Tuesday, March 6, 2012

WHO and UNAIDS Bless Crusade to Circumcise Africans

I recently mentioned a paper that exposes how poor much of the research into male circumcision as a HIV prevention is and I have now got hold of the full paper; 'Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns', by Gregory Boyle and George Hill. The authors show that the results of the trials are not reliable and should not be used to argue for mass male circumcision programs.

One of the most striking aspects of these trials is that the figures purporting to show that such programs can reduce HIV transmission are those for relative risk reduction, not absolute risk reduction. While a 60% relative risk reduction may sound impressive, a 1.3% absolute risk reduction is not even statistically significant. Why are we being given selective and highly misleading data about circumcision if it is as important an intervention as we are told it is by its proponents?

The simple answer is that there is no credible evidence in favor of mass male circumcision; it needs to be manufactured. In fact, there is evidence that circumcision substantially increases the risk of transmission of HIV from males to females and more than a hint that men risk being infected with HIV through the circumcision operation itself. As a result of the well funded propaganda surrounding these circumcision campaigns, a whole set of myths is emerging. Some people, male and female, think circumcision protects against HIV; it is claimed that it is not possible to be hygienic if uncircumcised; there are allusions to circumcision being more aesthetically pleasing; it is implied that the operation is 'fashionable' or modern, etc.

The levels of misinformation being spread about male circumcision are astounding. Arguments for adult male circumcision have even been used for infant circumcision, although the claimed effects of adult circumcision have not been demonstrated for infant circumcision. 'Experts' extol the multiple virtues of circumcision, ignoring the lack of evidence for their claims, indeed, apparently blind to the entirely unscientific nature of many of the claims. After stating that "a circumcised [male organ] is definitely cleaner than an uncircumcised one" 'Dr' Khumbulani Moyo, Clinical Director of Population Services International goes on to say "Circumcised men are also more likely to be assertive sexually as awareness of a good body image is a very important factor in building self confidence." I wonder what his doctoral thesis was on; yoga perhaps?

Boyle and Hill note that the three trials purporting to show the effectiveness of circumcision were carried out in countries where it was already clear that HIV prevalence was higher among uncircumcised men. However, there are just as many countries where HIV prevalence is higher among circumcised men. They ask why the evidence to support a program that may aim to circumcise as many as 38 million men is so selective and point out that with less selective analysis, the program would not be supported. There are so many biases and inadequacies in the data that it can not be used to justify carrying out what is likely to be a dangerous, unnecessary and perhaps even counterproductive program.

It's hard to do this lengthy and well researched paper justice in a short blog post, but it's worth mentioning that one of the many flaws in the research is that non-sexual transmission of HIV was not reported. Quite a number of the men infected with HIV during the trials were probably not infected sexually and could have been infected through unsafe healthcare, perhaps even the treatment they received through taking part in the trial. Mass male circumcision enthusiasts claim that the operation reduces sexual transmission, but many men (and women) might face high non-sexual risks in addition to any sexual risks. But trials into circumcision and other HIV prevention interventions rarely seem to consider non-sexual risk.

There is a substantial body of evidence showing that male circumcision either doesn't reduce HIV transmission or even that it increases transmission. This evidence is not often mentioned by those whose aim appears to be to promote the strategy at all costs. In contrast, there is evidence that 'circumcising' women may be associated with some reduction in HIV transmission without this giving rise to the same enthusiasm for female genital mutilation. There is something of the crusader about the circumcision enthusiasts, something cabalistic in their methods. But what appears to be entirely lacking is science and logic.

[For more about non-sexual risks for HIV transmission, see the Don't Get Stuck With HIV site and blog.]


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