Male Circumcision and HIV

MEXICO CITY: Doubts following the results of the African circumcision trials persist during follow up period

Reinforcement of safer sex messages and provision of condoms during a reported follow up period in the Kenyan circumcision trial continue to cast doubt on the reported protective effect of the procedure. The group of intact men who served as the control group may not have benefited from these additional inputs. This is the conclusion extrapolated from earlier criticism of all three African circumcision trials, namely that the experimental group received greater levels of safer sex counseling and condoms than the intact control group.

Barely half of the original participants in the Kenyan trial, headed by Robert Bailey, were followed for the reported 42 months while the rest dropped out or were not followed. This alone is troubling to skeptics of the reported results.

Apart from HIV, the differences between the intact and circumcised men for gonorrhea were insignificant. The differences between the two groups viz richomonas and human papilloma virus (HPV) were more significant, but barely so. The low numbers of men available for follow up may explain the differences.

Not discussed at the XVII International AIDS Conference in Mexico City were the likelihood that severe to moderate complications and death from the procedure in resource limited settings would more than offset any benefits to public health.

Link: Aidsmap | Protective effect of circumcision is sustained for at least 3.5 years; works against HPV too.

MEXICO CITY: AIDS 2008 Officials Ignore Opposing Views on Circumcision and HIV

This press release comes to us from the International Coalition for Genital Integrity viz the willful ignorance of AIDS policy makers towards the growing awareness that circumcision will likely harm anti-AIDS efforts.

Press Release

Issued by ICGI
Danbollinger@comcast.net
765-497-0150
www.icgi.org

AIDS 2008 Officials Ignore Opposing Views on Circumcision and HIV

West Lafayette, IN (PRWEB) August 5, 2008 -- The International Coalition for Genital Integrity notes that presentations submitted to the Mexico City AIDS 2008 conference challenging the value of circumcision for HIV prevention were rejected by conference committees. However, studies concluding the opposite, that male circumcision offers some protection against heterosexually transmitted HIV, were presented at the conference today.

One study that was rejected showed that condom distribution is 95 times more cost-effective than male circumcision in preventing the same number of HIV infections in sub-Saharan Africa.

“We are deeply concerned by the biases and one-sided view being given to AIDS experts around the world,” states study co-author and ICGI advisor, John Travis, MD, MPH. “Data showing circumcision is not cost-effective and that circumcision may cause serious harm in the HIV battle have been ignored. Before the world health community spends millions, if not billions, of dollars on male circumcision programs, AIDS policy makers need to carefully consider all data on the risks and potential benefits of the use of male circumcision, not just selective data.”

The published results of three African randomized clinical trials, conducted in optimal conditions with free condoms and extensive counseling, show that male circumcision was associated with lower rates of heterosexual HIV transmission during the 21 month to 24 month study periods. All three studies were cut short, and there have been no follow-ups. Other studies published since the trials have shown that male circumcision is not associated with lower HIV rates in the general population.

MEXICO CITY: New Study Shows Condoms 95 Times More Cost-Effective than Circumcision in HIV Battle

This press release comes to us from Wellness Associates as the XVII International AIDS Conference gets under way in Mexico City. John Travis examines the cost effectiveness of condoms vs circumcision in a paper to be published this Fall.

Press Release

Issued by Wellness Associates
JWTravis@mindspring.com
707-322-0116
http://www.thewellspring.com/

New Study Shows Condoms 95 Times More Cost-Effective than Circumcision in HIV Battle

Asheville, NC (PRWEB) August 4, 2008 -- Results of the new study, “The Cost to Circumcise Africa,” comparing the cost of male circumcision to the cost of lifetime distribution of free condoms in sub-Saharan Africa, found that condom distribution is 95 times more cost-effective in preventing the same number of infections in Sub-Saharan Africa.

“Male circumcision is too costly to justify in the HIV battle. Even if circumcision does offer some protection against heterosexually transmitted HIV, condoms clearly provide more protection, at a much lower cost,” says study co-author and Wellness Associates co-founder John Travis, MD, MPH. “We found that it just doesn’t make sense to perform mass surgeries in a region of the world struggling to meet the most basic healthcare needs, especially when there are more cost-effective plans for achieving the same results.”

In 1975, after six years in the US Public Health Service, and completing a residency in preventive medicine at Johns Hopkins School of Public Health, John Travis opened the world’s first wellness center, Wellness Resource Center (now Wellness Associates), in Mill Valley, California. His work attracted national attention, leading to an appearance on 60 Minutes with Dan Rather in 1979, and launching the hitherto unknown word "wellness" into the public domain.

The study will be published in Fall 2008.

MEXICO CITY: ICGI issues press release viz HIV as dangerous distraction in HIV fight

This press release comes to us from the International Coalition on Genital Integrity viz the XVII International AIDS Conference in progress in Mexico City.

Press Release

Issued by ICGI
Danbollinger@comcast.net
765-497-0150
www.icgi.org

Male Circumcision – A Dangerous Distraction in the HIV Battle

West Lafayette, IN (PRWEB) August 3, 2008 -- The human rights group, International Coalition for Genital Integrity, is continuing to raise concerns about the harms and costs of male circumcision at their booth in the AIDS 2008 conference in Mexico City this week, stating that circumcision programs will be a dangerous distraction in the HIV battle.

“Mass circumcision campaigns will result in hundreds of thousands of complications, and could make the HIV crisis worse,” cautions spokesperson John Travis, MD, MPH, “There are already numerous reports of males lining up to get circumcised so they no longer will need to use condoms.”

Recent studies show that male circumcision is not associated with lower HIV rates in the general population. One showed that the likelihood of circumcision being effective is nil.

Another showed that condom programs are 95 times more cost-effective than circumcision.

The ratio of physicians to patients in sub-Saharan Africa is much lower than in more developed countries. In Africa, there are 20,000 patients for every physician, compared to 400 patients in developed countries.

Dr. Travis further warns, “Male circumcision is a dangerous distraction in the HIV battle. Even if circumcision does offer some degree of reduced risk per sexual incident, individuals engaged in high- risk behavior are still at risk for HIV. And, circumcision does not protect women. Giving circumcised males and their partners the false impression that they are protected will make the situation worse by increasing risk-taking behavior. Further, mass circumcision campaigns will likely overwhelm the already overburdened African healthcare infrastructure and divert resources away from other needed and more effective HIV prevention strategies.”

The published results of three African randomized clinical trials, conducted in optimal conditions with free condoms and extensive counseling, show that male circumcision was associated with lower rates of heterosexual HIV transmission during the 21 month to 24 month study periods. All three studies were cut short, and there have been no follow-ups.

SWAZILAND: Circumcision gives men an excuse not to use condoms

"Many of the men I speak with think circumcision is like an AIDS vaccine. It's not. It's a useful tool to reduce chances of infection at a time and place where few other tools are available, but you can still contract HIV and pass it onto a partner," said a Zambian doctor who treats HIV/AIDS patients at government hospitals, and who declined to be named. 

He believes it's like a vaccine because that is what Halperin, Bailey and others have been saying for two years [abstract]. Amazing. A man takes the message and believes it, and suddenly he's at fault for it? Amazing, indeed.

As amazing is a Zambian doctor who is so clueless as to state there are "few other tools ... available." Africa continues to demonstrate that it is a special case. Collectively, it is not capable of containing this virus the way other poor nations have (such as Cambodia, Thailand, and Latin America). It's both an argument for circumcision and an argument that circumcision will not matter and could exacerbate the problem. It is a case where importing a cultural practice that correlates with lower rates in another setting will have little impact.

"The problem is not with the procedure, but the way it is abused by men, so that men think they are now immune from HIV contagion," said Siphiwe Hlope, an HIV-positive woman and founder of the support group, Swazis for Positive Living (SWAPO).

Well, yes the problem is with the procedure. It doesn't protect. How often does one get to witness a myth being birthed? We've seen it. HIV is a very tricky virus. So small, so deadly, so powerful to manipulate powerless men and to give the powerful another tool of manipulation.

Link: IRIN Africa | Southern Africa | Swaziland | SWAZILAND: Circumcision gives men an excuse not to use condoms | Gender Issues HIV/AIDS (PlusNews) | Breaking News.

Embarrassing findings "unfit to print" ... PloS One

And now from the mailbag ...

Date: Sat, 19 Jul 2008 11:55:59 -0700
From: "Frank" <frankxxxx@xxxxx.com>
To: "David Wilton" <wilt31@gmail.com>
Subject: Willingness of Men Who Have Sex with Men (MSM) in the United States to Be Circumcised as Adults to Reduce the Risk of HIV Infection

Hi David,

Would you be covering this article? And would you spell out the confidence lingo so that I may understand?

Frank

http://www.world-of-science-news.com/world-of-science-news/new-and-exciting-in-plos-one-a-blog-around-the-clock-14/

Willingness of Men Who Have Sex with Men (MSM) in the United States to Be Circumcised as Adults to Reduce the Risk of HIV Infection:

Circumcision reduces HIV acquisition among heterosexual men in Africa, but it is unclear if circumcision may reduce HIV acquisition among men who have sex with men (MSM) in the United States, or whether MSM would be willing to be circumcised if recommended. We interviewed presumed-HIV negative MSM at gay pride events in 2006. We asked uncircumcised respondents about willingness to be circumcised if it were proven to reduce risk of HIV among MSM and perceived barriers to circumcision. Multivariate logistic regression was used to identify covariates associated with willingness to be circumcised. Of 780 MSM, 133 (17%) were uncircumcised. Of these, 71 (53%) were willing to be circumcised. Willingness was associated with black race (exact odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.3-9.8), non-injection drug use (OR: 6.1, 95% CI: 1.8-23.7) and perceived reduced risk of penile cancer (OR: 4.7, 95% CI: 2.0-11.9). The most commonly endorsed concerns about circumcision were post-surgical pain and wound infection. Over half of uncircumcised MSM, especially black MSM, expressed willingness to be circumcised. Perceived risks and benefits of circumcision should be a part of educational materials if circumcision is recommended for MSM in the United States.

To: "Frank" <frankxxxx@xxxxx.com>
Subject: Re: Willingness of Men Who Have Sex with Men (MSM) in the United States to Be Circumcised as Adults to Reduce the Risk of HIV Infection
From: "David Wilton" <wilt31@gmail.com>
Date: Sat, 19 Jul 2008 19:01:16 +0000

Frank, as you know, circumcision has proven to provide no protection against HIV in gay men. Given this truth demonstrated across three studies, willingness to be circumcised is irrelevant. Seems more likely this study is a better measure of the willingness of black men to swallow lies and put their penis on the chopping block to prove how smart they are. This is likely what I would write about viz this article. - D

Sent with the Blackberry Curve 8320

Let me add to my reply to Frank that willingness to be circumcised was basically associated with being a gullible African-American recreational drug user. I think we don't have too much to worry about in terms of the majority of intact adults turning to circumcision in the United States for the dubious purpose of reducing their risk of HIV ...

Circumcision device inventor Tomlinson hitches a ride on the HIV/AIDS gravy train

Discover Magazine, in its effort to stay current, has published in its March edition an article claiming a new device has "idiot-proofed" circumcision. The title, Finally! A Nearly Foolproof Circumcision, no doubt is the magazine's attempt to communicate the author’s excitement about circumcision at a time of its being pushed for yet another disease. Specifically, the AccuCirc device is described entirely in the context of HIV prevention.

Fortunately, but perhaps inadvertently, the title also acknowledges the inherent dangers of circumcision methods. Yet, the breezy tone of the article alerts the reader that no discussion of the inherent negative effects of circumcision will be forthcoming. As if the debate over circumcision were now thoroughly muted by the WHO’s stamp of approval, the author avoids exploration of individual rights, the changing acceptability of surgical removal of healthy and functional body-parts, and the double standard of genital surgeries between the sexes.

If the reader doesn't thoroughly read the article, he will be mislead into believing  that  an inexpensive, disposable tool is now available to meet the demands of African men volunteering for the surgery. But the truth is that Dr. Tomlinson has developed a tool aimed squarely at American infants. In fact, AccuCirc was recently approved by the FDA for infant circumcision in the USA. The design is not at all intended for adults, and the article describes a device that is too simplistic for adult circumcisions. While it is possible to avoid stitches in a newborn as this design suggests, bleeding is difficult to contain without stitches in an adult.

There is no way of knowing when or if this will be adapted to adults and available in Africa, though African infants could be immediately targeted. Despite its pretense to assist those African men who want to be circumcised, the article is little more than an endorsement of infant circumcision in America. Parents reading this article may not understand that the WHO, in fact, does not recommend universal or neonatal circumcision.

Contact Dr. Tomlinson at:

David Tomlinson, MD
Phone: +1 401 782 8000
Clinical Instructor in Family Medicine
Bio Med Family Medicine
David_Tomlinson@brown.edu

Tomlinson's bio at Brown University

Posted by Adrienne Soti

[Minor edits for clarity to paragraphs two and three.]

The End of the Epidemic, Spray-on Prophylactic, Herpes and HIV, and The Future of MC & HIV

The End of the Epidemic?

The Independent reported this month that the World Health Organization believes the world-wide threat of a generalized epidemic has in fact passed. The story is rather long, but the message in a few words is that the disease outside of Africa remains and looks to remain localized and concentrated in sub-populations that engage in behaviors necessary for its spread, namely among marginalized people who inject illegal drugs, among sex workers, and in gay men whose sexual networks coincidentally mirror those of sub-Saharan Africa, i.e. multiple concurrent partnerships. (It bears noting that this last category is not all inclusive. Those most at risk are the gay men who maintain such networks, which isn't to say that this makes up a majority of gay men.)

This is a courageous statement. It goes against the two decade juggernaut that would rather use fear and hype to maintain attention on the problem than the humanitarian aspects of infection to keep the money flowing. To be fair, I'm not sure that this approach wasn't necessary given the world's antipathy towards the most affected groups. But it has had its counterproductive fall-out. 

Again, contrary to Halperin and Bailey and Gray and their acolytes, a concentrated, targeted response is still the best approach all things considered.

Spray-on Prophylactic?

Aidsmap has a more considered discussion on the recently reported research that spraying Estrogen on the penis could produce a barrier of keratin that may reduce the risk of HIV infection. Aidsmap interprets the study as a possible way for intact men to gain the benefits of circumcision without being circumcised. But as usual, the tone of the article belies the assumption that circumcision is the gold standard and spraying hormones is the next best thing. Again, the romance of circumcision continues to weave its way into the discourse.

Nevertheless, at least Aidsmap gives the reader a more nuanced view behind the idea.

Treating Herpes Still Not Predictive of HIV Infection

In a final report on research started some time ago to assess whether treating herpes with suppressive drug therapy would reduce rates of HIV infection, researchers have concluded that the approach has no apparent effect in reducing HIV in women and gay men.

This is contrary to the by-now common belief viz circumcision where the mechanism of reduction in transmission has been pinned on the reduction of ulcerative diseases in circumcised men. Of course, numerous studies have failed to demonstrate this. In fact, the literature is replete with contradictory studies viz the reduction of STDs in circumcised men. Demographic studies have also shown circumcision provides no predictive value of relative rates of HIV.

(It of course bears noting here that other research has concluded that the groups studied, women and gay men, receive no protective benefit from circumcision.)

An objective view would seem to support that STDs are simply not a risk factor for contracting HIV although they remain a predictor of risky behavior conducive to HIV transmission.

The Future of MC & HIV

June has been a lean month for the blog. It's not that there hasn't been news to report and comment on. In fact, this has been a busy month over all for that. However, the present model is less effective in keeping this website current and timely. I'm working on coming up with a sustainable solution.

In the mean time, I would point you towards this article on the "anti-preneurs." Is this method of economic support a possible avenue for influencing the public debate? Note the no-commercial radio station. I hope you will leave comments to this post on what you want to see here and how you would support it. 

Thanks for reading.

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.

Joint Harvard/Berkeley policy paper says drop ABC, adopt male circumcision

The points made in this paper to be published in the journal Science, are simply incorrect. In short, they are the opposite of the truth in HIV prevention. The authors urge dropping the ABC approach in Africa and focusing on male circumcision and campaigns to encourage the reduction of sexual partners.

If anything, this academically dishonest diatribe on what the authors say doesn't work, particularly viz condoms, is evidence of the authors' own agenda to promote circumcision for its own sake. Their reasons can only be explained as a personal infatuation with the act itself.

It is amazing to me that leading schools such as UC-Berkeley and Harvard have been the locus of this activity. It makes a mockery of academic freedom when biased, dangerous, and scientifically unsupported agendas rise to the top of such institutions' efforts.

At what point do people like Halperin, Potts, and their cohorts cross the line into the camp of deniers of HIV as the cause of AIDS, 9/11 government conspiracy theorists, and other assorted circus clowns? The level to which these people are capturing the attention and imagination of real policy makers is reminiscent of the beet juice and vitamin policies of South Africa's health ministers during the 90s.

[Note: I've done some minor editing and adding throughout for clarity.]

And the media obsession with circumcision continues in the Times of London.

The BBC has picked up the story as well, adding this sensible quote, "Roger England, chair of small Grenada-based think tank, Health Systems Workshop, said too much is being spent on HIV compared with other diseases which kill more people.

"He said globally HIV causes 3.7% of mortality but received 25% of health aid."

Where is the coverage of the antidote to Halperin's hysteria as demonstrated in Future Medicine?

Link: 05.08.2008 - More focus needed for effective HIV prevention strategies in Africa, says new policy paper.