The nutshell version of this discussion is that clinical conditions that show promise do not necessarily translate into a real world net benefit.

Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity

Recent editorials have asked the global health community to scale up male circumcision for HIV prevention in regions with HIV epidemics following the publication of three randomized controlled clinical trials (RCCTs) in Africa (in South Africa, Uganda, and Kenya).1–5 One editorial concluded: “The proven effıcacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”6 This “Current Issue” review questions not the internal validity of the studies, but their external validity, an issue that has been discussed more generally in two commentaries,7,8 an editorial,9 and a systematic review of research on prevention trials10 in this journal. External validity is the issue that questions the generalization from the RCCT results to a policy of “immediate and rapid adoption” of circumcision of men across Africa.

Five dimensions of external validity should be weighed before the global health community can determine that male circumcision is a widely effective, cost-effective, or cost benefıcial use of resources, as well as an effective and safe method for controlling the HIV epidemic in Africa. These trials provide a case illustration of how a policy might be adopted without due consideration of external validity in experimental trials that appear to have established internal validity for a short-term reduced risk of infection.

...

Recommending mass circumcision by generalizing from the particular RCCTs to the diverse populations of Africa highlights problems of external validity identifıed in several areas of preventive medicine and public health research. Studies published since the RCCTs show that (1) male circumcision is not correlated with lower HIV prevalence in some sub-Saharan populations 14,15; (2) circumcision is correlated with increased transmission of HIV to women 20; and (3) male circumcision is not a cost effective strategy.17,28 This new evidence warrants caution and further study before recommending circumcision campaigns. In addition, ethical considerations, informed consent issues, and possible increase in unsafe sexual practices from a sense of immunity without condoms must be weighed.

The global health community understands that the most important modifıable factor in sexually transmissible HIV is human behavior. 40 The policy questions to be considered are not whether a link exists between male circumcision and reduced rates of HIV infection, but, rather, whether mass circumcision is (1) an ethical and safe public health choice, and (2) the most cost-effective use of limited resources.

Download PDF: Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity

Four years and counting ... circumcision still has no place in HIV/AIDS prevention efforts

Four years ago today, I became so concerned about circumcision and HIV that I started this blog in the small hope that I could be one point of dissent in the then growing out-sized belief that circumcision would save the world from HIV. The world has reconsidered in that time and only the US and some African countries under pressure from US bribes and the influence of superstition have taken up the circumcision cause with any vigor.

It is heartening to know that even Robert Bailey, a notorious advocate, has found it necessary to back-pedal in his claim for circumcision in the HIV/AIDS fight. He has authored a paper entitled, "Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs" that he should have entitled, "Circumcision Not Associated with HIV Type 1 or 2." We shouldn't be surprised at the misleading title because Bailey and others are guilty of mistitling more than just this one paper. 

Whatever the case, the money quote is this. "This study did not detect the expected association between male circumcision and HIV seropositivity, possible (sic) due to limitations in sample size and prevalence. With 38% of men and nearly 65% of women HSV-2 positive, however, our ability to detect any association between genital herpes and circumcision status or preference for circumcised partners was improved - no association was found."

The Medical Journal of Australia has recently published a World Aids Day editorial concluding behavioral change is still the tip of the spear in HIV prevention. Entitled, "HIV will only be defeated when behavioural means of prevention become the basis of the global response," William D. Bowtell writes, "We can contain HIV by improving access to treatments and providing care to people with the disease. But HIV will only be defeated and eradicated when the lessons of behavioural prevention that we developed and applied in Australia two decades ago become the basis of the global response." Here there is no mention of the C word because it has no place in prevention efforts.

Fundraising and Longevity

I wanted to inform readers that I will be publishing a book in the new year with images of the intactivists who marched in the San Francisco Pride Parades of 2009 and 2010. It will be a limited edition intended to raise funds for the blog so I can implement some improvements and hopefully carry out and publish some original reporting at long last.

Few may realize that we came close to losing the blog last year due to a faltering TypePad platform that was averted by the sale of the company. I wasn't even aware of it until the danger had passed. I don't have control over the platform obviously although I pay for hosting rather than rely on free alternatives, such as Blogger or the basic version of WordPress.org. That is apparently no assurance that the whole thing won't come down anyway. I now backup the blog periodically. However, this is no real solution because backup capabilities preserve the content, but not the format. If the platform ever went down for good, it would be months, years or never before I could put everything back together again. The fundraiser will make it possible to move the whole thing to another service.

Anywho, thanks for reading and best to all in the New Year!

AVAC STUDY: Medical male circumcision effect on women likely universally bad

A bunch of focus groups were set up in East Africa to determine women's attitudes and perceptions (shaped no doubt by experience) to medical male circumcision. All the findings came out negative. From believing that male circumcision is by definition an indicator of a man's HIV status (i.e. negative) to the fear that male circumcision will lead to an increase in female circumcision to the experience of women finding themselves in a reduced negotiating position when it comes to safer sex, male circumcision is UNIVERSALLY BAD for women. What's worse is the researchers appear as ignorant as their subjects on the meaning and impact of male circumcision - albeit in a different way.

Link: New report provides women's perspectives on medical male circumcision for HIV prevention

Link: AVAC - Global Advocacy for HIV Prevention

image / flickr / davida3 / Samburu children

ZIMBABWE: A familiar fear - one intervention at a time, likely the norm in HIV prevention

Many critics of the African circumcision trials drew the obvious conclusion that a push for male circumcision in Africa and elsewhere would result in a corresponding drop in condom use. In a partially useful risk reduction intervention, such a result would necessarily negate any gains. Now we have proof from another intervention, the female condom.

Researchers did a follow up on a trial that sought to increase the use of both condoms and female diaphragms. They found that after the trial ended, the use of the dual technique dropped to pre-intervention levels. They concluded, and further commented on an upcoming intervention, "The results showed us that it is a challenge to use concurrent HIV prevention methods ... . If tenofovir gel becomes available, women may ask - if we have the microbicide, why use a condom?"

Does that last line sound familiar? It should.

Link: ZIMBABWE: Drop in Condom Use Following HIV Prevention Trial

image / flickr / Smath. / One Hundred Billion Zimbabwe Dollars

AIDSMAP: Contrary evidence for treatment-as-prevention "demands giant pause," contrary evidence for male circumcision not so much

With so much room for things to go wrong, the rush to roll out male circumcision has perplexed most dispassionate observers. Yet similar doubts re: treatment-as-prevention seems to have gained detractors calling for a "a giant pause" in light of a few studies showing real world conditions at odds with clinical trial results.

The Journal of AIDS has published a paper casting doubt on the use of treatment as prevention. The accompanying editorial is one that never appeared in the context of male circumcision and a similar disparity in real world conditions and the results of the African RCTs.

In an accompanying editorial, Dr Myron Cohen says that the results “demand a giant pause” and show that the ability of HIV treatment to reduce the risk of transmission outside the setting of clinical studies is uncertain.

image / flickr / genvessel / constant gardener

You will notice the distinction between the real world and clinical studies is key. It is also key to the conundrum of the three RCTs in support of male circumcision and the reality we have seen with higher rates of HIV among circumcised men in places like Swaziland and Losotho.

Reference

Wany L et al. HIV transmission among serodiscordant couples: a retrospective study of former plasma donors in Henan, China. J Acquir Immune Defic Syndr, 55: 232-38, 2010.

Cohen MS HIV treatment as prevention: to be or not to be? J Acquir Immune Defic Syndr, 55, 137-8, 2010.

Link: Does 'real world' study cast doubt on use of HIV treatment as prevention? - Aidsmap

LIVE: MC_HIV at the Folsom Street Fair 2010

Welcome to the periodic live broadcast from the Folsom Street Fair. We are hosting a booth distributing information on male circumcision and HIV. You can view the streaming content below or go to Live from the Folsom Street Fair to view and engage through chat with other viewers. You can also view the stream on our facebook fan page and leave comments there. Or watch here and leave comments here. Finally, if you'd like to watch the broadcasts again and take your time to reflect on what you'd like to say in the comments, see the archived video on our YouTube channel! Finally, remember this is experimental. If you can't see anything or the video is unwatchable, you can see the content later to YouTube. Thanks and enjoy!

AIDS PATIENT CARE AND STDS Vol 24 Issue 8: Circumcised men who have sex with men may be more susceptible to HIV acquisition

The latest study to suss out the impact of circumcision on rates of HIV acquisition among gay men has provided some important insights. The general conclusion to be drawn is that the failure to show a statistical difference between circumcised and intact men who have sex with men continues to appear in study after study. The study appeared in the journal AIDS Patient Care and STDs, and was entitled "Relations Between Circumcision Status, Sexually Transmitted Infection History, and HIV Serostatus Among a National Sample of Men Who Have Sex with Men in the United States."

The latest study has provided an interesting additional insight. Circumcised men are more likely to use condoms. Yet intact men as a group do not appear to show higher rates of HIV acquisition DESPITE this apparent disadvantage. The converse however may not be true. The higher rates of condom use among circumcised men may mask a greater susceptibility to HIV acquisition among men who have sex with men.

image / flickr / Photos by Mavis / rainbow love bench, yachats, oregon

The authors go on to describe a lower rate of herpes in circumcised men, a finding that can be entirely explained by higher rates of condom use in this cohort.

An additional finding that did not affect the relative levels of HIV in either group is that men who reported always vs. never using condoms was higher among a subset of circumcised men for always wearing condoms.  Yet apparently, never using condoms among a subset of intact men did nothing to change the over all balance between the two groups in HIV acquisition the fact this finding did not change the over all level of HIV acquisition between the two groups is underappreciated and the implications could be disruptive for those proposing circumcision campaigns generally.

The bottom line: circumcision does not result in a protective effect against HIV acquisition. It should be emphasised that circumcised men who have sex with men should be especially careful to continue to use condoms in every encounter with men of unknown HIV status due to the possible greater susceptibility to HIV acquisition.

Reference

Kristen Jozkowski, Joshua G. Rosenberger, Vanessa Schick, Debby Herbenick, David S. Novak, Michael Reece. AIDS Patient Care and STDs. August 2010, 24(8): 465-470. doi:10.1089/apc.2010.0082.

Download Jozkowski et al -Aids Pt Care - 2010