Monday, October 24, 2011

Another Unconvincing Plea for Male Circumcision to Prevent HIV

Yet another article has appeared arguing that male circumcision (MC) is one of the most effective ways of reducing HIV transmission, as if the sheer number of articles published is enough to make the case for the strategy. The number of articles questioning the effectiveness of MC may be smaller, but that could be related to the way HIV funding tends to support those who fight for the orthodoxy, to the death, as it were.

Because MC would only be likely to have an effect on sexually transmitted HIV, at best, those arguing for its effectiveness must also argue that most HIV is sexually transmitted. The usual array of 'evidence' for this is presented. But not so much of the available literature arguing against this view, also subject to the vagaries of HIV funding decisions, is presented.

Date about infections in children whose mothers are HIV negative, virgins, those who always practice safe sex and various other phenomena are in urgent need of investigation before non-sexually transmitted HIV can be dismissed as almost irrelevant, as it currently is by many researchers.

But there are many questionable claims in the article which it is beyond the scope of a blog post to go into. So I'll just concentrate on a few. Firstly, arguments for MC using the 'mainly heterosexual transmission' assumption are not appropriate to infant circumcision. The fact that infant circumcision is cheaper and more 'convenient' does not alter the need for separate arguments for routine infant circumcision, if such arguments exist.

Secondly, much of the evidence presented for the effectiveness of MC in reducing HIV transmission is similar to data on correlations between low HIV prevalence and high rates of female genital mutilation. Yet, no one is using this evidence to argue for the adoption of such a strategy, thankfully. But HIV rates are often far higher among females than males, so female genital mutilation could be made to seem an even more effective intervention than MC, using similar arguments.

Thirdly, countries with high HIV prevalence may not be ready to carry out so many operations, while at the same time guaranteeing the safety of patients. The article cites some eyewatering claims about numbers of people circumcised in Kenya but also notes that:

"of 81 government health facilities surveyed in Nyanza (the target location of MC services), none had the capacity to implement the full package of voluntary circumcision outlined in the national guidelines. Challenges included lack of a theatre, MC kits and supplies, medical personnel to perform the procedure, and data monitoring tools. Due to this, most of the reported 230,000 circumcisions were done by partner organizations largely in high demand settings using mobile teams."

With those findings in mind, is it credible that less than 1% of HIV transmissions in Kenya and other high prevalence countries results from unsafe injections and blood transfusions combined? Kenya may be a showpiece for mass MC programs but will the sort of money put into these programs also be made available in other countries for the next 10 to 20 years? And what about routine infant circumcision, which proponents also insist on?

Finally, some research suggests that, while MC may reduce female to male transmission of HIV, it does not reduce male to female transmission. There have even been suggestions that MC may increase transmission of HIV from males to females. This possibility needs to be investigated before any useful assessment of the effectiveness of MC can be made. Far more females than males are infected with HIV in high prevalence African countries.

It's interesting to pay some attention when reading peer-reviewed articles to the rhetorical tone adopted, the presumptuousness, the triumphalism, the selective use of data and superficial treatment of anything inconvenient, even the self-conscious use of journalese, like "magic bullet", "tool box", "perfect storm" and "surgical vaccine". But there would appear to be a lot of questions remaining to be answered before mass male circumcision programs can safely be scaled up.

[For information on how to protect yourself from HIV infection during medical circumcision, see the Don't Get Stuck With HIV site.]


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