Monday, July 11, 2011
In a letter to the editor of the International Journal of STD and AIDS, Gisselquist, Potterat and others note a finding from 2006 which estimates that "circumcising all African men by 2015 would reduce HIV incidence during the ensuing 2015–2035 period by a very modest 13%". And this estimate was made by some of the most rabidly pro-circumcision people in the industry.
Yet you still find articles, such as this one from Uganda, bemoaning the fact that governments are not doing enough to get as many men (and boys) as possible circumcised. Many of these articles are written about countries where safe healthcare can not be guaranteed and transmission of HIV and other pathogens through unsafe healthcare may spread more of the disease than it prevents.
Uganda itself is a good example of such a country. And the author doesn't seem to realize that 'up to' 60% means that the operation will give a lot less protection outside of randomised controlled trial conditions, where participants are given regular coaching about safe sex. Coupled with this, many men and women believe circumcision = no danger.
In addition to mass male circumcision, the author argues for 'combined' prevention, in particular, wider antiretroviral coverage. Those responding to antiretroviral drugs are significantly less likely to transmit HIV to their partners. But this apparent belt and braces approach may be deceptive. Circumcision already gives rise to false beliefs about protection, it may increase transmission from males to females and conditions in hospitals may make invasive procedures more risky than sex.
In truth, the fact that some evidence suggests male circumcision may give a little protection against HIV and other diseases does not address many of the very serious doubts. For example, in a number of countries, such as Malawi and Zambia, HIV rates are higher among circumcised than uncircumcised men. The figures bandied about are carefully selected.
The author of the Uganda article oversteps himself when he conflates childhood immunization against diseases like polio with infant circumcision to 'prevent' HIV: polio is an immediate danger against which polio vaccinations have had a huge influence in eradicating. Circumcision will not 'prevent' HIV in infants and children who are not sexually active. It may even prevent little or no HIV in sexually active adults.
Uganda may gain a lot more by improving its ailing health services. And while they are at it, they could improve education, infrastructure and other social services. This would help the country to address many of its immdiate needs. They shouldn't take their eye off HIV, of course, but mass male circumcision seems like a strategy of pure desperation.
It appears that a lot of Uganda's 'success' in reducing HIV transmission in the 1980s was due to improvements in injection safety. This would explain the utter implausibility of all the articles about abstinence and other changes in sexual behavior, which seem to be entirely without substance. Perhaps it's time for Ugandans, rather than the HIV industry, to take an unbiased look at the history of the HIV epidemic in their country.