Male Circumcision and HIV

Notebook: Puerto Vallarta Edition

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Omar and I were so-looking forward to our little trip down to Puerto Vallarta about three weeks ago. While our collective purpose was to escape the pressures of work, I, incidentally, had my own little private purpose, and that was to leave circumcision and HIV behind for a few days. Believe it or not, this issue taxes me more than my job. Welp, three days into our long sought paradise, whaddya figure pops up? Yep, an article in a local gay rag on circumcision.

The magazine is called Revista Estilo Libre, and the audience is largely gay men. I have seen few better examples of twisted hack journalism than what I read in Estilo Libre. While it's a little hard to get exercised over a mag that has an infinitesimal circulation, it gets easier as you realize the level of error the author achieves -- and who the audience is: mostly intact gay men.

First, the author goes on about the procedure requiring 20 sutures and two weeks to recover from, yet claims circumcision is a minor "intervention." One might think that such a contradictory description would be sufficient to stop the worry. Yet, the reader is quickly disabused of that notion as the author goes on to claim that circumcision prevents cancer of the penis by removing glands that produce smegma, a "carcinogenic." Bad enough, but it gets worse still. The author cites a study that he claims was published in the New England Journal of Medicine wherein 50 Ugandan men were circumcised and exposed to HIV-infected ... wives?? other men?? We aren't told. None were infected, according to the alleged study. Finally and less damaging to gay men specifically, but perhaps slanderous to Jewish people is the claim that ancient rabbis used to circumcise infants with their teeth!! Of course, we are to be calmed by the writer's reassurances that this has been stopped due to the dangers of transmitting tuberculosis!!   

Feel free to send them email and/or visit their website. It's in Spanish. So, it would be helpful if you could write in that language. Otherwise, English will do as I am quite sure they will be eager to get email from a concerned international audience.

http://www.revistaestilolibre.com.mx/

revistaestilolibre@hotmail.com
revistaestilolibre@yahoo.com.mx

A scan of the magazine article after the break.

Notebook: Kenya Braces for Epidemic of Genital Warts

Forgive The Onion-esque headline. Still, I'm just taking two sources and interpreting them together.

Kenya has decided to make circumcision part of government policy in the fight against HIV/AIDS, joining Rwanda, Uganda, and Ghana. I'm not sure what this means in terms of actual on-the-ground changes, apart from payment and training. But this being Africa circumcision, compulsion will likely take some ambiguous form, much as it has in the United States, with ridicule, guilt-trips, misinformation, and other assorted mind games.

To be fair, at least some lip service is being paid to the reality that men will likely skip condoms once circumcised. According to the Kaisernetwork, "Ruth Njeri, an HIV/AIDS advocate, said she fears the new policy might make circumcised men have unprotected sex and think they are safe. 'Men who have been using condoms or those who have been faithful to their spouses will now opt for unprotected sex,' Njeri said."

[Edit: Aidsmap has a much better piece on the Kenya story. Apparently, this is an effort to coerce the non-circumcising communities of Kenya to adopt it, as most of Kenya already circumcises. Of the ethnic minorities that don't, only the Turkana seem to be resistent. The others have already fallen victim to the meme of better sex and greater attractiveness. It's an interesting case of a community acting against its own interests that has its counterparts in politics and psychology.]

Take a study that shows a modest increase in incidence of sexually transmitted disease among the intact, and the MSM (that's mainstream media, rather than men who have sex with men) go ape-shit. Take a story showing a doubling of one type of STD in circumcised men, and you have to go all the way to Sri Lanka to find out about it.* Thank God for the Internet. The Tamil Star is reporting that circumcised men have much greater rates of genital warts than the intact.

Nearly 7% of whites reported having been diagnosed with genital warts

4% of African-Americans reported having been diagnosed

2 1/2% of Mexican-Americans reported having been diagnosed

Circumcision appeared to have an effect on rates of genital warts:

4.5% of circumcised men reported having genital warts

2.4% of uncircumcised men reported having genital warts

Source: April issue of Sexually Transmitted Diseases.

*Ok, I didn't search long and hard for this story elsewhere, opting instead to nick it from the Intactivism Pages. Thanks, Hugh (and others via email).

Editorial note. Coming up this week will be a belated Puerto Vallarta Edition of Notebook.

Hasta entonces!

Notebook: Apologies, faithful readers

This month has kicked my ass. As soon as I think I have it under control, I'm hit again with another wave, including a trial. The good news is that we (co-counsel and I) won that one, too.

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And now a few missed stories ...

The Alexander Sanger commentary on the Planned Parenthood site was interesting [also available here.]. The way I understand Sanger, he questions the allocation of resources to a very imperfect and contradictory claim for circumcision in HIV prevention. He calls for a level-headed approach to prevention that promotes the most highly effective means of prevention, i.e. condoms, testing, empowerment of women, and education. With circumcision being highly contested, expensive to administer, and likely to become a poor substitute for condoms in the minds of those who undergo the procedure, it's likely to cause harm. Plus, he seems to say that it's just bad policy to allocate money down the list of least effective measures when the most highly effective measures have yet to be fully implemented.

Other stories deserved attention earlier in the month. There was the story from Belgium regarding the jail sentences for parents who refuse to vaccinate their children against polio. That one has implications in the HIV/circumcision controversy, although important distinctions exist. Perhaps more on that later. Perhaps readers could help out on that one in the comments.

There was the news out of Ghana where circumcision will now be promoted despite the fact that circumcised men tend to be infected at higher rates than intact men in that country. Same old story, except out of Ghana instead of Rwanda this time.

Finally, Reuters is reporting this morning on that old story from last month, that circumcised men are no more protected from STDs than intact men. Actually, the data slightly favors intact men. We knew this already as study after study over the years has swung from protective to not protective. Do we need any more studies on STDs and circumcision at this point? I doubt it.

The importance of the STD story is that researchers have seen a correlation between levels of STDs and likelihood of infection with HIV. The developed theory was that STDs increase the likelihood of contracting HIV due to inflammation and lesions symptomatic of so many STDs. However, we saw that treating a prime suspect in this regard, herpes, did no good in reducing HIV rates. Therefore, it would seem the theory doesn't hold. Of course, we don't know for sure. But clearly, the theory needs more study.

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Apologies, dear readers, for the intermittent nature of this month's posts. I'll do better next month. Thanks for reading.

Notebook: This Week In HPV/HSV/HIV

Nothing focuses the mind like waking up to stacks of files with looming deadlines and an expectant client sitting in your office asking questions about the trial that, by the way, starts tomorrow. A couple of concentrated weeks of longer than usual days cleared my desk if only for the next wave and we won the trial. So all's good and I'm back.

Meanwhile, the press churned out more blogger fodder in the week that was.

Treating HSV Does Not Significantly Reduce Risk of HIV

As has been reported here in an earlier post viz. men, treating HSV (herpes) apparently doesn't reduce the risk of HIV infection in women either, according to a study conducted in Tanzania [Medscape, reg. req.'d]. As the rationale behind circumcision has been that it also may reduce some ulcerative STDs, it therefore should reduce the risk of HIV. If circumcision does reduce risk of HIV, it isn't apparently due to a reduced level of ulcerative genital conditions in men from treating HSV as the earlier study so urgently hoped. Now, we know that the women being treated also get no benefit.

Bottomline: Early detection is probably the best defense against the spread of both HIV and HSV, which we have known of course for decades.

Secondary lesson: We still have no idea why circumcision may reduce the risk of HIV. Researchers are just guessing when they offer a rationale.

1 in 4 Teenage Girls

Sounds like the title of a horror movie, but instead it was the latest hysteria (Yahoo! News, link will expire) from the media. A bunch of researchers at the Centers for Disease Control and Prevention looked at data broken down into age groups. It isn't clear from media reports where they collected the data, but accordingly nearly half of African American girls have a sexually transmitted disease compared with 20 percent of white girls.

Apart from the smear of young black girls and the obvious appeal to hysteria, appropriately enough during STD Awareness Week, more, much more needs to be known about the sample and where it was taken. Moreover, the most common STD was HPV, a disease for which we have two vaccines for the most common types and which can also be completely cleared by the body. Either the researchers were highlighting the lack of screening or commenting on the sorry state of healthcare in the United States.

Despite Vaccines, Bored Researchers Study Circumcision to Determine Prevalence of HPV Among Men

Nothing like a hysterical headline to grab attention. UNCIRCUMCISED MEN RUN TWICE HIGHER RISK (sic) OF CANCER-CAUSING HPV blares the International AIDS Society. Of course, many other studies have shown only a slightly increased risk and other developed intact countries have much lower rates over all. Therefore, uncircumcised men probably do not run twice the risk unless they are in a country with a feudal healthcare system or lack early detection. Perhaps the title should have been AMERICAN MEN RUN TWICE THE RISK OF HPV INFECTION or AFRICAN MEN RUN TWICE THE RISK ... or whatever.

Besides, aren't they about to approve the two HPV vaccines for use in men? Oh yeah, yeah they are!

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.]

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.

Notebook: Idaho Edition

Idaho Falls in the great state of Idaho didn't inspire any great insights into the problem of prophylactic circumcision. But whiling away the hours at my grandmother's house did provide me with the opportunity to catch a little C-SPAN. One program in particular caught my rapt attention for about an hour and a half.

I caught only a part of the program and at that, only Part II of the three part series. In the section I saw, George Lakoff, Frank Luntz, and Andrew Westen gave a panel talk at the New York Public Library on the science of communication in the political discourse of the United States. (I'm posting all three parts below.) This fascinating program, entitled THERE YOU GO AGAIN: Orwell Comes to America, goes straight to the core of how some ideas take off and others don't. Clearly, you don't have to be in politics to see this is a very important area of study.

Before we begin the show, I would like to share not exactly an insight, but a little insightful family history that I experienced anew while I was in situ, Idaho Falls.

My grandfather passed away some six years ago. In the basement of the house he occupied for half his life, he kept a small office. It was walled off from the rest of the basement by a small enclosure that he paneled in deep mahogany tones. There on the shelves he also built, books could be found on his many intellectual indulgences, including amateur radio, the classics, history, literature, alternative theories on just about everything and of course on the topic of his training and chosen profession, physics.

It was he who had not once but several times asked me in our occasional phone conversations between his office and my home in Texas whether I knew what the most common surgical procedure in the United States was. I of course did know, and with my grandmother on the upstairs phone, would proceed to tell my opinion on the matter. Eventually, my grandmother, who delivered my Uncle at age seven to the surgeon, would try to end my rant with, "Ok, we get it, ... moving on, moving on ... ."

I have no idea and did not ask, nor frankly was ever tempted to ask, whether my grandfather was intact ... although I wondered. He was born in 1910 in Michigan to a Dutch mother and a German father. So it is likely he made it through life just fine. He made it clear by the insertion of the word unnecessary in the question how he felt about it. But he was a patient man in a house run by a stern disciplinarian who raised her three children according to the dictates of her own upbringing that left no room for the tolerant easy-going acceptance of my grandfather.

So, standing in his small office, I looked around at the cleared shelf space once occupied by books and amateur radio equipment. The desk was a mess. The floor was scattered with records of long ago radio communications between amateur radio operators from around the world and my grandfather. Boxes of personal effects and records from nearly 30 years of retirement were scattered around haphazardly. A faded picture hung on the wall of the bell tower at my grandfather's alma mater, the University of Michigan. This was the inner sanctum, walled off from the rigid religious world of my grandmother, but which now was reduced to salvage by his surviving children and grandchildren.

This life is short. We all know that. Once we die, the book is finished. The story is set in stone. The pages will begin to fade. And there will be no more creating, legacy-making, or changing the world in the deceased person's unique way. And so, my grandfather leaves behind not the seed, but the encouragement that he provided by asking the question, and giving me the courage to challenge circumcision. It's a gift I cherish.

Outside, the sky dumped a foot of snow while I was there. And my grandmother, who I love very much, told me that she often thinks of my grandfather out there in the ground where he is buried and it is very cold. I told her that she shouldn't worry. He's not feeling it. I was thinking that, even as I was feeling his presence downstairs in that cold basement. And I felt very warm inside.

For your viewing pleasure, please click below to go directly to the program's page for a synopsis and the audio and video podcasts.

Live from the NYPL
THERE YOU GO AGAIN: Orwell Comes to America

Part I Propaganda Then and Now: What Orwell Did and Didn't Know

Part II Deceiving Images: The Science of Manipulation

Part III Soluitions: The Future Political Landscape

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Notebook: Happiness and Development

Human rights may be the luxury of a rich and secure society. Only in such societies can one contemplate happiness. Perhaps where the happiness is not defined by freedom from hunger and fear, the abstraction can be debated. Yet many a philosopher has postulated that wealth and security are the results of human rights in the sense that the fruits of a full stomach and security in one's person are the realization of one's maximum contribution to society. And a society where every member is contributing maximally to the best of his or her ability is one that is rich and secure. Kind of circular.

So on the upside of this circle, we debate the violation of one's physical integrity. Maybe this explains why Ugandans and Zimbabweans are said to be rushing to get circumcised, absent any real security and in the midst of plenty of hunger. And so it all comes back to development. The citizens of those countries and others will accept anything on the downside of the circle because they frankly don't have that much to lose. With low life expectancies, loss of sexual tissue for the off chance that life may be extended is an easy choice easily exploited by the likes of Halperin, Klausner, and Bailey.

But we in the West have plenty to lose. And so many of us will not accept circumcision. And so Richard Duncker, trustee of NORM-UK, gives us his take on happiness once violated by infant circumcision.

Link: Are you happy? Richard Duncker, yoga teacher & trustee, Norm-UK | Weekend | Guardian Unlimited.

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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Notebook: NYC Edition

I'm here in New York City, rubbing shoulders with people from every imaginable corner of the world. It's an experience that makes you think about the meaning of acceptability, a concept that has a lot to do with the promotion of circumcision in Africa -- and in developed countries.

A great deal of the news one hears about HIV/AIDS is characterized by its dire tone, desperation, guilt inducing pleas for sympathy, and calls for money. Calls for circumcision over the decades have shared many of these qualities, particularly the direness, the desperation, and the guilt trips. Leave it to Robert Bailey and Daniel Halperin to add the money element.

Money is a funny thing. Price something too cheaply and it appears, seems, and may even look cheap without regard to the reality. Give it away and it often goes begging. Price it too high and desirability rather than quality suddenly becomes the issue. A high price seems to actually induce buying.

Something for free? Take it or leave it. The illusion is of abundance and that one can always come back.

Cheap? You get what you pay for. It won't last. We'll just have to replace it or do it again whatever it is.

Expensive? How can we afford it? How can we rearrange not just our finances, but our very priorities.

What does all of this have to do with the controversy over circumcision as an HIV prevention? Bailey and Halperin have called circumcision an HIV prevention as opposed to a risk-reducing measure, claimed an absurd 75% protective effect, and deflected the controversy by claiming no personal interest in the subject other than helping people. Halperin has said to me personally and elsewhere that most of his writings are about behavior change. But of course, this is subject-changing and deflection to slip his agenda passed lowered defenses. And one he will not be able to honestly make for much longer.

The economics of it are this. Claim an outsized value on something, and get people to pay dearly by buying into what is essentially a genital mutilation. The analogy is not perfect. It breaks down in developed countries when you consider that the value is claimed to be very high while the personal and financial costs are offered as inconsequential. The reality is that the value is close to nil in real world settings while the high cost is disguised.

The analogy is much better suited to Africa. Circumcisions are astronomical in cost both in actual money terms and in the over all resource loss to the medical system while providing no real prevention. It's basically a zero sum gain for prevention and a net loss for the provisioning of not just HIV testing, treatment and prevention services, but for basic medical services in maternity, vaccination, education, and other essential areas of health care. And the personal cost is rightly perceived as very  high because adults are the target and circumcision is not common in the targeted areas. Hence, the promise of a discount for later generations, if only the current targeted group will only pay high now, by the introduction of infant circumcision where it has been unknown before.

So Bailey and Halperin have gone shrill in their calls for money, calling for expensive mobile circumcision services, and their alleged rightful share of the HIV pot to fund them. After all, circumcisions aren't going to perform themselves. And so, the campaigning for cash has begun.

So what can we do? A lot is the short and hopeful answer.

The interest of people of conscience should be two-fold. First, HIV prevention, education, and the integrity of any system that purports to participate in this endeavor. Second, providing these services at the lowest possible cost to the individual and society without dictating how individuals should go about their prevention strategies. And the irony is that working towards the lowest possible cost to the individual is ... you guessed it, expensive.

Therefore, I will be placing all contributions to the Tip Jar and my own personal contributions in trust, pending the formation of an entity that will provide the financial wherewithal and emotional, political, and personal moral support to do this work. We can make a difference, get the attention this cause deserves, and compete (yes, I mean literally compete) with the likes of Halperin and Bailey, who by the way have the full authority and economic support of their institutions behind them.

Finally, I would like to thank Joe Pellegrino for being our second contributor to the Tip Jar. Your contribution is more than financial. It encourages us all. Thanks.

[REVISED third paragraph.]