Thursday, December 22, 2011
Daniel J Ncayiyana, the editor of the South African Medical Journal, presents a rarely heard view in a professional medical journal: he is critical of mass male circumcision campaigns that make claims to reduce HIV transmission, by widely varying amounts. In fact, it is rare to hear someone in such a position criticizing anything to do with theory (and hence programming) relating to HIV in Africa.
Despite the often vast claims of Western proponents of voluntary (so they say, anyhow) male circumcision, Ncayiyana opposes this as a strategy, finding the evidence mixed, sometimes exaggerated and never completely convincing. Perhaps the claim that "'Male circumcision is the most powerful intervention we have at this point in time" should be interpreted as reflecting the lack of success in other areas of HIV prevention, rather than the effectiveness of circumcision?
Enthusiasts of circumcision seem to forget that if they diminish the potential effectiveness of other prevention strategies, people may get the impression that circumcision on its own is effective, which it is not. All trials of male circumcision consisted of a combination of prevention strategies, including condom use. If circumcision results in a reduction in use of other prevention strategies, sexual transmission of HIV from females to males could increase.
Of course, male to female transmission, which is far more common in African countries, will not be reduced by male circumcision; it may even be increased. This operation, which is ostensibly aimed at couples who tend not to use condoms (and other groups), sounds like it will fail to reduce transmission in the very contexts where reduction is most needed. So far, the various pronouncements about circumcision seem to have produced little but confusion.
Ncayiyana mentions the fact that prison services in South Africa report a "near-stampede" by inmates demanding circumcision (though this may be another exaggeration), who seem to think the operation will protect them against non-heterosexual, perhaps even non-sexual HIV transmission. There is simply no evidence that circumcision protects against male to male transmission, or even male to female transmission where anal sex is involved.
One of the most puzzling things about female to male sexual transmission of HIV is that it occurs so much in African countries. Counterintuitive as it may seem for a virus that is claimed to be almost entirely sexually transmitted, female to male transmission hardly ever occurs in most Western countries. The bulk of transmission is from men having sex with men and intravenous drug use. Even the percentage of female to male transmission estimated in Western countries may fail to exclude cases where people were not altogether frank about the risks they have faced, or where health professionals failed to report all the risks.
While criticizm of circumcision is not often cited, there is some published criticizm, some of which Ncayiyana alludes to. He even alludes to the lack of certainty about the relative contribution of heterosexual transmission, as opposed to other sexual and non-sexual modes of transmission. And he notes that arguments for adult male circumcision have been used as arguments for new-born babies, which is simply ridiculous.
Van Howe and Storms put it succinctly: "It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection)." It is not hard to see, but the calls for tens of millions of men (and perhaps even more babies) to be circumcised to reduce HIV keep coming in. Even Bill Gates has forked out $50 million for circumcision.
One of Ncayiyana's main worries is that all this attention for circumcision will take attention away from HIV prevention strategies that work, at least to some extent, such as condom use. If sexual behavior needs to change, circumcision is unlikely to have much long term impact on this. If men's attitudes towards women need to change, as we are so often told they do, circumcision is not going to bring this kind of change about. And the list goes on.
I don't have as much faith as Ncayiyana seems to have in condom use, however combined with partner reduction and the like. I think they may all be useful when it comes to reducing sexual transmission or HIV, but this will not shed light on non-sexual transmission. Non-sexual transmission through unsafe healthcare, cosmetic practices, traditional medicine, tattooing, scarification and oathing may be rare, as UNAIDS claims. But UNAIDS may be wrong, they haven't checked yet. However, circumcision seems like more of an unwise leap of faith than a genuine HIV transmission prevention strategy.