Monday, September 6, 2010

HIV Policy Based on Anecdote and Hearsay

A recent paper entitled “‘‘When I Was Circumcised I Was Taught Certain Things’’: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu, Kenya” extols the virtues of male circumcision for protection against HIV infection. The paper is authored by a number of prominent circumcision evangelists, some of whose names crop up constantly in the literature. And it’s not just the title that sounds anecdotal.

But there is a much older paper entitled “Soap and water prophylaxis for limiting genital ulcer disease and HIV-1 infection in men in sub-Saharan Africa”. This paper has only been cited six times in the seventeen years since its publication (although others have investigated genital hygiene and its relationships with HIV and other diseases). Pro-circumcision papers, in contrast, are cited hundreds of times, even ones that were only published in the last few years.

Circumcision, the frequently cited papers tell us, can reduce HIV transmission from women to men by up to 60%. They don’t dwell on the fact that male to female transmission could actually be facilitated by male circumcision, or on the fact that circumcised men still need to use condoms after they are circumcised if they want to protect themselves from HIV infection.

After all, ‘up to 60% protection’ means that the risk is only deferred. Proper use of condoms will increase protection to very high levels. But then, proper use of condoms would increase protection just as much for uncircumcised men. Such use of condoms would also increase protection for women, who are far more likely to be infected than men. In some parts of Kenya, there are three HIV positive women for every HIV positive man.

A lot of recent work has gone into demonstrating the efficacy of male circumcision in reducing female to male HIV transmission. Why this work didn’t take place in the early 1990s, when this ‘discovery’ was already widely acknowledged, is a matter for medical historians (or political ones, or both).

But, far more importantly, why has the use of soap and water as a HIV prophylactic not been investigated with the same zeal that we now associate with male circumcision? Not only is it very cheap, socially acceptable, non invasive, harmless and many other things, but it would also play a part in reducing transmission of other sexually transmitted infections (STI). Has it been ruled out by some randomised controlled trials? If it has, I haven’t read about them, ad nauseam.

It's probably no coincidence that mass male circumcision campaigns have attracted the interest of Bill Gates, who regularly demonstrates his non-expertise in public health, agriculture, development and education. Like his attempts to find a vaccine for a handful of trophy diseases, ignoring alternatives to circumcision seems to have little to do with philanthropy or even the reality of HIV transmission. Access to clean water and sanitation would reduce incidence of countless diseases, HIV being yet another possibility to add to the list.

It is estimated that the mass male circumcision campaign currently taking place in Kenya will cost around $50 million. That's nothing compared to what it will cost in all the other countries where circumcision rates are even lower, but it's a lot of money for an intervention that will only significantly affect a relatively small percentage of Kenyan men (albeit with a prevalence of HIV).

Of course, the same amount of money probably couldn't ensure clean water and sanitation for the whole of Kenya. Even Gates, with his millions and his notoriously generous nature, probably would balk at the costs of providing all high HIV prevalence countries with clean water and sanitation. Besides, it would do a lot of damage to the pharmaceutical industry, which provides the Gates Foundation with a fair bit of money.

But why the obsession with circumcision? Given the risks associated with nosocomial transmission of HIV (transmission taking place as a result of medical treatment), one might have expected the HIV mafia to steer clear of further bad publicity. After all, their record for reducing transmission of their one single disease is far from enviable. Another failed attempt and people might suspect them of being incompetent, money grabbing bullshitters. And then where would we be?

The fact is, the HIV industry doesn't have a lot of tricks in the box. They have been furiously waving their magic wand for years, little realizing that they forgot to put the batteries in (which is why the little pink bulb doesn't light up). But the least they could do now is admit that sexual hygiene is a health issue. It requires public health measures for everyone, rather than the railroading of a couple of million men to undergo an  invasive operation. The evidence for the effectiveness of male circumcision in reducing transmission of HIV is not strong enough to justify continuing with this potentially destructive intervention.

Male circumcision is just another intervention that assumes HIV is mainly transmitted sexually in African countries when this has not been demonstrated. On the contrary, there is a lot of evidence that non-sexual transmission plays a significant role in high prevalence epidemics. This program will not reduce HIV transmission and it risks doing a lot of irreversible damage. Concentrate on establishing what exactly is driving HIV epidemics before hitting out at easy targets.

By the way, did you hear about the latest scheme to eradicate conjunctivitis? It involves cutting off people's eyelids and it can be done preemptively. Hello, is that Bill?


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