Tuesday, May 15, 2012

Appropriate Penile Hygiene, Not Circumcision, Reduces HIV Transmission

Despite the questionable evidence for the effectiveness of mass adult male circumcision campaigns to reduce HIV transmission from females to males, apparently Kenya is going to roll out a program for children as well in areas where circumcision levels are low and HIV prevalence is high. People who are too young to give their consent for this operation will have their fate decided by their parents, who are being blasted with misinformation about various 'benefits' of circumcision.

But Alice Nyambai of Homa Bay District AIDS coordinator's office, while approving of the operation for minors, also highlights a need for swabs, surgical spirits, latex gloves and Jik (a brand of bleach). This comment corroborates findings that supplies used in infection control in health facilities in Kenya (and other African countries) are poor. Just how safe are conditions in facilities that are trying to handle thousands of circumcision operations when they are often unable to cope with routine health provision?

Nyambai points out that circumcision in children and infants can be cheaper than for adults, citing a $60 figure for the latter and a $12 figure for the former group (though, as the $60 dollar figure doesn't include all the costs, the $12 figure probably doesn't either). But does the fact that the operation is cheaper make it any more justifiable, under the circumstances? The cost of more vital and cost-effective procedures is far lower, but those costs are frequently not met, with the number of children and infants dying of treatable and preventable illness running into tens of thousands every year.

Nyambai seems disappointed that 'only' 11,000 men out of a possible 42,000 have been circumcised. But many will breath a sigh of relief that they didn't swallow the hype when they hear that the very people promoting circumcision with claims of 50 or 60% relative risk reduction also found that waiting at least 10 minutes after sex and then wiping their penis with a dry cloth can reduce the risk of infection by 83%. This is a far higher reduction than was claimed for Truvada, which is to be approved in the US as a pre-exposure prophylactic (PrEP) on the basis that it might reduce risk by up to 44%.

HIV prevalence in parts of Nyanza province is high among the Luo people, among whom circumcision rates are also low. But the same research that purported to show that circumcision reduces the risk of transmission from females to males also showed that it may not be the lack of circumcision that increases HIV transmission risk, but something else entirely. Which makes one wonder why circumcision enthusiasts were so cavalier about having no idea what mechanism might be involved in the claimed protective effect of circumcision.

Circumcision proponents continue to ignore their own evidence about a cheap, safe and effective strategy for reducing HIV transmission: penile hygiene. Indeed, they continue to withhold some of the data they themselves collected. Instead, plans to circumcise tens of millions of adults, and probably similar numbers of children and infants, are to go ahead This is all costing billions of dollars that would save far more lives if spent on genuine priorities, with all the well-documented risks involved in rolling out such a program. It sounds as if these public health 'experts' are not answerable to the people they claim to be serving.

[For more about non-sexual HIV transmission and injectable Depo Provera, see the Don't Get Stuck With HIV site.]


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