Male Circumcision and HIV

"Sex, Rights and the Law in a World with AIDS"

2008-08-16T11:00:21-07:00

The AIDS2031 initiative in association with the International Center for Research on Women and the UNAIDS Global Coalition on Women and AIDS is calling for abstracts for a meeting to be convened in early 2009 called "Sex, Rights, and the Law in a World with AIDS." The main purpose seems to be to explore dispersed methods of addressing HIV prevention that are not top-down, solely public health oriented.

In the words of the request for abstracts [pdf]:

The goal of the meeting is to identify effective strategies to address sexuality and gender-related vulnerabilities to HIV. The objective of the meeting is to uncover existing strategies, generate innovative thinking and develop recommendations on addressing:

The complex social, legal and political obstacles to the successful prevention of sexually transmitted HIV, and

The barriers to effective, gender-transformative and human rights-based approaches to treatment, care and support.

The meeting will produce succinct but thorough guidance for programs, policy and action. The meeting will take place over 2.5 days in late January/early February of 2009, location to be determined.

This is an opportunity for groups concerned with genital integrity to offer their own guidance and opinions on what could become an influential document in developing future programs. Specifically:

How will the international programmers and program donors express respect for people and groups of people, such as the Luo of Uganda, who abhor sexual surgery or view such surgery as mutilation?
Will the organizations who take up the call to promote circumcision avoid creating a social environment where genital integrity is disrespected or denigrated?
Will those who refuse circumcision be refused other resources?
How will informed consent be formulated?

The possible questions to be posed are really quite unlimited. There was some talk in Mexico City of male circumcision leaving women out of the policy discussion, causing disempowerment, and generally keeping prevention male-centered. Therefore, despite this initiative's focus on women, it involves men, and hence, male circumcision.

If you have an academic bent or occupy a position in an advocacy organization, you should consider participating. Even you are simply an individual with ideas, you should look into this opportunity to be heard.

Evidence of complexity: Different ethnicity, similar behavior, varied rates of infection, circumcision status plays no part

2008-08-14T15:39:07-07:00

HIV prevalence varied widely between groups:

White British and black African: 8-9%

Black Caribbean and Caribbean mixed: 12%

South Asian: 3-4% (none of the small group of Bangladeshis had HIV)

East Europeans and Chinese 4%, Arabs 7%

Latin Americans: 17%.

...

Sexual risk behaviour did not vary between the ethnic groups. Despite having the lowest rates of HIV, South Asians reported the highest rates of unsafe sex, with 15.5 episodes of actually or potentially serodiscordant unprotected sex over the previous three months compared with 14.5 in black men (all categories), 13.7 in white British and 11.2 in other groups, though these differences were not statistically significant.

Circumcision rates varied widely, with Eastern Europeans, Chinese, Indians and Caribbeans having circumcision rates similar to white British (17%) and other groups, not unexpectedly, having much higher rates. However HIV rates were identical between circumcised and uncircumcised men.

Yet more evidence that circumcision is irrelevant in rates of HIV infection among gay men ... . Moreover, the complexity deepens as we see risk behaviors compared between groups do not explain relative rates of infection.

The researcher, Jonathan Elford, said qualitative interviews "revealed ethnic minority gay men 'trying to reconcile a 21st century lifestyle with 1950s family values.' ” And what does this mean? Some groups had high rates of risk behavior and low infection rates. Others, the opposite. Choice of partner? ~~Fewer incidence~~ ~~Limited types of sexual activity~~ Who knows? It's uncertain.

The data was presented at a satellite conference on gay men and HIV held before the International AIDS Conference in Mexico City. Poster presentations on the data were displayed at the main conference as well.

Link: Aidsmap | Ethnic minority gay men in UK have very different rates of HIV infection despite similar behaviours.

Uganda turns to mass circumcision ...

2008-08-13T08:56:21-07:00

"All I know is that when I am circumcised, it will not be as easy for me to get infected with HIV/AIDS," said one young man, Kizeja Michael, as he lined up for the operation.

"People who are circumcised are not able to get AIDS," said his friend, Peter Kibatsi.

The blood will be on the hands of the Ugandan government, donors, Robert Bailey, Daniel Halperin, Auvert and others ...

Link: Uganda turns to mass circumcision in AIDS fight - Yahoo! News. [Link will expire.]

Fair use article after the break.

Uganda turns to mass circumcision in AIDS fight

By Frank Nyakairu. Wed Aug 13, 6:39 AM ET

Ugandan authorities have launched a mass circumcision drive with the hope it will reduce HIV/AIDS rates in the east African country.

Some studies indicate circumcision could be 70 percent effective in protecting men against infection by the disease during heterosexual intercourse, when used in conjunction with condoms and other safe-sex practices.

Government officials in Kampala have decided to take advantage of a month-long traditional "circumcision season" practiced by some tribes to drive the message home.

"Socially, it is uniting, and now it has also been proven medically, that is gratifying and it is part and parcel of now the strategy for fighting AIDS," Kibale Wambi, chairman of Sironko district in eastern Uganda, told Reuters.

The government plans to circumcise more than 3,000 local youths between the ages of 12 and 18. HIV activists say there needs to be more money and efforts like this on a global scale.

But some critics of circumcision in Uganda say it is brutal and dangerous. In traditional settings like Sironko, circumcisers have used the same knife for each young man.

This time, the government has introduced a strict one knife per operation ruling to ensure no infections are passed on.

"If a knife is to be re-used on another person, it first has to be sterilized," Wambi said, wearing a traditional hat covered with cowrie shells.

"We have also discouraged the traditional practice of forcing the circumcised males into sexual intercourse to prove their manhood after the wound heals, to avoid the spread of sexually transmitted diseases."

Some experts fear that some of the newly circumcised men may believe they are immune following the procedure -- translating into even more risky sexual behavior.

"All I know is that when I am circumcised, it will not be as easy for me to get infected with HIV/AIDS," said one young man, Kizeja Michael, as he lined up for the operation.

"People who are circumcised are not able to get AIDS," said his friend, Peter Kibatsi.

Uganda has been widely praised for an education campaign about condoms that is credited with cutting HIV prevalence rates from 30 percent two decades ago to about 6 percent today.

Nyakairo, Frank. Uganda turns to mass circumcision in AIDS fight. August 12, 2008. Reuters.

New media, original reporting ...

2008-08-11T07:00:00-07:00

A three part series on the future of MC & HIV (Part 3 of 3)

Read Part 1 and Part 2 of the series.

Independent and Specialized Journalism

The fact that anybody can create a weblog in seconds shouldn't be confused with what a weblog can be. In its initial form, it was a way to record ideas or events or to communicate. Personal blogs are a great example of these. The internet is full of personal blogs communicating to friends and family the daily goings-on of their creators.

Soon, weblogs became a way to comment. Political blogs filled this niche. Just about anyone could be a political commentator. Some have become quite successful at it.

Lately, blogs have become a medium for reporting. Tech, fashion, and local newspaper blogs have popped up in this space. Scattered among this last category have been a few blogs that seek to do investigative reporting. The most promising combine elements of freelance reporting with NPR tactics* for support.

These blogs use video, audio, text and photos. Yet, it has become very apparent to this inexperienced producer of content that video is massively time-consuming. Audio is less so, but only just. Interviews aren't so hard if you can get people to trust you. This requires long lead times. Investigative reporting is a full-time job.

Obviously, it has quickly become apparent that one person, even doing a labor of love, can't create a dynamic journalistic enterprise and maintain a full-time job (as I must at the moment).

What is the solution?

If this blog had an independent income from advertising or some other source, or a strong donor base, could I produce more original content? Undoubtedly, yes. Would I be able to do it under the current circumstances? Not quickly. That's the irony. You either go full-bore with the expectation of some future goal of sustainability, or you remain amateur.

From my research, two ways currently exist to make MC & HIV sustainable. Either traffic picks up significantly and advertising becomes a viable source of income or the donor base strengthens considerably. That's to say, NPR tactics come into play.

MC & HIV is New Media

Tech, fashion, and political bombast receive lots of eyeballs. Serious journalism and activism less so, much less so.

The Frontline Club recently sponsored a discussion that seemed to pit the mainstream media against bloggers concerning financial viability. It's a fascinating discussion because it shows that Big Media spends a lot of money on infrastructure for, so far, no return while bloggers of various stripes use TypePad and WordPress for very little money and hence a pretty significant return on investment.

I'm not saying either side has direct applicability to what we're trying to do here. But the lessons are instructive looking forward. The discussion below gives the reader an idea of the discussion going on now between Big Media and bloggers viz financial viability and relative political and social influence. The medium can be powerful once we get going with it. And once we get it going, it can be sustainable.

Join us, please.

*NPR tactics refer to the quarterly interruption of programming on National Public Radio in the United States to beg for money to keep operations going. It is an annoyance that has worked quite well for over four decades.

Weblogs evolve, so must we ...

2008-08-10T07:00:00-07:00

A three part series on the future of MC & HIV (Part 2 of 3)

Read Part 1 of the series.

The Vision & The Reality

This is what I envisioned for this blog:

Male Circumcision & HIV seeks to engage the public in policy questions regarding the nexus of male circumcision and HIV. It is an aggregation of media critique, interviews, original reporting, and travelogue to the regions of the world where HIV has hit hardest.

This is how the blog has developed in reality.

Male Circumcision & HIV is a layperson's weblog that posts primarily media critique and the occasional summary of recent studies on the issue of male circumcision and HIV.

In the beginning, I invited various people to step in and post items occasionally in order to ensure frequent posts with a multitude of voices on this issue. This was a tricky proposition because it takes a special type of person to write about this issue. Thoughtful, literate, and sensitive are three important characteristics. So is thick skin that won't easily chafe under the strains of difficult and disagreeable news. It is important that contributors are committed to the issues, which has narrowed the candidate pool considerably to those I have some familiarity with.

Little came of my entreaties to join me. A few people expressed interest, but nothing came of any of it. It was in these dark moments when the posting schedule had become once a week or long stretches of no posts were followed by two or three in a week, I began to wonder what is the impact of this blog anyway.

We get between 50 to 75 hits a day. About 35% are returning readers who receive the posts by RSS feed or who have presumably bookmarked us. About 55% are random and come to us through search engines. The rest, about 10%, come through Google Ads.

We also have regular visits from the Centers for Disease Control and Prevention, Harvard, Stanford, UC Berkeley, the London School of Hygiene and Tropical Medicine, the National Institutes of Health, and many other professional organizations and educational institutions. South Africa and other African countries provide a large group of visitors as does the rest of the world, particularly North America, Australia and New Zealand.

Moving the Reality Closer to the Vision

Bringing the reality closer to the vision requires two things. Money and time. True, dedication is necessary. A strong stomach for a fight doesn't hurt. A formal plan would be useful. An assistant and an intern would be welcome. But the prerequisites are money and time. In that order.

Why is money important? Because money buys time. Mine and that of others who would work on this project. Infrastructure is cheap. About 50 cents a day. But the costs of molding the raw material of information and information technology into a coherent and effective policy voice are not inconsequential.

Tomorrow, Is A Business Model for Independent and Specialized Journalism What We Need? (Spoiler: Yes.)

Crawling out of the muck ... or rather "Our Future"

2008-08-09T07:00:00-07:00

A three part series on the future of MC & HIV (Part 1 of 3)

Much like the first creatures who crawled out of the muck and realized that they possessed human consciousness, I have lately been asking myself, why are we here? What is our purpose? If I speak, does anyone hear? And lastly, but perhaps most profoundly, where are we going?

No, I'm not having a "come-to-jesus" moment. Rather I am talking about the future reach and evolution of this weblog. I have tried to define MC & HIV as a place for policy debate and discussion. I have mulled over its real and potential reach and impact. At times, I have wondered whether I was the one who should be responsible for it.

In the beginning ...

In December of 2006, the worlds of male circumcision and HIV prevention collided. While the AIDS community was throwing up its hands in despair over the raging epidemic in Africa and the somewhat eroding interest of the rest of the world where AIDS has not been a disaster, the message of a cabal of researchers with a longstanding, prior interest in circumcision reached a crescendo that was a long time coming. They pitched the idea that all we had to do was circumcise the world and the HIV/AIDS problem would be largely solved.

They based their hypothesis on the relatively lower prevalence of HIV in West Africa vs. East Africa and Muslim Asia vs. Thailand. At the same time, other researchers had been predicting wildfire epidemics in the rest of Asia and Eastern Europe and Russia for a decade or longer. All the world was at risk, we were to believe, from heterosexual transmission.

This was a ripe environment to conduct studies to see if a difference could be discerned in HIV infection rates between intact and circumcised men. Small differences were detected after 18 months. Instantly, the studies were shut down and the scientific (or should we say sciencey) papers were written. This happened despite:

Absolutely no statistically meaningful differences in infection rates on a demographic level within countries of similar or same ethnic practice, save circumcision;
Failure to consider non-sexual means of infection, particularly iatrogenic causes such as infection caused by defective medical practices;
Failure to investigate, let alone, factor in the possibility of non-heterosexual transmission;
The impossibility of following up on the majority of participants for logistical and practical reasons; and
A naive or dishonest interpretation of the admittedly incomplete data.

This new wave of circumcision hysteria, often employing loaded phrases such as "lack of circumcision," threatened to undo decades of work by intactivists and human rights activists concerned about genital mutilation, both that of the male and female variants. It was suspected and almost immediately confirmed by the usual suspects themselves that the real target of this research was not populations at risk, but rather the waning circumcision rates in the United States and implementation of neonatal circumcision on an industrial scale with presumably industrial scale funding in hard hit areas of East Africa.

In case the rest of the AIDS community was not listening, these same researchers with an agenda began a campaign to discredit targeted education and outreach, and even attacked condoms as lacking evidence of effectiveness.

The operative word in non-profit is profit as any good non-profit CEO will tell you quietly. Many a talented executive has made a small fortune in the non-profit sector. The Baileys, Halperins, Klausners, and Kilmarxes of the world know this well. This is not to say that good intentions and a strong motive to do good in the world isn't a prime force in its own right. This is in fact what motivates the funders of new and emerging programs.

However, circumcision is different. Its acceptance and promotion speaks to the guilt that the Western World, more specifically the English-speaking world, carries from having ignored genocide to having oppressed or murdered circumcising communities, respectively, from the Jews of Europe to the Muslims of the Middle East. It is in this broad context that a procedure with great potential for mischief, oppression, misuse and abuse has found a new constituency: the American-dominated AIDS prevention community of NGOs.

And so, the doubts and questions are left to lay persons to express, lay persons who don't have constituencies or powerful institutions to pose the necessary questions and doubts. Instead, what we have is the 'net.

Tomorrow, Vision vs Reality

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

2008-08-08T16:21:59-07:00

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.

OPEN THREAD on the XVIIth International AIDS Conference aka AIDS 2008

2008-08-08T07:00:00-07:00

<<<SCROLL DOWN FOR REGULAR BLOG ENTRIES>>>

FYI, I am monitoring the conference through webcasts and as time permits. I have missed much. If you have heard something interesting or you are there, leave a comment. I will elevate a comment to the top of the page if it so warrants.

August 8, 2008, PM - The XVII International AIDS Conference closes today. My impression of the state of HIV/AIDS activism and research is that optimism continues to drive a depressingly hard slog towards better treatment, prevention, and human rights. However, the AIDS pandemic has the unfortunate effect of creating tunnel vision. The successes are under appreciated and the failures are overblown. The only real answers to prevention are condoms and equality and more equal opportunity between the sexes. If circumcision reduces transmission, is the pressure off societies to work towards greater human rights, not to mention equal rights between the sexes? It was mentioned that pushing male circumcision has the effect of sidelining women viz their ability to be involved in prevention strategies, their power to negotiate, and the continued focus on them in the development of prevention technologies. Essentially to support male circumcision is to separate women out of the equation and to give men free reign to do as they please even while circumcision promises no immunity and no refuge from risk. Rather it represents an invitation to take greater chances. And that's not an invitation that should be extended to anyone.

August 7, 2008, PM - Probably the most interesting speaker at today's plenary session was Dr. Anthony Fauci of the United States National Institutes of Health. He discussed in some detail in rapid-fire succession the two pronged road ahead. First, he was optimistic that a cure would be found, but only in a limited number of patients who begin treatment early and aggressively. He believes that for most of the world as presently configured, early enough detection would be difficult. But he referenced the astounding success already achieved in ART that now allows a person to live a relatively normal life for a relatively normal lifespan as evidence that the seemingly impossible can be and is overcome. Second, he believes that a nontraditional vaccine will be constituted. However, it will be a vaccine that is highly specific to a person's genetic make up and likely won't benefit everyone. He suggests that it may be preventive in some people and controlling of the virus in others. While he didn't specifically say so, I got the distinct impression that he was shooting for the big picture.

August 6, 2008, AM - Elena Reynaga of Asociacion de Mujeres Meretrices de la Argentina took the stage this morning and proudly proclaimed for the first time in a plenary session of an international AIDS conference that she was coming before the delegates as a proud sex worker responding to the AIDS crisis. After the serious pronouncements of all the alphabet-credentialed scientists and experts so far, it was refreshing to hear that the solution to HIV is actually localized in the individuals most affected. Elena is a strong personality from Argentina whose presentation was repeatedly interrupted by shouts of "ELENA! ELENA! ELENA!" She described the current conditions of sex workers in Latin America and the response those who are allowed have launched. She ended her speech in teary but fiery defiance of the obstacles and judgments of individuals and governments. Her organization like those of gay men is where this fight should be fought and will be won.

August 5, 2008, AM - Bailey and associates will present evidence today that the protective effect of male circumcision is "sustained and possibly strengthened" out to 42 months of follow-up. The abstract in PDF is available for download. Of course, an examination of the abstract clearly shows that follow up was wholly incomplete and self-selected, making the results highly questionable. Again, Bailey and crew get a pass on the science at this year's AIDS conference.

August 4, 2008, AM - I've listened in on some of the plenary sessions, and the emphasis is indeed on reaching the disadvantaged, marginalized and unpopular groups. Male circumcision has been mentioned sporadically, usually in the context of the African epidemic and usually by specifically African delegates. One interesting statement in the opening session by one Dr. Alex Coutinho of Makerere University in Uganda was that we don't have a good measure of the effectiveness of circumcision in the real world. He stated the country to watch is ~~Zimbabwe~~ Rwanda as this country is rolling out a full-blown circumcision campaign. Of course, we do have a study published in South Africa this year. He's obviously not interested in it or hasn't heard of it. Fascinating to me is the fact that circumcision is apparently accepted at face value without the benefit of better data. What other measure would get this kind of reception without good data? It's a monument to the power of surgical intervention over the human psyche.

Only one session to address cultural meaning and (maybe) ethics of circumcision in the HIV fight

San Francisco, CA, August 2, 2008 - The XVII International AIDS Conference is set to kick off tomorrow in Mexico City. Two sessions are devoted to implementation of male circumcision. Only one is devoted to the cultural aspects and whether circumcision is effective in HIV risk reduction. This is in spite of a number of submissions to the conference questioning the wisdom of widespread implementation that were rejected without explanation.

The first to address implementation includes a panel that will speak on the impact to sexual function and satisfaction. It doesn't look promising, considering that Robert Bailey is on this panel. The second session will address the "science" of cutting. This one is depressingly presented by a Swazi and an Israeli.

The session which may pay some service to ethics has the hopeful title Male Circumcision: To Cut or Not to Cut. However, only 10 minutes is devoted to effectiveness.

For the first time, this year's emphasis will largely be on aspects of the epidemic that affect marginal populations, such as the discrimination and violence that exacerbate the spread of HIV within these same groups.

Aidsmap has an excellent overview of the conference's emphasis and focus here.

This is a featured post to remain at the top of the entry page so that readers can post reports, impressions and any other thoughts or details gleaned from the proceedings that run from August 3 to August 8, 2008 in Mexico City.