PrePex Circumcision: a 'Bloodless' Coup

About a year ago, the BBC got so excited about PrePex, a "new, simple, plastic device, which needs no anaesthetic, surgery or stitches [which] will be used to circumcise up to two million men in Rwanda" that they produced an infomercial about it which PrePex now use on their site. It's great to get the free advertising as there are other such devices; but clearly not as well connected with good infomercial producers. Perhaps the BBC haven't heard of clinical trials. (Warning, viewers are protected from most of the operation but may find the overall tone of the video disgustingly smug, particularly when the PrePex CEO comes in; discretion advised.)

PrePex has been all over the place in the media because if one outlet says its good, none of the others want to feel left out. The New York Times have announced that it will be 'tested' in at least nine African countries. I wonder what the criteria for success or failure will be, given the current enthusiasm for circumcising as many men as possible before anyone notices that the intervention will have very little positive impact on HIV transmission from females to males and a highly likely negative impact on transmission from males to females.

Exactly how much money will be thrown at mass male circumcision and exactly how many will be tricked into undergoing the operation has never been clear. Estimates about cost per operation are often around 60 to 80 dollars. But these are highly selective costs and around double that figure is much more likely, not including the costs associated with adverse outcomes in the short and long term. Numbers of adults to be circumcised cited range from 20 million to 38 million.

The oft cited randomized controlled trials of male circumcision show that around 76 men need to be treated for each infection averted. But the director of PrePex claims that around 4 million infections could be averted over a period of several years. This would require over 300 million men to be circumcised. The cost for this could be up to 10 times more than the 3 to 5 billion estimated and would probably mean that babies and children would need to be targeted, not just adult men.

One of the people in the BBC infomercial states that circumcision is the most efficient tool for reducing HIV transmission. It's not clear whether the woman has been taken in by the hype or whether she is saying what she has been told to say. But it seems highly unethical to tell outright lies about the intervention when so much is at stake. The HIV industry can usually be trusted to tell half truths and to omit things that are inconvenient rather than telling outright lies. Perhaps they feel that's less unethical. But condoms and appropriate penile hygiene are far more efficient than circumcision.

It is also highly questionable to persuade parents to consent to their infants and children being circumcised on the basis that this may protect a small percentage of them from sexually transmitted HIV some time in the future, perhaps 20 or more years hence. In fact, the claimed reduction in transmission is for those circumcised in adulthood. High HIV prevalence in countries that already practice infant and/or child circumcision, sometimes higher than for uncircumcised males, may suggest that a bad argument for adult circumcision is being used for an even worse argument for infant and child circumcision.

Those filmed in the BBC's infomercial are all smiles; one man says his penis was ugly but it's now smart. But the biggest smiles are those of Tzameret Fuerst, the CEO of PrePex. I guess that's to be expected when you look at the figures. She talks of 'unwanted tissue' and compares using PrePex to cutting nails. I wonder, if any part of female genitalia could also be called 'unwanted', should PrePex start branching out in that direction? Lack of hygiene and unsightliness are among the reasons often cited for female genital mutilation, too.

It must be remembered that the 'up to 60%' reduced transmission from females to males is from very carefully controlled trials, where those taking part received a lot of care and support that will not be available to those 'lining up' for the operation in the future. So the number of circumcisions needed to 'avert' an infection could become so high that there is no noticeable benefit. But only after a hell of a lot of money is spent (and probably a lot of damage done); and that's what it's all about, isn't it?

The NY Times article claims that no surgeon is needed and that the operation can be carried out by two nurses. This is just as well, given the shortage of surgeons in countries where most of these operations will be carried out. Apparently it is hoped to circumcise 20 million men by 2015. Let's hope other countries are better off than Uganda, where "2,300 Quack Nurses [have been] Exposed". Unfortunately, being exposed as a quack nurse means not having the required certification, rather than any attention being paid to what those with certification know or how they perform.

This is particularly embarrassing for the HIV industry because Uganda is often held up as an example of HIV prevalence declining because the country took all the industry's advice. Now that prevalence is increasing, the industry needs to show how Uganda didn't really take their advice, because they certainly can't admit that their advice was wrong. But I'm sure the media will help them along, they always seem to follow the money. But even the latest cool thing, treatment as prevention, is not looking good in Uganda.

One of the possible reasons for the extremely low levels of success in reducing HIV transmission in African countries might be the insistence that most HIV is heterosexually transmitted. Interventions such as male circumcision are intended to reduce sexual transmission from females to males, not any other kind of transmission. The fact that this will be another intervention that doesn't work will probably not be seen as a problem for the HIV industry or for the CEO of PrePex. But it must worry ordinary African people, perhaps even African leaders.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]