Doubts About Male Circumcision and the HIV Industry's View of African Epidemics

Even the title, 'Not a Surgical Vaccine', flatly contradicts the claims of circumcision enthusiasts; the term 'surgical vaccine' is rejected for being entirely unscientific. But it's in good company with many of their other claims. Authors Robert Darby and Robert van Howe look in particular at the issue of infant circumcision in Australia which aims to reduce heterosexual HIV transmission. They find there is no case for this intervention.

The authors question the 'robustness' of the three African trials constantly cited in favor of mass male circumcision and find that possible risks of such an intervention are being ignored. They also raise questions about the ethical and human rights implications of such programs, which are already well underway in a number of African countries. The authors recommend that Australia continues to discourage infant circumcision.

However, many of the reasons for finding the pro-circumcision arguments unconvincing are also relevant to African countries; they are also relevant to adult male circumcision. The authors ask if the incidence of heterosexually transmitted HIV is rising to a dangerous level and whether circumcision is the only effective way of countering this challenge. In high prevalence African countries it would be better to demonstrate how heterosexual HIV transmission is so much more common than elsewhere. As for the question of whether circumcision is the only effective way of countering HIV transmission, it is not particularly effective; but there are effective ways.

For example, condoms are very effective at reducing HIV transmission. But also, male circumcision only reduces transmission among men who also use condoms all the time. In other words, it is pointless unless men are going to use condoms on all occasions where they are not aiming for conception. The condoms won't just prevent conception and HIV, they will also substantially reduce the risk of transmission of all sexually transmitted infections (STI).

The authors list six reasons for disputing the proposal that all infant males be circumcised in Australia but with the exception of number two, they all cast doubt on the circumcision programs in African countries, whether for infants or for adults:

1 [The proposal] ignores doubts about the African evidence on which it relies and passes over numerous critiques of the clinical trials and the manner in which the WHO recommendations arising from them have been implemented.
2 It is irrelevant to the Australian situation and the specifics of Australia's HIV problem.
3 It departs from the principles of evidence-based medicine.
4 It underplays the harm and risks of circumcision.
5 It violates accepted standards of medical ethics and human rights.
6 It is marred by unscientific thinking and hyperbolic language, such as the description of circumcision as a ‘surgical vaccine’.

In addition to a whole host of criticisms of the randomized controlled trials, the authors say "Perhaps the most crucial flaw in these three studies is that the researchers assumed that all the men who became HIV positive during the course of the trials were infected through sexual contact." But that flaw can be found in many trials of HIV prevention interventions, perhaps most. The authors suggest that as much as half of the infections were acquired non-sexually. And the authors also note the lack of a convincing biological explanation as to how circumcision is supposed to protect against HIV and other STIs.

It's interesting that the authors combine scepticism about mass male circumcision campaigns with less than whole-hearted acceptance of the HIV industry view that serious HIV epidemics found in African countries are a result of high levels of sexual activity. They suggest that "It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures." I hope these researchers' findings are applied, as they should be, to countries other than Australia, where HIV rates are extremely high. Their findings have implications for the entire HIV industry view of HIV in African countries, not just the doctrinaire decision to fund mass male circumcision campaigns.

[For more about healthcare associated HIV infections, see the Don't Get Stuck With HIV site and blog.]