Saturday, February 25, 2012
Male circumcision as a HIV prevention intervention has often attracted the response that if you use a condom it's unnecessary and if you don't use a condom it doesn't work; so why not just use a condom? But similar remarks have been made about Depo Provera and other hormonal contraceptives; if you don't use a condom along with Depo, you risk being infected with sexually transmitted infections, such syphillis, gonorrhea, herpes and HIV. While if you just use condoms, you will be protected against those diseases and you will also avoid unplanned pregnancies; so why not just use condoms?
But there are deeper problems with both male circumcision and Depo Provera. The former almost certainly increases HIV transmission from males to females, and females are far more likely to be infected already; HIV prevalence in many groups is several times higher among females than among males. And Depo Provera may increase HIV transmission in both directions; the WHO is still out on that one and have said it could take years to give the product the all clear. So why don't they just recommend that people use condoms? Instead, they recommend that people use both Depo Provera and condoms.
One of the selling points of Depo Provera was that it would prevent conception for women who couldn't be guaranteed that their partner would use a condom. But if a condom is not used and both parties are at increased risk of being infected where Depo is used, using the hormonal contraceptive is more dangerous than not using it. There are alternatives to Depo Provera, but if they are not viable, available, accessible or whatever, it seems clear that it should not be used without condoms. Using neither condoms nor Depo Provera cannot be recommended, but using Depo Provera on its own is foolhardy. People don't weigh up the dangers and then decide that HIV is a less worrying risk than an unplanned pregnancy; they want to avoid both. Only population control hardliners believe in birth control at all costs.
There seems to be some confusion about Depo as a result of WHO's 'high level' meeting. There's an article about what may or may not have been discussed at the meeting to review the evidence about Depo Provera and it says that no conclusive decision was agreed. In a sense that's true but WHO have said that people should continue using the product, even if they are at risk of being infected with HIV or if they are already infected; however, they should always use a condom. The problem is, that's what they said before the meeting as well. In other words, the evidence they say they are going to take several years to consider has made no difference to the advice they give. Perhaps some are worried that evidence that can trigger years of research should also trigger a higher level of caution?
Articles on the subject of Depo Provera often mention that it is one of the most popular forms of modern contraception, but it has also been marketed very aggressively in African countries, at married women, at sex workers and at young, unmarried girls and women. Strangely, Depo Provera is nowhere near as popular in Western countries, except among certain ethnic populations. Hormonal contraceptive marketing is often dressed up as public health advice about family planning and birth control, which points to a dangerous conflict of interest. Marketing is not disinterested advice, quite the contrary, and it is not WHO's job to market pharmaceuticals, though people could be forgiven for thinking otherwise. But from whom do African women now get impartial advice?
Over a billion dollars, perhaps two billion, have been earmarked for an enormous and senseless mass male circumcision program; some say over 20 million men and boys will be circumcised. Many may be too young to be sexually active, too old to be sexually active, sexually inactive for other reasons, not facing any sexual risk, facing too high a sexual risk for circumcision to be of any benefit (for example, those who are engaging in anal sex with men or women), facing non-sexual risks that are far more serious, etc. Many more will probably give up using condoms in the belief they no longer need them, though some circumcision enthusiasts deny that this is a risk. Even some women already believe that circumcised men pose no HIV risk and that unprotected sex with them is safe.
Worries raised about Depo Provera are not the kind you can just ignore until several more years of research has been carried out; what if the research confirmed earlier suspicions about the product doubling risk of transmission in both directions? And with male circumcision, the evidence is slim; the 60% risk reduction is a reduction in relative risk. The reduction in absolute risk is almost negligible. Many hundreds of operations would need to be carried out to prevent one infection; but the increased risk through reduced condom use and other precautions will probably result in an overall increase in transmission.
It could be asked why international health institutions and other parties are pushing ahead with these two interventions when they both seem more likely to increase HIV transmission than reduce it. Doing nothing would seem preferable, although there are a lot of positive things that can be done. For example, prevention of mother to child transmission is successful but it needs to reach all mothers, and earlier rather than later. Reducing transmission through unsafe healthcare would also be very cost effective as it would also reduce transmission of numerous other diseases. And condoms are good for preventing sexual transmission of HIV and other diseases, as well as unplanned pregnancies. Instead, there are huge sums of money behind useless and risky circumcision programs and highly suspect Depo Provera and birth control programs; perhaps therin lies the answer.
[For more about non-sexual risks for HIV transmission, see the Don't Get Stuck With HIV site and blog.]