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.]