Thursday, December 16, 2010

Circumcision Could Increase HIV Transmission But Strategy Will Continue

With all the publicity about mass male circumcision (MMC) and the great part it could play in reducing HIV transmission in high prevalence countries, little is said about the likely effect of such a strategy on women. After all, it is women who are most likely to be infected, women who are most susceptible, women who are said to have the least power in relationships, etc.

Well, something like a report, but without the balance you might expect, has been published on MMC and women. The fact that AVAC (a pharmaceutical industry front) and the Gates Foundation are involved means that, whatever the report finds, it will be used to support MMC. It certainly won't be used to slow things down and consider whether this is the right way to go about it.

The report finds that women lack detailed factual information about how MMC is supposed to play a part in HIV prevention. This is not surprising, considering the heavily biased reporting on the technique. The average of '60% protection' claimed on the basis of three brief trials involving small numbers of people doesn't stand up to scrutiny.

The fact is, it is not clear how circumcision protects men against being infected with HIV, if it really does protect them. What is clear is that HIV prevalence is only lower among circumcised men in some countries. In other countries, HIV prevalence is higher among circumcised men. How that problem will be resolved is not clear.

Also, MMC does not directly protect women at all. It could be argued that if fewer men are HIV positive, fewer women will become infected, so they are indirectly protected. But, in addition to the lack of clarity about how much it protects men, it is not clear than most women are infected with HIV through sexual intercourse.

Many HIV positive women have a HIV negative husband, yet many of these women only have one partner. Even if their husband is as sexually promiscuous as African men are said to be, something there is no evidence for, their husband didn't infect them if they are not themselves infected. If some people are not being infected sexually, circumcision will have no benefit for them.

But are circumcised men who are HIV positive less likely to transmit HIV to women, or more likely? There is evidence that they are more likely. Many HIV positive men are circumcised and many more will become infected. It needs to be clear whether MMC will also reduce transmission by men who are already infected or who have yet to become infected.

The 'report' finds that many women think they are directly protected from HIV transmission if their partner is circumcised. But many men also believe that they are protected and they will argue that they don't need to use other precautions, such as condoms. Even the circumcision trials advised those taking part to use condoms. Circumcision, even according to its most ardent advocates, does not guarantee against infection and the 60% figure refers to circumcision in conjunction with consistent and correct condom use.

When it comes to negotiating 'safe' sex, it will be even harder for women to negotiate for condom use if the man, and perhaps even the woman, think that circumcision obviates the need for condoms. And even if the man doesn't believe that he can safely have unprotected sex, he could still use the claim to support his case, if he wished to. If people associate circumcision with a lower likelihood of being infected with HIV, the operation could put women in more danger from unprotected sex, rather than less.

There is also the problem of circumcision performed in a non-clinical setting, which carries high risks of various kinds of infection, including HIV. Many men have been and many will continue to be circumcised outside of clinical settings, where the may not be tested, before or after, and the risk of transmission under such circumstances may be increased as a result of circumcision.

Some have even conflated male circumcision with female genital mutilation(FGM), whether inadvertently or otherwise. Even the promoters of MMC have not tried to promote FGM, but there are those who believe, or wish to believe, that it also reduces HIV transmission.

This is where things become more mystifying. Areas with high rates of FGM tend to have low HIV prevalence (such as the Kuria and Kisii tribes in Nyanza province). And some areas with low FGM rates have high HIV prevalence (such as the Luo tribe, also in Nyanza).

This is not because FGM reduces transmission, although the reason for the correlation is not clear. In other words, even if there is a correlation between high rates of FGM and low HIV prevalence, most people wouldn't claim that there is a causal connection between the two phenomena.

But then, advocating MMC on the basis of similar correlations seems particularly foolish. There is speculation about why removing the foreskin could possibly give some protection but there has been no explanation of exactly how this might work. And the assumed process is not just unclear, it is not even consistent if circumcised men in some areas show higher prevalence rates than uncircumcised men.

This report makes it clear that, despite evidence against the claimed benefits of MMC, including the finding that it will increase the vulnerability of women, MMC will go ahead. The findings of the report are profound, but not as profound as the stupidity of continuing with MMC under the guise of reducing HIV transmission. It is difficult to comprehend, but advocates of MMC have always intended to procede with the intervention, regardless of the consequences. Amazingly, this report confirms that intention, without explaining what advocates, or anyone else, has to gain.

This report claims to be opposed to stigma and advocates dispelling myths that support stigmatizing attitudes. But an MMC strategy ony lends support to the common belief that 'promiscuous' women spread HIV. The conflation of FGM with MMC also goes back a long way and is also being used to justify this and other violent acts against women. But the almost guaranteed failure of HIV prevention strageties has never put the HIV industry off in the past, so why should it do so now?

[AVAC and the Gates Foundation are also deeply involved in the CAPRISA 004 vaginal gel trial; more on my other blog]


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