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.

The Centers for Disease Control Need to Hear from You Today [UPDATED4]

UPDATE4: The information formerly in this post is now available on the  The CDC/AAP Project page.

UPDATE3: I have reorganized the information below and put it on The AAP Project page, now rechristened The CDC/AAP Project.

UPDATE2: Some people have received form letters from the CDC regarding this issue. We still have time to press the point. I have added additional names, addresses and emails of individuals you may contact regarding the impending endorsement by the Federal Government of male circumcision. This is your government getting deeper into the business of genital mutilation and forced circumcision of children. Form letter added below.

UPDATE: At the end of this post is a list of key people to contact at the CDC and the AAP. Your voice is important. Please write the people speaking in your name.

Visit The CDC/AAP Project

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

What will Klausner do if people simply don't want it?

Jeffrey Klausner has published a shrill piece [summary] in Future Medicine decrying the apparent lack of interest in circumcision, which he says is at least as good as any vaccine and the "'only modality for preventing' sexual HIV transmission that has been proven to work by the 'highest standards of scientific evidence.'" [Reference.] Moreover, he claims it prevents a myriad of other sexually transmitted diseases.

He's crazy.

Frankly, I'm not sure whether this is good news or bad news. Such shrillness surely signals the author's sense that people aren't as interested as he would like them to be. On the other hand, he clearly is signaling to the world that he intends to make this his life mission.

There's only one thing to do. Sharpen your pencils and ready yourself for Target Klausner.

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.

Happy New Year and Here's to Our 166th 165th Post!

Ok, so it isn't the 100th or the 200th post or some other even number. Nevertheless, it is a new year and since we didn't do a one year anniversary post, which would have been on December 27, 2007, we would like to take this opportunity to wish you a happy and successful year ahead in all your activism.

Have a safe new year, which means practicing safer sex where appropriate. Thank you for visiting, reading, and subscribing.

TIME Magazine's Top 10 Medical Breakthroughs: #1 - circumcision prevents HIV

Time magazine claims that circumcision "can prevent HIV" infection. Apart from naming the lie that such an assertion is, what else can you do about it? I suppose you can write them a letter, go to their talk back page.

Let me share a little insight I have finally begun to rediscover recently. People in the United States are just not equipped to deal with issues requiring critical thinking skills. In this way, Americans are more tribal than our counterparts in the developed world. As such, people in this country by and large simply see nothing wrong with performing medical procedures of marginal value on patients of whatever age. If the parents or some perceived authority figure says it's ok, then it's ok. This is our reality in the United States.

Diseases, such as HIV/AIDS, will come and go as justification and the circumcision rate will rise and fall, but it is a practice that has integrated itself like some annoying viral infection into our DNA. Not until some major disruption comes along will the people of the United States in the masses learn to assess what is or is not good for them.

Link: Top 10 Medical Breakthroughs - 50 Top 10 Lists of 2007 - TIME.

World AIDS Day Observance

No grand post today. No philosophical musings. Just observance.

Today is World AIDS Day, and the victims are not just those who have HIV. They are also those who have fallen victim to the politicians and medical hucksters who have used the disease to their own ends, whatever the motive. Take a moment to think about them, too.

A word about fundraising on MC & HIV

In the last two months, I have received three contributions to the Tip Jar. First, thanks guys. Now for an important word on fundraising.

As of this post, no money has been withdrawn from the Paypal account in which all funds contributed are deposited. I have taken the step of enrolling in Paypal's money market fund in order to maximize the value of each person's contribution. I do not intend on withdrawing any of the money for the expenses of running this blog. I will continue to pay Typepad subscription fees, Google Adword fees, and any other expenses out of my own pocket. Any tax consequences of my collecting this money and retaining custody of the funds will be borne entirely by me.

This site can serve as both a point of dissemination and a flatform for fundraising. Of course, contributions are not tax deductible and I have taken no steps in that direction yet. Some who read this blog may remember that pledges were asked for at the Ninth International Symposium on Circumcision and Genital Integrity in Seattle, in August of 2006. If that effort ever gets off the ground, I will consider channeling the funds collected here to that fund. Meanwhile, I will be exploring the possibility of setting up an independent non-profit charity.

If and when such a charity is set up, I will let everyone know and encourage everyone to give what each can afford. Rest assured that any org set up for the purposes of doing the work we do will be transparent and governed by a board of directors with oversight capacity and the power to choose suitable projects and individuals to support.

Thanks again for reading, supporting, and taking a stand.

Obsessive Monitors, Rigorous Analysts, Gonzo Writers Needed

The interesting ideas are not always in the stories specifically about circumcision and HIV. Much can be gleaned at the crossroads between the prevailing currents and the backlash. That's what I have always believed.

People concerned with children's rights, human rights, bad science, personal agendas, and puritan pressures on freedom have much to contribute to this debate. Never again will circumcision blanket the educated masses. The cat is out of the bag. However, there will be battles won, skirmishes lost, and  a tugging to and fro.

That's where good ideas come in. Monitoring and analysis followed by compelling writing will keep the debate fresh. Humor and biting sarcasm wouldn't hurt either. Ranting is ok as long as it doesn't become just another tiresome diatribe.

Posting here once a day keeps us in the search engines, near the top of Digg and Technorati. Not posting regularly causes the stats to fall and our influence to wane. Not that we've got a lot of influence -- yet. The goal of this site is a post a day. Two if possible. And 100 RSS subscribers by the end of the year. To do that, we need more than one guy sitting in a SoMa apartment nights, after a long day roaming the San Francisco Hall of Justice, dreading checking the usual sites or email for fear of more bad news.

Nope. We need brave souls. A team of them actually. There is no blog out there covering this story with regularity. We are it. For now. So let's keep it going.

What You Need To Write Here

A broad curiosity about culture, sexuality, world events, public policy, human rights, children's rights, immigrant rights, yourself and others. An interest in HIV, first and foremost. This site is about circumcision, but it is first and foremost about HIV. HIV is the enemy. Circumcision is the bad policy, the weapon of the people who care less about HIV than they do about promoting their deep attachment to cutting. A literate but punchy writing style. A unique vocabulary. A unique viewpoint.

There are a number of people who have commented regularly here. You would be good candidates. If you want to post regularly, then let me know. We can set you up. I may contact you eventually. But it would be easier if you made your interest known. Intact and of parenting age are encouraged to apply.

Thanks and Ciao for Now.