Friday, December 3, 2010

Effectiveness of Circumcision in Preventing HIV Has Not Been Demonstrated

The Journal of Medical Ethics [apologies for citing it as BMJ, earlier] has an uncharacteristically sane article on male circumcision as a proposed means of reducing HIV transmission, a subject that seems to attract an amazing number of nutters. The HIV industry in general is crazy about mass male circumcision campaigns and some barely credible claims have been made about how many operations have been carried out in Kenya. Let's hope they have been exaggerated, like so many HIV related statistics in Kenya.

This JME article reminds us that a 2009 Cochrane review about the effectiveness of the operation in preventing HIV transmission may have found some evidence but it also called for further studies into feasibility, desirability and cost-effectiveness. Until these studies have been carried out, mass male circumcision is still an unknown quantity. Despite this, numerous articles, by journalists and health professionals alike, have spewed out pronouncements about how this operation will turn around the epidemic.

Even if it works, it will not turn around the epidemic. It may even increase transmission. Kenya's hospitals have an unenviable reputation for cleanliness and hygiene and the reputation of other high HIV prevalence countries is no better. At present, HIV prevalence among men is often substantially lower than it is among women in many demographic sectors and among many tribes. But that is unlikely to remain the case.

So there are two main problems (although these are not the ones dealt with in the JME article). Firstly, circumcision is unlikely to prevent HIV transmission through heterosexual intercourse to any great extent and it may even increase it.

And secondly, a very significant proportion of HIV is probably being transmitted through non-sexual routes. According to WHO, 14% is transmitted by unsafe injections. Other forms of medical transmission are likely to make an additional contribution.

There are several other non-sexual routes, such as unsafe cosmetic practices. And the number of transmissions from mother to child is extremely high in high prevalence countries, despite antiretretroviral drugs being widely available for some time. Also, there is a lot of transmission through intravenous drug use in some countries.

The hype about circumcision is quite extraordinary, considering that the people who are most in favor of it should also be most aware of the reasons why the approach is flawed. They should be aware of conditions in hospitals, the fact that sexual transmission of HIV has been wildly exaggerated, the fragility of the handful of field trials that have been carried out and the statistically insignificant effect of circumcision in many countries.

The fact that countries where circumcised men are more likely to be infected than uncircumcised is usually not mentioned is disturbing. But those who express their support for circumcision must be aware that they have been quite selective in the figures they cite.

The JME article questions the ethics of advocating an intervention for which the evidence is highly questionable. It makes it quite clear that there is, as yet, insufficient evidence to proceed with such an intervention. Yet, if some sources are to be believed, well over 100,000 circumcision operations have been carried out in Kenya's Nyanza province and tens of thousands in other countries.

Not content with imposing the operation on adults, there is even talk about imposing it on infants as well. This is supposed to 'protect' them from HIV transmission through unsafe sex. Not only are they probably not at risk of infection through unsafe sex once they become sexually active; but people are being led to believe that they are safe from HIV if they take a handful of precautions that could only, at best, protect them from sexually transmitted HIV. None of these precautions will protect them from non-sexually transmitted HIV, the very possibility of which is often barely mentioned.

The behavior of the circumcision advocates is unethical in promoting an operation that will have minimal benefit. But they are also at fault in failing to inform people about the extremely high risk of being infected through unsafe healthcare. This results in people being unaware of how to protect themselves from healthcare transmission of HIV, hepatitis and various other infections. Such nosocomial infection is very common, but it is rarely mentioned in the literature.

The best known method of reducing HIV transmission through sexual intercourse is correct and consistent use of condoms. Even after circumcision, men need to continue to use condoms correctly and consistently, otherwise there is no guarantee the intervention will have any benefit. Advocates of circumcision would be better off forgetting about circumcision if they really wish to reduce HIV transmission and just concentrate on condoms. The worrying thing is, they are already well aware of these considerations but they behave as if they are oblivious to them.



Anonymous said...

Just for clarity, this is not from the BMJ (British Medical Journal), but from the Journal of Medical Ethics.

Simon said...

Thanks for the clarification! I've made a note in the text as well.