Tuesday, March 20, 2012

Get Circumcised or Get Labeled

My first big shock when I started to follow HIV related issues in East Africa was that it was assumed almost all transmission was sexual in Africa (though nowhere else). Then, to 'work out' how this could possibly generate such massive epidemics, there was also the tendency to go from the number infected, or said to be infected, to the absurdly high levels of unsafe sexual behavior that would be needed to explain high levels of heterosexual transmission of HIV. There has never been any evidence that unsafe heterosexual sex alone could explain Africa's worst HIV epidemics. But all the 'work' to prevent infection appeared to concentrate on sexual transmission.

If not all HIV is transmitted sexually, many interventions that target sexual behavior, whether levels are real or assumed, will fail. Abstinence and other associated campaigns didn't even sound plausible before they were implemented, but enormous amounts of money was ploughed into them. Some equally dubious interventions were dreamed up and most probably also had little positive effect; as for any negative effects, these are unlikely to have been measured, let alone alluded to in the copious self-congratulatory literature that has emerged from what became the extremely lucrative HIV industry.

When circumcision was mooted as a possible intervention, it seemed to suffer from the above problem; it would, at best, protect against heterosexual transmission; it would not protect men who have sex with men, infants who are infected by their mothers or intravenous drug users. Indeed, it turned out that it wouldn't protect women either, and probably increases transmission from men to women. It will not reduce non-sexual transmission of any kind, including that through unsafe healthcare or cosmetic practices. Worse, in the sub-standard health facilities that ordinary Africans are forced to use, mass male circumcision programs might add to the problem, with men being infected in the health facility where the operation is carried out.

But those receiving circumcision related funding continue to insist on the effectiveness of such programs, shouting down any opposition, churning out figures which could be interpreted to show that male circumcision reduce transmission from women to men, but never actually engaging with the opposition. There are now so many problems with male circumcision as a strategy that the whole exercise to circumcise between 22 and 38 million African men should be suspended. There is so much disinformation and consequent misunderstanding that the campaign is unlikely to do any good and is in serious danger of doing a lot of harm. At best, it is just another neo-colonial excess of the kind that probably ensured that HIV would become the pandemic that it now is.

Kenya's Nairobi Star is currently doing a great job adding to the obfuscation that seems to pass for scientific journalism. The article 'Study Claiming Cut Does Not Inhibit HIV Rejected' makes a shaky start by incorrectly suggesting the study was not published or that its findings were refuted, or were even addressed by those promoting circumcision. The cited claims from the study are, in fact, correct, but they are only the tip of the iceberg. Interviewing those who would have a lot to lose if the circumcision program was suspended and asking their opinion is easy enough. But is it adequate journalism? Does the public really need more of the selective use of factoids to justify spending hundreds of millions of dollars on a campaign that is likely to be of so little benefit (at best)?

Other countries have less to say about the latest paper, one of several that has managed to get through the HIV industry's censorship process (peer review). Uganda's press has commented on circumcision from time to time, but only to beat the orthodox drum. It is claimed that 600,000 men have already been circumcised under the program since 2009, but it is unclear where this figure comes from. Naturally, it is claimed that 80% of HIV is transmitted heterosexually (with 18% usually said to be accounted for by mother to child transmission or MTCT). It is also reported that "the target of the ministry is to circumcise four million male by 2013" and that the "programme stands until the HIV/Aids prevalence rate is down to zero" (which is hardly the same thing!).

Meanwhile, the latest HIV prevalence figures for Uganda may show that prevention interventions have not been working very well, rising from 6.4% to 6.7% between 2005 and 2011. The article estimates that the number of people living with HIV has risen from 1.1 million to two million in the same period. It is not possible to corroborate these figures yet, but it is quite possible that prevalence flatlined or increased just when HIV spending was peaking. At the same time several hundred thousand people died of AIDS, so ubiquitous claims about large numbers being kept alive by antiretroviral drugs may also need to be more closely examined.

One commentator, Dr Alex Opio, even has the cheek to claim that "HIV incidence is also low among the circumcised people, which shows that the circumcision campaign is working". It doesn't show any such thing and Dr Opio should be well aware of this. Or would he also like to accept that the higher HIV prevalence among women is also a result of the circumcision campaign? Apparently sex (notice, not 'heterosexual' sex) accounts for only 76% of infections while 22% is now accounted for by MTCT; is that also a result of increased male circumcision resulting in higher rates of transmission to women, and thus to infants?

Not content with circumcising adult males on the basis of flimsy evidence, Uganda is also talking about 'circumcision camps' to be set up in schools so that teenagers can also be circumcised. Perhaps they could be called the 'Halperin Youth'. Even the US ambassador has weighed in with an article entitled 'Circumcision does reduce HIV spread' on the Ugandan US embassy site. It seems the ambassador is not an expert on circumcision and it's hard to discern exactly what angle he is taking, but I guess ambassadors don't get to make that many choices.

The most pathetic part of the ambassador's feeble article is the claim that "circumcision is also a gateway to a range of male reproductive health and HIV prevention services" such as "HIV counseling and testing, treatment of sexually transmitted infections, promotion of safe sex practices, condoms and information and tips on how to use them correctly and consistently". Is he hinting that it's all or nothing from now on, that men will only receive the sexual health services they need if they agree to be circumcised? Or am I reading too much into the word 'gateway'?

A school in Tanzania has decided that HIV positive children should identify themselves by wearing a red ribbon "at the parents' request to excuse sick children from strenuous activities". Just how far are the ambassador and his fellow circumcision enthusiasts from suggesting some symbol for uncircumcised men to wear to identify their current status, which now appears to be thoroughly stigmatized; or perhaps circumcised men could wear wristbands... ?

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]



Joseph said...

Yes, it seems intact males are simply incapable of grasping the concept of safer sex and hygiene unless they are circumcised.

Circumcision must activate the neurons that causes men to listen to advice on safe sex, you see.

Our knife-happy circumcision advocates don't seem to fear the opposite kind of labeling; that African women will come to see circumcised men as AIDS-free, and that there is less need to use a condom.

"Researchers" cannot keep back the truth forever. When this circumcision/HIV hoax comes crashing down, who is going to hold these "researchers" and the organizations that bought their "studies" accountable? People need to take names for when this happens. The "researchers" and those accepting aid for circumcision are only digging themselves deeper.

Simon said...

Thanks Joseph. I never wanted to get so involved with circumcision but the whole thing gets creepier by the day. Have you heard about the Tara KLamp being used in South Africa, which was found to be dangerous a long time ago?


What the hell is the US ambassador doing, giving advice about circumcision? Why 'circumcision camps'? Are they a bit like concentration camps where people can compare the risks of being circumcised by some bloodthirsty functionary and the risks of remaining uncircumcised in a world where that appears to be tantamount to being some kind of criminal?

Joseph said...

The Tara KLamp is old news. And where is the WHO's edict against it, knowing full well of its adverse effects?

Now it's the PrePex, who is waiting for WHO approval to sell 20 million devices and cash in on the HIV pie. Nevermind the Mogen clamp, which, by the way, the went bankrupt after they couldn't pay off their umpteenth lawsuit against them for circumcision mishaps.

It should be obvious by now that HIV prevention is the last thing on these people's minds.

Where is the "informed consent?" Where is the "voluntary" if not circumcising is not an option?

Do they have information packets ready for those men who would rather not get circumcised?

Or is not getting circumcised simply not an option?

Who in the right mind would choose to get circumcised, if they knew they had to wear a condom anyway?

I can only deduce that the men aren't being given complete information. They CAN'T be if they have a quota of 20 million men they need to achieve at all costs.

It gives me hope to read, however, that African news outlets are slowly, but surely, questioning the circumcision campaigns, thanks to dissenting papers such as the one written by Boyle et al.

In the past few months I've read on African news outlets that programs are failing to meet their quotas.

This tells me that, despite all he hype, a lot of African men aren't buying it.

You can only hide the truth, especially one this glaringly obvious, for so long.

It is absolutely shameless the way the US Ambassador simply repeats the party line and refuses to address what is being questioned from the outset. Who knows if he even wrote the response; it seems awfully scripted. It also seems a bit anxious and apprehensive. If the evidence is so solid, why not hold it up to the questions asked instead of dismissing them from the outset? I sense desperation in the tone of the response. Could the collapse of the circumcision/HIV hoax be eminent?

Simon said...

Here's one of the articles on failing to meet targets:


No, I think the 'voluntary' bit is just nominal.

The medical devices industry has been very uncoordinated in its response but PrePex seems to have pushed the right buttons with the establishment.

I'm wondering if that PrePex woman drooling about cutting off 'useless pieces of flesh' on that video will eventually end up on the sex offenders' register. I guess if she does all her drooling over African foreskins it's ok.

Joseph said...

You can read about the Soka Uncobe failure in Swaziland here:

They boast 34,000 men circumcised. (They were aiming for 200,000)


You can read more on Tzameret Fuerst here:

And read up on the WHO's "chief expert on circumcision," who also happens to be the inventor of the "AccuCirc" device.

Feel free to look up the rest of the site; the gang's all here. (Well, at least the ones people were able to get dirt on...)

Simon said...

Thank you for the links, and good use of a wiki, there's seems to be quite a need for something like that. Maybe you'll also list the main opposition as well? Or even just put them all together, pros and cons.

Petit Poulet said...

"Halperin Youth" Thank you for this, you have made my day. I hope the appellation sticks.

When talking to a variety of the people from the CDC and WHO and researchers (now lobbyists) who are pushing circumcision, a friend of mine noted that they are all circumcised and they all have only disgust for the foreskin. For them it is not scientific it is visceral.

This may explain why Marie Wawer, when she her study found that for every 17 circumcisions performed on an HIV-infected man an additional woman became HIV-infected. Instead of recommending against circumcising HIV-infected men and thus protect their female partners, she recommended that HIV-infected men be circumcised so they won't be labeled or stigmatized. She has expressed her disgust for the foreskin in other venues. So what if more people die, at least the guy gets to look like his buddies.

At what point is this hate speech? At what point is it tribalism? At what point is it academic misconduct?

The US ambassador is just mouthing the party line. Several Americans are heavily invested in the circumcision solution. The NIH or Bill Gates paid for these studies, so their reputation is on the line. So are the reputations of Johns Hopkins and Harvard University. It is too soon for the ambassador to backpedal.

Simon said...

So choosing not to be circumcised is not an option for Wawer and friends. Even if the operation reduced HIV transmission a lot, surely people would have the option to refuse and/or to choose a different method of protecting themselves from HIV. The circumcision crew seem to think that it's a foregone conclusion that people who don't get circumcised will be infected with HIV. They must see that surveys show that not everyone faces a high risk; most face no risk at all. You're right, it's visceral, there's nothing scientific about it. But a lot of money must go into making it seem to be a matter of science.

Incidentally, the following article from a Ugandan newspaper is unambiguously sceptical about circumcision:


The gloves are off.

Anonymous said...

That ambassador is totally out to lunch-what a pack of lies! I doubt he even read or understood the articles he mentions. Clearly, he has no statistical or scientific background or else he is a moron who has drunk too much of the kool-aid. Clearly, he is also circumcised. At least the last article from All Africa is finally saying what needs to be said: The U.S. has the highest rate of HIV and the highest circumcision rate.

Simon said...

Even if US ambassadors have some kind of democratic mandate, and that's highly questionable, the Ugandan ambassador does not represent the Ugandan people; it is not his place to make 'recommendations' relating to public health. The 'voluntary' aspect of these circumcision programs has never been credible, but it is getting less credible every time some pampered lackey jumps on the bandwaggon.

It would be worse if he did appear to know something about circumcision, but the exercise has always been political. There's more than a hint of charting out human 'territory', leaving an indelible mark on those who are 'with us' and also identifying those who are 'against us'.

Isn't it becoming another version of the various colonial powers' identifying groups of workers, collaborators, traders, outlaws, cannon fodder, etc?