Thursday, March 8, 2012

To What Extent Does Male Circumcision Reduce HIV Transmission?

Probably in common with many bloggers, HIV in Kenya is my own take on things of interest to me that relate to HIV, development, Africa, health and various other subjects. I am not 'giving a voice to the voiceless', just saying what I think because few people or institutions that I know of are saying the same thing. Taking a keen interest in something does not necessarily make me an expert, but if I am wrong, surely I am more likely to be set right by airing my views in public, with arguments and citations that I feel support my views? In the process, sometimes I change my views imperceptibly (perhaps even to myself), sometimes I do so radically.

But one thing I will not do is leave what can be highly technical subjects to those who are seen as, and/or who see themselves as, experts. I may at times defer to them, but I also question them. This is because I have read many apparently well researched and well written papers, with mountains of citations and erudite passages, often published in respected, even venerated, peer-reviewed journals, whose conclusions seem to fly in the face of my own analyses, observations and experiences. We may not all have the same academic credentials, but we should have a lot in common in virtue of being humans. Yet, I constantly find myself reading 'scientific' papers that either state, imply or evidently assume that some humans are capable of behavior that would be beyond the ability, inclination or both, of most people.

There are so many overlapping groups who have been 'identified' as being at risk of infection with HIV, often mistakenly, that this approach is of very limited value on its own. Aside from at times stating, incorrectly, that 'everyone' is at risk, or is at equal risk, at other times the finger has been pointed at men, women, children, Africans, Haitians, gays, soldiers, teachers, young brides, older men, long distance truckers, immigrants, migrant laborers, prisoners, sex workers, clients of sex workers, intravenous drug users, victims of female genital mutilation, uncircumcised men, fishermen, widows, alcoholics, internally displaced people, sex tourists, sugar daddies, partners of sugar daddies, poor people, rich people, uneducated people, students, people with certain diseases, especially sexually transmitted infections, and the list goes on.

Almost all of those groups listed above are said to be at risk of infection with HIV because of some kind of sexual behavior, and some of them are indeed at risk, others may be at risk. But HIV is not always transmitted sexually. Aside from the more obvious intravenous drug use and mother to child transmission, there are additional non-sexual HIV risks that are rarely mentioned in the literature except to be denied or diminished. What I would really like to know is the relative contribution of non-sexual HIV transmission, especially from unsafe healthcare, and perhaps to a lesser extent from unsafe cosmetic practices. It could be true that unsafe healthcare plays a very minor role in serious HIV epidemics in Africa. But I don't believe that, especially when I read documents such as the Service Provision Assessment documents for Kenya, Uganda and other countries.

Similarly, there is much written about the potential effectiveness of conditional and unconditional cash transfers, particularly to young girls, mass male circumcision, pre-exposure prophylaxis, testing everyone (or at least 80% of people) in HIV endemic countries and treating everyone found to be infected, microbicides and various strategies, including abstaining from sex. Indeed, organizations involved in all sorts of activities, such as birth control, poverty, gender based violence, alcohol and drug abuse, reproductive health, religious practices, sex education, even selling commodities such as condoms, pharmaceuticals and various devices and services, all find their best market, sometimes their only market, in HIV. Some of these may be effective, even good value, some are probably not effective and others are harmful or potentially harmful.

Among the many disputes that I have been part of though my blogging are marketing of inappropriate pharmaceutical products, questionable ethical practices, especially in drug trials, dissemination of questionable data and information that affects peoples' health; I have also specifically raised questions about use of injectible Depo Provera hormonal contraceptive, strategies such as 'ABC' (abstain, be faithful, use a condom), pre-exposure prophylaxis in populations where it is unclear who is at risk of HIV infection and what kind of risks they face (whether they are sexual or non-sexual); and in particular, I have raised questions about mass male circumcision, over and over again. True, there are quite a number of recent papers about circumcision which make strong claims about its effectiveness. But there is also a wealth of literature that is more critical, much of which is ignored in the favorable papers.

In a word, the debate is highly polarized. There are those who only seem to concentrate on what they see as advantages in circumcising 30-40 million Africans, at vast expense; and there are those who keep asking questions about what seems like a lot of propaganda, and citing numerous possible disadvantages. Living in East Africa, I have heard people talking about circumcision and they have all been in the first group, those who only mention the advantages. As a result, many of the recipients of this information think they are already protected, being circumcised; many women seem to share this view. Uncircumcised men are, unsurprisingly, more reticent. But if the numbers we read are true, tens of thousands, even hundreds of thousands are turning up to be circumcised. It would be interesting to know what it was that convinced them and if they were convinced by propaganda, because there doesn't seem to be a lot else readily available.

Anyhow, I have cited many of these papers that are clearly in favor of mass male circumcision, often regardless of their research findings; and in addition, I have cited papers which are opposed, all of which seem to get far less attention from the mainstream, health and scientific press. One of those papers, written by Gregory Boyle and George Hill, makes a claim about the absolute risk reduction for male circumcision not being statistically significant and comparing this to the relative risk reduction. Whereas the relative risk reduction looks impressive and is endlessly cited by the mainstream press and in academic sources, the absolute risk reduction figure is very small, certainly not useful for propaganda purposes. But is the absolute risk reduction statistically significant? A visitor to my blog post on believes it is and accuses Boyle and Hill (and myself) of lying by claiming otherwise. I have notified the corresponding author and will leave it to them to defend their claim.

This is not the first time I have cited something that has turned out to be questionable. I have also inadvertently drawn incorrect conclusions, even miss-cited sources and made other errors. Thankfully, either I have noticed and made amends, or someone has contacted me to let me know there is a problem. At other times, people are not particularly polite, perhaps because they have an axe to grind or some kind of interest, financial, political, personal, whatever. Nevertheless, I'd rather get a kick in the ass from someone who is right than a pat on the back from someone who is knowingly or carelessly peddling rubbish. And much though I hate to admit it, 'you would say that, wouldn't you' is a fallacy. Even if someone is saying something because it's their party line, and not because they always fight for their convictions, that doesn't mean they are wrong.

Even at risk of saying (or citing) something that turns out not to be true, I am going to continue objecting to what I believe to be wrong until I become convinced that it is not wrong. I have yet to be convinced that mass male circumcision will reduce HIV transmission, just as I have yet to be convinced that HIV is almost always transmitted through heterosexual sex in Africa. Therefore, I shall continue to express these views on my blog.



Petit Poulet said...

Boyle and Hill made a mistake in that they were imprecise with language. Something can be statistically significant, yet clinically unimportant, which is the case with the results of the overpowered RCTs. While the person accusing them, and you, or lying goes a little overboard and perhaps needs to refill his Zoloft prescription. For example, a company could do a large study and find that their gas additive significantly increases milage when added to gasoline. The increase may be only 0.1 miles per gallon and cost per tank of the additive $5. While it does "significantly" increase gas milage, the difference is inconsequential and the additional cost not worth the expenditure.

The other side of the fact that the complainer focused on this minor error because it was the only thing in Boyle and Hill's article that he could attack. This tells me that what Boyle and Hill had to say has certain people worried and that they hit the nail directly on the head.

Simon said...

Yes, the person in question really underlined the weakness of the case for circumcision by going on about a technicality. He hasn't presented any argument at all in favor of circumcision. But he has a tendency to pick on a small detail and to call people liars. Perhaps he's hoping for the more litigious to sue him or something like that. I've heard of him being referred to as a writer but I've never seen anything he's written, aside from his copious trolling! Others commenting on Boyle and Hill's article have also failed to address any of the issues, preferring ad hominems and the like. The US ambassador to Uganda's article on circumcision is a case in point.