Male Circumcision and HIV

IAS 2009: The perils of success: what if the new HIV prevention methods work?

At the International AIDS Society Conference in July, a session was devoted to preparing for success in the PrEP and microbicide trials. One talking head had this to say on getting people to buy into and utilize prevention approaches that are only partially effective.

Nonetheless, Francois Venter maintained, it was going to be an extremely hard job persuading funders to pay for approaches with only partial efficacy. It’s not just about whether these interventions will work and can be promoted ethically; can cash-strapped health systems pay for them?

Of course, this was no problem when circumcision came along as the new thing to spend donor funds on. In fact, the problem has turned out to be that countries, individuals, AND donors who have adopted the approach now think they are more protected than they actually are from acquiring HIV. Why aren't the policy wonks talking about misperceptions among those who jump in with both feet? 

Again, new methods of prevention may be welcome and useful, but they are not needed except in the most god-forsaken pockets of the epidemic. Like some unprepared lottery winner, enough never feels sufficient. We have to keep acquiring in order to feel we are progressing. Such is the corrosive effect of misallocated resources.

Link: Aidsmap: The perils of success: what if the new HIV prevention methods work?

IAS 2009: Observations from the booth staffed by NOCIRC - South Africa [photos added]

Thanks to the participants for putting the following together and to Dean Ferris specifically for arranging to allow this blog to publish it.

Andy Fabre of NOCIRC - South Africa, Dr. John Travis, and Martin Novoa staff the NOCIRC - South Africa booth at the 2009 International Aids Society Conference in Cape Town, South Africa. (If anyone is misidentified, please email me with the correction [wilton31@gmail.com].)

From the booth staff: Here are our observations from serving at IAS 2009 Sunday-Wednesday, July 19-22, 2009.

Our booth placement -- over which we had no control -- could not have been better. As you might expect, the deep-pocketed drug companies commanded the largest high-profile spaces at the front of the hall. They brought (or had built) special flooring and enormous displays with backlit graphics. They even sponsored all-day coffee bars, to the chagrin of the food vendors. Unfortunately, to my estimation, their displays were so slick as to be dull. Staffed by attractive representatives, they relied on familiar logos and furniture to draw people. Their reps carried out little to no active solicitation of passersby, and by Day Three they looked irretrievably bored.

The next tier of booths belonged mostly to entrepreneurs hawking HIV test equipment and other services. We were on the good side of the next border, between the entrepreneurs and the -- how to characterize them? -- emotionally motivated exhibitors.

Among them were ACT-UP; Medecins Sans Frontiers; some very sincere living-with-HIV support organizations; and a vendor called Play Nice, which I took to be selling safe-sex equipment, marked by a 20-foot-tall image of a buff, naked man.

We were not line-of-sight with any of them, giving the more serious conferees no reason to steer around us. I believe our professional look (coat-and-tie) helped us in approachability. Thank God we were not marginalized through no fault of our own.

Nonetheless, on Day One, the conference director stopped by with some questions that felt like veiled threats. He asked whether we planned "direct action" at the conference. Of course we did not, and Martin handled his queries deftly. (His concerns were borne out Wednesday, when the ACT-UP people -- including others -- staged a roving rally to confront the drug companies over prices.)

Anyway, to the point of all this: Thanks to our great placement, graphics, and appearance, I noticed a pattern as people passed us. They paused at a distance to read one of the two excellent posters Dean produced, which laid out in large type the four reasons "Male Circumcision is a Mistake." Time after time, once they'd taken in the message, visitors approached our table for more information. We obliged them and solicited questions. If they lingered, we detailed why circumcision won't stop HIV transmission and how it will likely make it worse. I'd guess at least two-thirds of them engaged us in further discussion.

My advice for anyone staffing a booth like this in the future is:

• Don't let anyone draw you into a "Well, what do you propose to stop HIV?" discussion. You may think it's safe to recite, "condoms, counseling, safe sex," etc., but they'll just pick something out of that list and throw it back at you as ineffective. In so doing, they assure themselves that although circumcision isn't very effective, it's "new" so it must be better than whatever you're advocating.
• It may be helpful to assure every questioner up front that we also want to stop HIV. Our message is so opposite the trend that we may have some people wondering if we're a fringe group. This dawned on me when a doctor -- resisting new information -- characterized us as HIV deniers (those who claim HIV isn't the true cause of AIDS). It took me a second to realize he was actually accusing us of this, and I had to start all over with him. Never underestimate people's willingness to marginalize a challenge to their knowledge.
• As Martin's report noted, we took numerous questions about our motives and funding. (What are you doing here? Why don't you have an answer to HIV like everyone else?) The metaphor I resorted to was, If I see someone standing on a railroad track and a train is approaching, I'm going to do everything I can to get him off those tracks. I do not have the luxury of evaluating the most effective means of train-signaling. Besides, mass circumcision will spread HIV faster for these four reasons (etc.).
• Be prepared for different learning styles. In an earlier message on the Centers list I described a young doctor who "learned by talking." Instead of trying to counter every wrongheaded notion coming out of her mouth, I just let her talk herself out, then went for the slam-dunk. There are so many learning styles out there. Sometimes, when you're patient, the questioner will give you the keys to his own lock.
• Finally, stay on message. Circumcision doesn't pass the common-sense test. Only by three dubious RCTs has the case ever been made for circumcision preventing AIDS. Against that, we presented a long list of studies saying HIV doesn't care about circumcision, plus the 60-year experience of U.S. vs. Western Europe, in which circumcision practices were opposite yet HIV rates turned out similar. If circumcision is really supposed to slow down AIDS, why hasn't it?

Going into this exercise I wondered how, at the end of it, we would conclude whether we'd been successful. Our purpose was to educate. How to know if we'd succeeded?

At the suggestion of someone (can't remember who), I drew up a stroke sheet with five categories for the people we met: Very Positive, Positive, Neutral, Negative, and Very Negative.

• Very Negative were those who expressed skepticism toward us, perhaps at a distance, and wouldn't try to understand our position.
• Negative included those whose body language or expressions suggested skepticism. They might have taken some literature at our invitation, out of politeness.
• Neutral -- no obvious response.
• Positive was, in my estimation, the most important category of all. These were people who collected our materials with interest, and/or expressed surprise or intrigue at our information. They may not have said they agreed with us, but their words or actions indicated that they were learning something they would not have learned in our absence. That's who we most needed to reach at IAS 2009.
• Very Positive were people who already agreed with us. Their gratitude was heartwarming to receive, but it wasn't a critical measure of our success. Nonetheless, we served them by providing resources to take the fight back home.

In the flurry of activity, we were not able to record every encounter. However, I hope you are as thrilled as I was to see the distribution:

2 - Very Negative
5 - Negative
16 - Neutral
65 - Positive
26 - Very Positive

Based on that, I'd call the IAS 2009 booth a resounding success.

Our other mission was intelligence-gathering. I sat in on two sessions: the poster discussions and Tuesday's Plenary Speakers.

For those unfamiliar (as I was before this conference), the posters are kind of a sideshow where studies and surveys are documented on large, laminated posters displayed on partitions for attendees to wander past and read at their leisure. There were dozens, possibly more than 100, on display in a side room of the hall. My guess is most of them were done by graduate students or other research teams. There were a few that looked like drug-company propaganda. I didn't see any polemical stuff.

Only five of these posters' authors were invited (or had paid?) to present their findings orally. Each had 10 minutes to present, then a brief Q&A with audience members.

This was the most dismaying hour of the conference for me. I knew going in that circumcision was the accepted "new big deal" with respect to fighting HIV, but to hear every last one of these people begin his presentation with, "As we all know, circumcision is shown to prevent...." just appalled me. They are moving right along with the how, when, and where. No time for "whether"; it's a settled issue.

For example, the first presenter spoke on Kenya's infrastructure and how to most wisely locate clinics to conduct the most circumcisions in the least time. Bang for the buck, in other words, taking into account the availability of staffing, tents, and utilities, and walking distance for the population. She also announced that Kenya -- at their request -- had just made it legal for nurses, in addition to doctors, to circumcise.

The next presenter covered the issue of tracking down HIV-discordant couples (husband with HIV, wife without) to offer them circumcision as prophylaxis. He was a native of sub-Saharan Africa, and inadvertently provided some black humor when, in fragmentary English, he wondered aloud why the women he'd surveyed seemed more accepting of circumcision than the men.

Number Three boiled my blood. He'd gone to the Dominican Republic and surveyed some of the country's least-educated men (farm workers) on their beliefs about circumcision. First he'd asked them if they wanted to be circumcised. Maybe 20 percent said yes. Then he'd fed them pro-circ propaganda. Then he'd repeated his question about whether they wanted to be circumcised. Surprise! He got 67% to say yes. Oh, and almost all of them said they wanted their future sons circumcised, too. !!Eleventy!!

Next up was the most laughable of all: A study of rural Kenyan couples before and after the husband was given a free circumcision (along with health-care services they could not have otherwise afforded). He couldn't get through his report with a straight face. The absurdity of a stranger polling traditional women about something as complex, emotional, and personal as their sexual satisfaction was not lost on him. Neither did this get past a skeptical audience member, who quizzed him on how "satisfaction" was actually measured. He withered under even this light questioning, but not without a cheap shot regarding penile hygiene.

Last up was a presentation on men-who-have-sex-with-men (MSM) in Soweto. This one really seemed like a mess. They wanted to show circumcision benefitting MSM, but the complexities of studying homosexuals in a none-too-homosexual-friendly environment seemed to stymie their efforts. It was the weakest presentation and offered the least useful conclusions. I think even circumcision fans have trouble seeing how the surgery would benefit MSM.

Although in retrospect one can always come up with an incisive question, I saw little opportunity for one. Most of those offered were of the "How awesome are you?" variety.

The First Plenary Session on Tuesday listed the following speakers:

• Ronald Gray (United Kingdom), Johns Hopkins University, Biomedical Prevention, Including Microbicides, Vaccines, Circumcision and PrEP
• Bruce Walker (United States), Harvard University, Immune Control of HIV Replication
• Stefano Bertozzi (Mexico), National Institute of Public Health, Financing the Long-Term Response to HIV
• Prashini Moodley (South Africa), University of KwaZulu-Natal, HIV and Extremely Drug-Resistant Tuberculosis

Dr. Gray covered four bases, including circumcision, with roughly equal time for each. Interestingly, he said a few things that could be used against the case for circumcision:

• Of microbicides (tested by applying to genitals before sex, and showing little promise in trials): "We need more research on the mucosal barriers to HIV." This from a man who's demonized a mucosal barrier.
• He faulted HIV-discordant couples for the failure of circumcision (the Wawer study) to stop HIV transmission, when those couples resumed sex before the surgical damage had healed. Essentially, he's admitting the cure can be worse than the disease. I also found it odd to hear a medical interventionist relying on abstinence for success.
• "Circumcision raises viral load in men just after the surgery." Again: Kill the patient.
• In one trial, suppression of lesser STIs failed to impact the transmission of HIV. This is an important finding, as the presumption has been that sub-Saharan Africa's high heterosexual HIV transmission rate is caused by its scarcity of medical care. This means people continue having sex while suffering lesions, the real "welcome mat" for HIV. But if that isn't proving true, it bolsters the case that HIV is being spread in Africa through medical instruments and the blood supply, a finding supported by at least two studies. Of course he didn't cover that possibility.
  

Next up was Bruce Walker, a sincere and well-educated microbiologist who presented some esoteric but interesting findings on the proteins secreted by infected cells. Toward the end of it, he expressed dismay that his all-consuming work might not yield useful tools for 10 years, while today, 66 percent of mothers in KwaZulu Natal test HIV-positive by age 22. I've rarely seen a technical person show such heart. You had to hear it to believe it.

Stefano Bertozzi (aids2031.org) covered the world economic crisis and its likely negative impact on AIDS funding. He spoke common sense, noting that when money is limited, you must focus on what works and discard what doesn't. He pointed out there was little to no cost-effectiveness data on HIV interventions, which governments, NGOs, and foundations should request as a condition for further grants. In what I saw as a shot at Dr. Gray, Bertozzi said it was more effective to counsel HIV-discordant couples than to target the men for circumcision.

Dr. Moodley detailed the resurgence of tuberculosis among HIV-weakened peoples, which was interesting but seemed to have little implication for resisting circumcision, except to underscore the fact that there are enormous, unmet medical needs in Africa that will continue to go unmet if circumcision sops up all the money.

I'll leave our other delegates to report on what they saw and heard. Overall, this was a worthwhile effort. We got a good picture of what the opposition's up to, salted the field with new and challenging information, and spotted some cracks in the circumcisers' armor.

I hope our other participants will chime in with their observations. I welcome especially any different perspectives on what I perceived.

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AIDSMAP: Circumcision's effectiveness a distant third

Researchers from the British Columbia Centre for Excellence in HIV/AIDS have presented a study, based on mathematical modeling, to determine the level of efficacy in a high prevalence country from condom use, treatment, and male circumcision. They found, to their "astonishment," that male circumcision isn't anywhere nearly as effective as its promotors wish it to be. The results were presented at the International Aids Society 2009 conference in South Africa.

According to an Aidsmap summary, male circumcision rates were examined at 51% (current level), 75%, and 90% with an assumed protective effect of 53%. Condom use was examined at 14% (current level), 50%, 75%, 80% and 90%, assuming a 10% failure rate. Treatment coverage was examined at 21% (current level), 50%, 75%, 80%, and 90%, with a CD4 cell count of 200 cells/mm³ or lower as the primary criterion for initiating ART (antiretroviral treatment). See the article for a detailed description of the methodology and other variables considered.

Researchers determined that scaling up heterosexual condom use to 50% and treatment availability to 80% would avert nearly one million cases by 2019. The numbers were similar if condom use were scaled up to 80% and ART was made available to 50% of those who need it. Raising both condom use and ART to 50% would avert about 700,000 new cases. However, increasing circumcision to 90% would only avert an additional 48,000 cases during the same time period, which is less than a 7% reduction requiring a massive investment.

If the number of new HIV infections averted in South Africa over 10 years is only 48,000 with an adult prevalence rate at nearly 20%, what impact could be expected in developed countries with a prevalence rate of 0.6% or less and where female to male heterosexually acquired HIV is the least common mode of transmission?

The answer is far fewer than 48,000. The truth is that circumcision would change the face of the epidemic very little. Moreover, the massive costs of circumcision, both in money, adverse surgical consequences, and new education and reinforcement of the condom message to prevent disinhibition, etc., should be redirected to increasing condom use and treatment, which in turn would likely reduce additional infections far more than the projected <7% reduction from circumcision.

Condom use and ART coverage, alone or in combination, were found to reduce new HIV infections by from 64% to 95% by 2025 and to reduce mortality by 10% to 34%. Circumcision brought about a 3% to 13% reduction in new HIV infections and a 2% to 4% reduction in mortality; according to Lima, its impact “was overshadowed when combined with the other interventions."

“We were surprised by how little effect it had,” she said.

[emphasis mine.]

The solution to the HIV/AIDS epidemic has been well known for a long time. The early prevention efforts in Uganda and Brazil's leading example of universal access to HIV medications and widespread distribution of condoms has shown in the real world precisely what this mathematical model has shown in the virtual world.

Circumcision has no such real world corollary. In fact, there are examples of where it has had no discernable effect, such as in Lesotho, Malawi, and even parts of Kenya. In the United States, high levels of male circumcision and high levels of HIV conflict sharply with Europe and Japan where levels of both are very low.

Funds diverted to circumcision campaigns, especially those targeted at children who are not at risk, reduce resources for interventions that do work. This is a truth we have repeated often.

Coupled with the recent news from a randomized controlled trial in Kenya showing that male circumcision provides no protection in women and in fact likely increases their risk, male circumcision looks not only unattractive, but dangerous.

Reference

Lima V et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5^th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105, 2009.

CIRCUMCISION: Haiti and the Dominican Republic; Dominicans are a hard sell, Haitians ready to sign up

Bailey et al. wish to employ a strategy to pick off the weak (impressionable youth and mothers) and hope to build a bulwark (a generation of circumcised to displace the older intact generations) and then launch an offensive against the powerless (infants). Such is the conclusion of the following study.

I wonder about how much the local health authorities (Balbuena, Caso) know about Bailey et al. and whether the need for such an intervention got any attention in setting up this study. It is doubtful in the extreme that the disadvantages and harms were offered in any of the discussions with participants or local sponsors. And most telling of all is the use of prevention in the title of this article rather than risk reduction.

ABSTRACT: Acceptability of male circumcision for the prevention of HIV/AIDS in the Dominican Republic [We aren't even using risk reduction anymore.]

Presented by Maximo Brito (United States).

M. Brito¹, H. Balbuena², L. Caso², R. Bailey³

¹University of Illinois at Chicago, Section of Infectious Diseases, Chicago, United States, ²Secretaria de Salud Publica, Santo Domingo, Dominican Republic, ³University of Illinois at Chicago, School of Public Health, Chicago, United States

Background: The objective of this study was to assess the opinions and attitudes about MC, the acceptability of the procedure , the circumcision status , sexual practices, and history of sexually transmitted infections (STIs) among men 18 to 50 years of age in the Altagracia Province in the Dominican Republic.

Methods: A survey was administered to 368 men in 5 municipalities across the province. The questionnaire was divided in 3 sections: 1) background demographics, 2) male circumcision and 3) sexual health. Data were analyzed using SAS version 9.1.3. Descriptive statistics were generated for each of the variables corresponding to specific questions in the survey and contingency tables were constructed to calculate measures of association. Logistic regression analysis was performed .

Results: The sample consisted of 238 (65%) Dominican men and 130 (35%) Haitian immigrants. Almost all the men were uncircumcised (95%) and about half (52%) were single. Overall, Haitian men were more likely to agree to a circumcision than Dominicans (OR=1.89, 95%CI, 1.18-3.02). Similarly, younger men (18-30 year-old) were more agreeable to the procedure compared to their older (31-50 year-old) counterparts (OR=1.65, 95% CI, 1.02-2.66). After controlling for age, the difference between Dominicans and Haitians persisted (OR=1.83, 95 % CI 1.14-2.95). Participants who believed that circumcision improves hygiene and may reduce the risk of STIs, HIV or penile cancer were two to three times more likely to say that they would have the procedure if it was offered to them. The acceptability of circumcision increased considerably after an information session describing the benefits of the procedure [I think it's fair to assume this was the hard-sell].

Conclusions: We believe that rolling out circumcision services in the DR is feasible. An education program aimed at sexually active young males and mothers [?] is essential to increase the acceptance of the procedure in the population.

Updated: IAS 2009 Live [Open Thread in the Comments]

Ok, I'm a little late and haven't covered this much. My bad. Here is a link to live coverage.

IAS 2009 Live Shared via AddThis

EDIT: Ok, I blew it and missed the IAS 2009 conference in its entirety. Still, let me take this opportunity to be critical.

The following post on the live blog from the conference strikes me as self-serving and desperate in these difficult economic times.

IAS: New Evidence of Broad Benefits of HIV Investments

At the conclusion of IAS 2009, the International AIDS Society released a statement highlighting new evidence illustrating how investments in HIV have contributed to reductions in infant mortality and TB incidence, improved access to health services for women, and expanded health systems capacity.

Research presented at the conference -- as well as an IAS two-day meeting on health systems strengthening, sponsored by the Rockefeller Foundation and the World Bank, in conjunction with IAS 2009 -- included evidence suggesting that the scaling up of HIV programmes can lead to improvements in outcomes related to other health conditions and bolster health care infrastructure overall.

Read more…

Read more if you want, but it is more of the same claims that AIDS spending to the detriment of other more pressing health problems is good because it is really just a way of addressing all sorts of other health issues. Before I can buy that in a continent where starvation, war, and water born diseases kill far more than AIDS, I need to see evidence that spending on these problems  directly can't measure up to the secondary effects of AIDS spending. I doubt such evidence is out there or would be forthcoming if studied.