Saturday, February 11, 2012

Circumcision: Non-Paternalistic Public Health is Possible in Africa, Isn't It?


After holding out for a while, apparently the Malawian government has now had a change of heart about male circumcision and has caved in to pressure from the international HIV industry to include the operation in its HIV 'prevention' strategy. There were good reasons for holding out: prevalence is a lot higher in the Southern part of the country, where almost everyone is already circumcised. While the headline figure is 'up to 60% less likely to be infected', there are many countries where men are more likely to be infected if they are circumcised, aside from Malawi (see table of HIV infections in circumcised and intact men).

The country claims to have circumcised 5,000 men already but they plan to circumcise another 245,000 by 2015, despite the conflicting evidence about the effectiveness of the program. It is also revealed that only 4% of the country's medical staff have been trained to carry out the procedure. That's extremely worrying in a country where there is such a shortage of medical staff, regardless of what they know about circumcision. Other research in Malawi has shown that living close to a health facility is a serious risk factor for being HIV positive. But I don't expect that to be mentioned in the evangelical literature.

The last sentence in the article is particularly badly phrased: "people still had to be reminded that male circumcision alone is not 100 percent safe". The sentence aims to express the idea that male circumcision on its own will not protect against HIV and the 'up to 60% protection' requires the use of condoms (which is why some people ask if the circumcision is even necessary). But sadly for Malawi, figures suggest that HIV prevalence is far lower among both males and females who never use condoms than among those who ever use them.

Another reason why the sentence is unfortunately phrased is that it sounds like it means the operation itself may carry risks which, ironically, is true. In addition to many unexpected HIV infections in male and female virgins, where prevalence was similar to or higher than that among non-virgins, there have also been questions raised about mass male circumcision programs, where some of those circumcised might have been infected as a result of the operation itself. In countries where health facilities are in such bad condition that they may carry as high or even higher a risk of HIV infection, mass male circumcision sounds like an extremely dangerous HIV prevention strategy, particularly in Malawi.

Meanwhile, Uganda claims to have already circumcised 600,000 men since 2009. Uganda has had quite a few probable healthcare associated HIV outbreaks, including during the Rakai circumcision trial, which is supposed to show that circumcision is a viable strategy for HIV reduction. There, the aim is to circumcise 4 million men, until HIV prevalence "reaches zero", which will be a very long time from now at the rate things are going. Notably, despite evidence for healthcare associated HIV transmission in Uganda, the ridiculous claim about 80% of transmission being through heterosexual contacts is still being made (and elsewhere it is claimed that almost 20% more is from mother to child transmission).

The article also claims that 768,000 men have been circumcised in Tanzania, against a target of 1.3 million. Strangely, it is also claimed that Kenya has only circumcised 76,000 men against a target of 860,000 men by 2011. Other claims have put the figure in the hundreds of thousands, against a far higher target, and that was just among the Luo tribe of Nyanza province, a few million people. Another country where circumcised men are more likely to be infected than uncircumcised men is Rwanda, and it is stated that they have already operated on 415,000 men, out of a target of 900,000.

Paternalism behind African 'public health' programs funded by Western countries is questionable enough, but can't these circumcision evangelists at least wait until the more dubious arguments been re-examined and until there is stable and convincing evidence for carrying out what is probably an unnecessary and clearly an unsafe operation on more than 20 million people? Jacques Pepin (in The Origins of AIDS) has shown the sort of damage that resulted from public health programs carried out in colonial days (motivated by a desire to maximize profits);  we now know far better than to carry out mass male circumcision programs, but it seems we're still going ahead with them anyway.


[For some of the less well publicized details about the three circumcision trials used to advocate for mass male circumcision, see the Don't Get Stuck With HIV website and blog.]

allvoices

10 comments:

Anonymous said...

Could the reason why uncircumcised men in Kenya have a much higher HIV prevalence rate than circumcised men be because uncircumcised men mostly live in malaria-endemic areas and are therefore more like to get malaria and seek treatment at an unsanitary health facility?

Anonymous said...

*more likely ...

Simon said...
This comment has been removed by the author.
Simon said...

Not all uncircumcised men live in malaria areas, nor do all circumcised men live in non-malaria areas. What you say is possible, or malaria plays a part in both sexual and non-sexual transmission.

Here's a paper where the assumption that HIV is mainly sexually transmitted but the risk is increased by malaria:

http://www.ncbi.nlm.nih.gov/pubmed/21224274

Other research shows that malaria has declined substantially in several countries because the malaria carrying mosquitoes have been dying out. Kenya is one of the countries but the health services there insist it's because of their eradication programs!

They also insisted that drops in HIV prevalence in the early 2000s were a result of their prevention programs with hadn't really started then and wouldn't have reduced prevalence anyway, the most they would have done was reduce incidence, had they started on time and been widespread enough.

Anonymous said...

If you get malaria, you'll need a blood test and possibly blood transfusion. If this happens at an unsanitary health care facility, then you're 1,800 times more likely to get HIV than a man having unprotected vaginal sex with a HIV+ woman.

http://en.wikipedia.org/wiki/HIV#Transmission

Am I correct?

Malaria-endemic parts of Kenya have a high HIV prevalence rate.

Malaria prevalence map

http://kenya.usaid.gov/programs/health/72

HIV prevalence map

http://www.hivspatialdata.net/?page=comments&blogid=8

Simon said...

Anonymous writes:


If you get malaria, you'll need a blood test and possibly blood transfusion. If this happens at an unsanitary health care facility, then you're 1,800 times more likely to get HIV than a man having unprotected vaginal sex with a HIV+ woman.

http://en.wikipedia.org/wiki/HIV#Transmission

Am I correct?

Malaria-endemic parts of Kenya have a high HIV prevalence rate.

Malaria prevalence map

http://kenya.usaid.gov/programs/health/72

HIV prevalence map

http://www.hivspatialdata.net/?page=comments&blogid=8

Simon said...

Much of what you say may be true, however blood tests are not likely to pose a very high risk of HIV transmission and transfusions are common, but not widespread enough to explain a huge proportion of HIV infections, though bigger than it should. As for the probability figures you cite, they are hotly contested. But whatever figures are correct, probability of infection through certain medical procedures would often be far higher than that through heterosexual sex.

The correlations between malaria and HIV are only partial: the area in Northeastern province in the malaria map is not a high HIV prevalence area. On the contrary, that province has the lowest prevalence in the country. The area in Western province, especially the very high malaria prevalence area, also does not correspond to especially high HIV prevalence. Nairobi, which has the second highest HIV prevalence by province, has very low malaria prevalence (though the highest level of bednet ownership in the country). And while Coastal province, especially Mombasa, has high HIV prevalence, the area on the border between Coastal and Eastern province, as far as I know, is not a high HIV prevalence area.

I think the claim is that malaria (and other diseases) facilitates sexual HIV transmission; but this doesn't explain high prevalence of HIV in low malaria prevalence areas. I don't think those currently writing about malaria and HIV are paying too much attention to the possible role of malaria treatment in HIV transmission; personally, I am interested in both.

Petit Poulet said...

The power of money. They could only hold out so long. The HIV industry knows they have to implement circumcision as quickly as possible before it becomes apparent that it doesn't works and may make things worse. They have had a window of 5 years now, and may feel that they are running out of time.

Simon said...

Petit Poulet: true enough but they have other, far more commercially viable 'solutions' to play with so I don't see why circumcision is still so high up the agenda. There are PrEP and 'treatment as prevention', for example. But perhaps they are not really intended for developing countries, only wealthy Western countries.

Anonymous said...

Simon,

My name is Robert O'Hara and I am the news director for A Voice for Men, a website that deals with men's rights and male issues. Recently I published a couple of articles concerning the drive to circumcise 28 million men in Southern Africa over the next four years.
I am very interested in gaining a contact with someone who is familiar with the program who is living in Africa and has first hand knowledge of what is going on.
Please email me at vfm_news@yahoo.com I would really like to get in touch with you!