Thursday, November 4, 2010

If Counselling and Condoms Are So Effective, Why Bother With Circumcision?

Male circumcision enthusiasts once worried that men who were circumcised as adults in order to reduce their susceptibility to HIV infection might subsequently engage in risky sexual behavior. This phenomenon is called 'risk compensation'. It was feared that men would only undergo the operation if they could then safely have sex without a condom, even though circumcision is only claimed to be 50-60% effective, at best.

While the evidence for the protective effects of circumcision are not very convincing, I'm surprised anyone would undergo the operation at all if they still have to use condoms afterwards. If you have no aversion to using condoms you'll probably still use them after the operation. But if you have an aversion, you are unlikely to lose it as a result of the operation.

Now the enthusiasts are claiming, on the basis of a survey of a handful of people (30, with a plan to circumcise over one million), that risk compensation is not occurring. They also claim that people are having safer sex after being circumcised because the counselling, pre- and post-operation, is so good. But then the question is, why could everyone not just receive counselling on its own?

If being circumcised gives little or no benefit unless you use condoms and avoid other risks, why not just advise everyone to use condoms and avoid other risks? The operation seems like an expensive and unnecessary burden on both clients and health services. Condoms on their own provide the highest level of protection against sexual transmission of HIV, whether you are circumcised or uncircumcised.

It's worth noting, those who were circumcised in traditional ceremonies do not receive the sort of counselling that those being circumcised in hospitals are getting. Yet there is no evidence that those circumcised in traditional settings are less well protected than those circumcised in hospitals. So it sounds as if the author of the study, Thomas Reiss, is going well beyond the evidence in making his claims about the effectiveness of both circumcision and the accompanying counselling.

Another article talks about risk compensation in connection with people on antiretroviral drugs (ARV). Again, it was feared that people would engage in 'risky' sex once they were on AIDS treatment. This would be tempting because they are said to be far less likely to infect others if they are responding well to the drugs.

This article is based on a study by Neil Martinson and it also puts low risk compensation behavior down to the experience of 'staring death in the face', in addition to 'counselling and safe sex messages'.

Treatment is a vital element in a country's overall AIDS strategy, as are counselling and other measures. But these two articles give the impression that sex, safe or otherwise, might not be as important a factor in African HIV epidemics as we are led to believe by the HIV industry mainstream. People may well be reacting to all the fuss about sex, but perhaps they were never as sexually incontinent as UNAIDS and their followers claim.

There is a proposal to test everyone in a population regularly and immediately put those found to be HIV positive on ARVs, called 'test and treat'. It has been found that the immune response in those on treatment can be so high that they can even have unprotected sex with a HIV negative partner without much risk of transmission.

If conditions are such that a test and treat strategy can be implemented in developing countries, perhaps in conjunction with various types of counselling, support and condom use, this may reduce sexual transmission of HIV considerably. Non-sexual HIV transmission may continue, unless it is reduced by appropriate measures. But the success of these efforts to reduce HIV transmission depend a lot on the accuracy of researchers and the extent to which policies are based on genuine findings, rather than on a political gloss.

HIV policy in African countries, up to now, seems to have been based more on wishful thinking and a completely unwarrented assumption that Africans are far more promiscuous than non-Africans. The two articles above don't give much cause for optimism. Evidence suggests that HIV is not solely, perhaps not even mainly, driven by sexual behavior. Technical fixes, like ARVs and mass male circumcision, only target sexual transmission of HIV. And they may not even be particularly effective in that respect.



Joe said...

Simon, an excellent observation about the results of the circumcision "study" (a term which I use loosely). The reason you're seeing such poorly reasoned out conclusions is because they are simply wanting to promote circumcision itself. All the lead researchers and most of the money comes (of course) from the US where circumcision is prevalent and where they've been groping desperately to justify it.

Those (such as the author of this paper perhaps) would deny that saying that it's simply to control HIV and often they say circumcision offers a way to get men into clinics to provide counseling, and that the two shouldn't be mutually exclusive. A statement which may (to some) seem reasonable until you notice that in many of these countries they are making calls to circumcise infants. Truthfully, it's not clear to me how you're going to include the safe sex component for the infants and then what do you use to introduce "safe sex" when they are of age? How then do we get them into the clinics to discuss the critical role (far overshadowing circumcision) of safe sex practices?

When you see actions such as that, you know it's only about circumcision and not about HIV education.

Simon said...

Thanks Joe, you're absolutely right. If they are trying to promote infant circumcision they can't really use the counselling argument!

But if counselling relating to voluntary counselling and testing (VCT) is anything to go by, I wouldn't have much confidence in it. I know that there is often neither time for much counselling, interest in giving or receiving it nor much evidence that it is as effective as enthusiasts claim.

The same goes for all the other technological fixes, they always try to make the intervention seem a lot more than it really is.

In the end, a lot of HIV programming is about two things: making money and shoving a rarefied form of Western morality down people's throats when they have a lot more to worry about than a single disease, which could probably be eradicated far more easily if the welfare of people who live in developing countries was taken into account.

So thanks again for your comment.

Hugh7 said...

I know it's a long way from Kenya, but in KwaZulu-Natal, they've just circumcised 17,690 men and announced that it's a big success because the HIV rate among the men is only 0.5% (national rate, 11.9%).

Someone doesn't understand statistics (or time) if they think that figure proves anything about the effectiveness of circumcision.

If anything, the low rate among those men, intact till now, shows that being circumcised has nothing to do with it. It's just another illustration of Joe's point that some people just like the idea of circumcising.

Simon said...

Thanks Hugh
Some sources in Kenya claim that 100,000 to 120,000 have been circumcised but I find some of these figures too high to be credible, especially as it's not that long since the mass male circumcision program started and Kenya's health services are a disaster that many people are lucky not to be able to access (though they could do with decent medical services).

The .5% rate you cite for men must be incidence, the yearly rate of new infections. The 11.9% figure is prevalence. That's the cumulative percentage of HIV infected people in the adult population.

As .5% incidence would probably be equivalent to a fairly high prevalence rate, you're right, it doesn't prove very much! And I agree, circumcision is, for some reason, 'on the agenda', there's very little evidence to support it that doesn't also support female genital mutilation.

Hugh7 said...

'"We have circumcised 17,690 men and we are pleased to report that 99.5 percent tested negative for HIV," KwaZulu-Natal provincial health department head Sibongile Zungu told a workshop on the programme...

Health officials in the northeastern province launched the large-scale circumcision programme this year...'


So it's not annual incidence. I think it's just a snapshot of prevalence among those 17,690. We don't know how old they are and hence how much sexual activity they may have had, nor whether men known to be HIV+ were turned away, so it's just crazy to present that as evidence for the effectiveness of circumcision, as they seem to be doing.

Simon said...

You're right Hugh, it's probably neither incidence nor prevalence but it's a short period, it's like saying nobody has been injured by GM crops, therefore they are safe. The people circumcised may have a lengthy period of sexual activity to go through and if incidence is half a percent, or even less, over a one or two year period, that's very high. It means that a lot will be HIV positive, eventually. Nothing to boast about.