Thursday, September 27, 2012

Where Circumcision is the Bottom Line, Health is an Externality

It's remarkable how many different areas of daily life people who have heard of the Voluntary Medical Male Circumcision program (VMMC) in Kenya associate with male circumcision, and its claimed effectiveness in reducing transmission of HIV, and even various sexually transmitted infections (STI). Many of the things people talk about when asked about VMMC have little to do with the program and do not correspond to any of the findings of the three randomized controlled trials (RCT) commonly used to justify the plan to circumcise between 20 and 40 million African males.

Some tell you that sex is better, for men and for women, more satisfying, more pleasurable. This seems like a rather subjective argument for carrying out an invasive operation on millions with the aim of reducing HIV transmission, especially as those carrying out the program are also urging people to have fewer sexual partners, to wait until they are married, etc. One man I spoke to said it's easier to put on a condom if you are circumcised. He runs a large clinic that carries out VMMC, among other things. He agreed that the relative ease of putting on a condom is not a scientific finding, though. One can hear similarly subjective appeals to the aesthetic appearance of circumcision.

However someone else I spoke to, who has been involved in 'mobilizing' people to be circumcised, said that for every person who says sex is better after being circumcised, or that putting on condoms is easier, and various other claimed 'advantages' of the operation, there is someone who will say the opposite. More tellingly, he said he felt under pressure to emphasize the 'advantages' and claimed advantages of circumcision and ignore or dismiss any perceived or claimed disadvantages.

Over 80% of Kenyan males are circumcised as an infant or as an adolescent, for cultural or religious reasons. As a result, a lot of people will already tell you that it is better to be circumcised. Those who do it for religious reasons follow the relevant teachings of their faith. And those who do it for tribal reasons follow their tribal customs. Among those who are circumcised for tribal reasons, it is a rite of passage. It is the time when a boy becomes a man. Even adults who are not circumcised, whether they belong to a circumcising or non-circumcising tribe, are considered to be mere boys, unfit to take part in adult affairs, including leadership. Most of the uncircumcised males in Kenya are members of the Luo tribe.

The above mentioned RCTs did not make any such claims about unfitness for government, of course. But they were used to persuade Luo elders and Luo politicians to get behind the campaign, particularly by openly declaring their support for it, by stating in public that they would not, as Luos, object to circumcision on the grounds that it is not part of the Luo tradition, even by getting circumcised themselves if they had not already been circumcised for some other reason. The fact that many senior Luos got behind the campaign is said to be one of the reasons for objections to it being dropped. This didn't result in large numbers of Luo adults agreeing to be circumcised, but it did result in large numbers of Luo parents, apparently, giving their consent for their teenage boys to be circumcised.

Perhaps members of other tribes will no longer be able to say that Luos are not manly or mature, or that they are otherwise unfit for government on the basis of their circumcision status. But it seems unlikely that inter-tribal animosities will be assuaged so easily. The fact that mobs carrying out forcible circumcisions have been heard to claim that they are 'kicking AIDS out of Africa' may suggest that 'traditional' reasons for certain practices can readily be supplemented with non-traditional justifications. Indeed, the association of circumcision status with HIV status may further enforce the already high levels of stigma and discrimination faced by HIV positive people.

But one of the most invidious of all the inappropriate arguments for VMMC is the appeal to hygiene and cleanliness. One of the RCTs did find evidence that HIV transmission may be related in some way to genital hygiene. It was found that men waiting for a while after sex and then cleaning with a dry cloth, rather than soap and water, gave better protection against HIV than circumcision status. In other words, uncircumcised and circumcised men alike could reduce their chances of being infected by employing appropriate hygiene measures. But those measures do not appear to be a part of the current VMMC campaign.

On the contrary, people I asked about hygiene and cleaning practices said they washed straight away, with soap and water. One even said you must wash before and after sex. While these beliefs may not relate directly to the VMMC campaign, nor do they appear to have been addressed by the campaign. There are things people should know about genital hygiene, but washing immediately after sex and using water, soap and even disinfectant may increase HIV transmission, rather than reduce it. The VMMC campaign appears to tap into some existing beliefs about hygiene that could be modified; but this doesn't appear to be one of the aims of the program.

Perhaps one of the reasons why those promoting VMMC are so reluctant to discuss the importance of genital hygiene is that they know that hygiene is a long standing and, so far, intractable problem, that goes way beyond HIV and STIs. The health of everyone is compromised by lack of access to clean water and sanitation. Removing foreskins does not improve hygiene if the very conditions that enable health and cleanliness are missing; it could even increase the risk of those circumcised, especially in the months following the operation. Health facilities themselves often lack access to water, sanitation, soap, disinfectant and other supplies that are vital to ensure adequate levels of infection control.

People's beliefs about hygiene may be influenced by the constant mention of germs in TV advertisements for soap, disinfectant and other hygiene related products. Several people I spoke to talked about germs and dirt, apparently believing that circumcision would help with these problems. But even they agreed that being circumcised is not enough to ensure that a person washes properly. The hygiene related products they mentioned, Smile (brand of soap), Jik (brand of bleach), Dettol (brand of disinfectant) and Omo (brand of soap powder), are useless in the absence of clean water and sanitation.

It is shocking enough to find that the VMMC campaign doesn't appear to address people's knowledge of genital hygiene, nor even to attempt to address lack of access to water and sanitation, which proponents are well aware is vital to all aspects of health, not just sexual health. But it is also disappointing that the people who tell me that circumcision is 'cleaner' do not also complain about problems like lack of running water, open defecation, pools of stagnant water, piles of smouldering rubbish and deplorable housing. Given the state of the slums where the majority of urban-dwelling Kenyans live, do they or those promoting VMMC really think male circumcision is a priority, even a sexual health priority?

Proponents of VMMC can be vague about what kind of people makes up the 450,000 who have already been circumcised under the current program. Even they have admitted that a lot are teenagers, rather than adults. Some are not Luos, they are members of tribes who already practice circumcision. But how many of them are adults, particularly adults who are at high risk of being infected with HIV and who, the story goes, would be protected by 'up to 60%' if they were circumcised? And how many are people who live in such appalling conditions that circumcision, or even HIV, are not among their top priorities, nor even among the highest health risks they face?

Those working on the VMMC program are well aware that most people who are claimed would be protected by the operation have not agreed to be circumcised, and that most people who have agreed are at low risk of being infected with HIV. They just seem completely unconcerned by these matters. The reasoning seems to be that VMMC attracts a lot of funding, whereas genital hygiene does not. Health in Kenya will never improve appreciably until clean water and sanitation are accessible to all; they are even prerequisites to the effectiveness of all other health provision and all other fields of development. But it's VMMC that has attracted the money, therefore circumcisions will be carried out. The consequences in economic terms, the only terms that seem to count (or to be counted) in development, are mere externalities.

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


Tuesday, September 25, 2012

Circumcision Protects All From HIV, Except Luos...and Women

There are many anomalies in arguments claiming that mass male circumcision can be used to reduce HIV transmission. But in Kenya, the biggest anomaly relates to the Luo tribe; over 20% of Luos are already circumcised, yet HIV prevalence is almost the same among circumcised (16.4%) and uncircumcised men (17.3%). These figures were available to those who have been promoting the current Voluntary Medical Male Circumcision (VMMC) program, which has been going on for 4 years and reports that 450,000 men (though most of them are said to be boys) out of a target of 850,000 have already been circumcised, and the program has another 6 years to run.

Not one person I spoke to seemed aware that, whatever level of protection the operation is claimed to give (everyone says 60%), circumcision does not appear to protect Luos. Those I spoke to who were promoting VMMC didn't mention this anomaly, though they must be aware of it. But ordinary Luo (and non-Luo) people are convinced that lack of circumcision is one of the reasons for high HIV prevalence among members of their tribe; also, that almost all HIV is transmitted through heterosexual sex. How can people be so convinced of this, especially when you consider that many ask why HIV prevalence can be high among circumcised people in some countries, and even among some Kenyan tribes?

Another thing that no one seemed aware of is that you can not compare HIV prevalence among circumcised and non-circumcised members of non-Luo tribes. There are too few uncircumcised non-Luos to make any kind of comparison. The neighbouring Luhya tribe, who believe their practice of circumcision protects them to some extent from HIV don't even seem to notice that it does not protect Luhya women, among whom HIV prevalence is 12%, 50% higher than the national figure for women and more than 6 times higher than among Luhya men.

Those promoting the program appear to have concentrated on generalized figures that, taken on their own, suggest that HIV is associated with low circumcision rates. They have studiously avoided mentioning that there are as many figures available showing that HIV is also associated with high circumcision rates. In other words, the data on circumcision and HIV prevalence is ambiguous. Some of the people I discussed this with are now asking why they were told that they should get behind this program, and why the reassurances they received were based on incomplete data.

The Kenya Demographic and Health Survey says: "Although it may seem that low rates of circumcision may account for much of this difference [in HIV prevalence among Luos], surprisingly, Luo men who are circumcised have roughly the same HIV prevalence as Luo men who are uncircumcised (16 percent compared with 17 percent). These findings indicate that multivariate analysis including circumcision status and risk factors for HIV transmission is needed to better understand the relationship between circumcision and HIV transmission in Kenya."

So where is the analysis that explains the above anomalies? All the analysis I've seen shows that, if circumcision gives some protection against HIV, and it may give some slight protection in carefully controlled conditions, it is not clear how or why it would give protection. It is not known what mechanism is behind this protective benefit. So the circumstances under which this mechanism may work are also unclear. Those promoting VMMC are not just feeding people the convenient bits of data, they are papering over the gaps in the data with hot air.

Even the randomized controlled trials did not exclude from their figures the people who were infected non-sexually. This is crucial, because VMMC assumes that almost every HIV positive person in Kenya was infected sexually and that the main risks HIV negative people face are sexual. The trials did not establish this, they simply assumed it. Therefore, proponents of VMMC are not in any position to make promises about protection against sexual HIV transmission; they don't even know what proportion of HIV transmission among participants in the randomized controlled trial were infected sexually, let alone in the population as a whole.

Far from being an shining beacon to the uncircumcised populations of high HIV prevalence African countries, the VMMC program in Kenya should serve as a horrific example of what can result from public health programs that are based on selective use of data and lies. There are billions of dollars behind this program, but the Luo people should not be participants in an experiment to which they did not give their consent, and for which the outcome was already known before the program started. Whether it is driven by cultural superiority, academic hubris, political machinations by those promoting the program, huge amounts of money or a combination of all of these, this program needs to be investigated fully before it goes any further.

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


Sunday, September 23, 2012

Circumcision: Bullied by Scientists, Betrayed by Donors

One might be shocked at the Victorian prudishness to be heard in discussions about HIV throughout East Africa. I was at a meeting of young peer educators, who should already be in a position to know better, they are in their late teens and twenties. But several of the male educators agreed that HIV is 'women's fault' because they only wear two layers of clothing below the waist, underwear and trousers or skirt. The other layer they are 'traditionally' (amazing what is referred to as tradition) supposed to wear are either 'cycles' (shorts that go to just above the knee), or a petticoat (so perhaps even trousers are deprecated).

Those who agreed with this, when pressed, said that they and others were tempted by women who did not wear the requisite number of layers. Considering we were supposed to be discussing modes of transmission, the phenomena involved in HIV transmission, blaming it on the way women dress seems a bit far removed from helpful details of what to avoid and why such things should be avoided. Eventually people moved on to 'sharp objects', but eliciting what kinds of sharp objects and explanations of precisely why sharp objects should be involved in HIV transmission took a lot of prompting.

Even then, there was a lengthy discussion of whether 'deep kissing' can transmit HIV if one or both parties was bleeding profusely from the mouth, and another about whether HIV really 'dies in seconds' or if it can survive for minutes, or longer. There was no mention of blood borne diseases aside from HIV, or of whether it was vital to avoid having the blood of other people introduced into your own bloodstream via some kind of sharp object, whether it was from a medical injection with a reused syringe, a razor, a tattoo needle or an infant's teeth. In case you are wondering, it is prudent to avoid having contaminated blood in your blood stream. It may sound obvious, but people do seem a lot more worried about things like underwear and kissing.

The conversation moved on to 'idleness', perhaps continuing the Victorian flavor. People should not be 'idle' because 'idle people' have unsafe sex and 'spread' HIV. Far from advocating for economic interventions on the grounds that people are poor, unemployed and unable to provide for themselves, unemployed and underemployed people are in need of something to do to help them resist temptation. The discussion was long and tedious, as they tend to be, and I eventually had to move on before the idleness discussion ended. But I was sorry I didn't have the time to say that HIV prevalence tends to be higher among employed people, often among the best educated and wealthiest employed people.

For example, the latest HIV related statistics I could find are for Uganda, and prevalence is 8% among the employed, but only 5% among those who are not employed. Indeed, the biggest differences seem to relate to what kind of employment a person is engaged in. Other figures find that HIV prevalence is lowest among those in 'domestic employment'; 'housegirls' (often being blamed for 'bringing HIV into the house', echoes of Charles Dickens?), at 6.9%. But it rises to 16.3% among public administration workers. I may be missing something, of course. 'Idleness' may be more prevalent among those in employment, and far more prevalent among those in certain types of employment.

I was asking a lot of people about the current voluntary medical male circumcision (VMMC) program, of which most people seem to be in favor, and the subject of hygiene arose repeatedly. Perhaps this moves us on from the Victorian era to herald in a more 20th century obsession with hygiene, especially popular among many of the big philanthropists, Carnegie, Rockefeller and others. But it's difficult to see what kind of hygiene the VMMC program hopes to promote, even the obvious, genital hygiene. I was taken to slum areas, where the most obvious lack in hygiene include large pools of stagnant water, piles of smouldering rubbish, mud houses, open defecation and the like. It will take a lot more than circumcising men to improve even genital hygiene.

It may seem shocking to those who have been to slum areas, where the vast majority of urban dwellers live, that proponents of VMMC think circumcising men could come anywhere close to being a priority. If seeing the conditions people live in is not enough, they should have a look at the conditions in hospitals and hear about the amount of disease and injury that comes from the very places where sick people are supposed to be attended to. Even street kids, who sleep rough, often in wet, filthy places and struggle to feed and cloth themselves have been targeted by the current program. Is it even ethical to carry out an operation on someone that you know lives in such conditions, where they are susceptible to all kinds of infection, probably for months?

Moral and even religious associations are often close to the surface when talking to people about HIV. It doesn't take much to prompt reactions suggesting that many people have little time for talk about the viral explanation of AIDS. A few mention taboos or 'chira', but others talk of or hint about the 'low morals' of people who are infected with HIV. This may suggest that, although they all say 'safe sex' can protect you from HIV, ultimately they may not really believe that safe sex is enough! Some appear to believe that people's levels (and type) of religious faith determine their likelihood of being infected, protected, perhaps even of being cured of HIV.

I interviewed a Pastor who belongs to an indigenous Kenyan Church that circumcises boys on the eighth day (following Leviticus 12). He seems quite convinced that circumcision reduces HIV transmission, citing all the publicity that everyone else seems to be able to recite like articles of faith. But others have pointed out that HIV prevalence is also high among his church members and among some circumcising tribes. The pastor, seemingly being prompted by his bishop, concluded that people must accept that HIV is being caused by unprotected sex, so they must decease from their bad behaviors and that they should also accept circumcision.

I'm not faulting the pastor on his biblical interpretation. But the relevant chapter has more to say about cleanliness than just circumcision. If cleanliness and hygiene are so important, the highest priority would seem to be the provision of clean water and sanitation for everyone. Circumcising all the men who live on the street, work in the lake, live in slums and face so many preventable health and HIV risks in their daily lives (to say nothing of the risks women face) could do a lot more harm than good. Without clean water and sanitation, lack of hygiene will continue to be behind much of the morbidity and mortality among people, whether they are circumcised or not, even whether they are male or female, adult or child.

The problem with all the talk about sin, idleness, evil, immorality, bad behavior and the rest is that it seems to miss the biggest denials of human rights that most people in Kenya face: the rights to health, education, water and sanitation, infrastructure, employment and many more. Given the conditions people have to live in, the explanatory power of individual sexual behavior in HIV transmission is completely deflated. Perhaps the pastor and others are looking for splinters, rather than beams. Walk through a slum, and I don't think the need for circumcision will be the first thing that strikes you. And if you see street kids, even the ones who don't (yet) sniff glue, you will probably think that circumcision could not possibly be safe for them, given the conditions they have to live in.

Those wielding their scientific data (and scalpels) are happy to bully anyone who threatens to get in their way, and everyone is happy if they are recipients of donor largesse. Even those cajoled into being circumcised by promises of '60% protection' (whatever people think that means), of being 'men' and of making the wise/smart choice (according to the billboards), free healthcare (as long as it's just circumcision), protection from various other sexually transmitted infections, better sex for them and their partners (yes, this claim is also used) and the endorsement of Luo politicians and elders, seem to be happy.

Most of those who have had the operation under the current program so far are not sexually active adults (or would have been circumcised anyway, but are availing of the free option), and therefore are not likely to face high risk of being infected through their sexual behavior. But all circumcision operations are being counted towards the (movable) target, any drop in HIV transmission can be attributed to the program and any increase in transmission can be attributed to the individual behavior of those infected, to the fact that they did not practice 'safe sex', as they were advised to do. Meanwhile, appalling living conditions, hazardous healthcare, poverty and lack of opportunity, low levels of education and multiple other factors ensure that people's lives remain blighted, with HIV being only one of many sources of the blight.

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


Friday, September 21, 2012

It's Amazing What Scientists Can Do These Days

Prompted by a comment on a one and a half year old blog post, I realize that the number intended to be circumcised in Kenya has gone down a lot. It was 1.1 million, it's now only 850,000. That's a drop of about 20%. The claim then was that an estimated 900,000 new infections would be prevented over a period of 20 years. That may be about half the number of infections that could be estimated going by current rates of transmission. I suppose the number of infections averted will also have to be cut now, but these figures are easily produced.

There are epidemiologists, publicists, politicians and other professionals, all making sure that, whatever the voluntary medical circumcision (VMMC) program achieves, it looks good. Whether it will look like it's worth a few billion dollars is another matter. Whether Luos will be happy with a program that pretty much brands them as highly promiscuous if they don't agree to be circumcised (and even if they do) doesn't seem to be an issue at present. And unless Luos themselves take it up, it's unlikely to become an issue.

Interestingly, the January 2011 article reports that "the implementing team has raised new concerns. The project targets males over the age of 15 considered sexually active but during the holidays there is a heavy turnout of younger boys." Most boys don't become sexually active until several years later, before which time they will not face sexual risks, which are the only kind circumcision protects against, if at all. Therefore, it will probably be at least 10 years, perhaps longer, before the true impact of VMMC is known.

The article goes on "More than 45 per cent of clients were younger than 15. Circumcising such young boys will not have an immediate impact on the HIV epidemic, because most of them are not sexually active". Not only that, but those who are said to be at high risk, the putative target of the program, are still not turning up in large numbers. One man working on the program that I spoke to last week estimated three quarter of the people already circumcised under the program are teenagers, many younger than 15. It's also worth bearing in mind that other tribes, who already circumcise their boys, are allowed to avail of the free and safe VMMC program (assuming it is safe). So, they would have been circumcised anyway, but it's a meeting of minds; they get it for free and the VMMC people get to pump up their figures.

In addition, the latest Demographic and Health Survey Figures for Kenya show that 21.5% of Luos are already circumcised. HIV prevalence among circumcised Luos is 16.4%, compared to 17.4% among uncircumcised Luos. Does that suggest to you that high HIV transmission rates may not be related to circumcision? There are Muslims among the Luo population in Nyanza, who tend to circumcise. Also, there is a christian sect that practices circumcision that is prominent in the province. Many members are Luos.

It has been pointed out to me that HIV prevalence is higher among circumcised male virgins in Kenya than among uncircumcised virgins. Circumcision among adolescents, despite the claims of the proponents of VMMC, does not appear to provide protection against HIV, do date. HIV positive adolescents who have not had sex are very likely to have been infected through the circumcision itself, as a result of exposure to HIV contaminated blood, or even through other unsafe healtcare procedures. Of course, many adolescents are circumcised during traditional ceremonies, where conditions may not be ideal in terms of safety.

Is there any other way to massage the figures? Well, up to 70,000 HIV positive men could already have availed of the free circumcision and whatever else goes with it (however, this figure is more likely to be around 25,000 if most people already circumcised are at low risk of being infected). They should, of course, be entitled to health services. But VMMC will not protect them from being infected. There is no evidence either that it will protect their sexual partners. Indeed, there is evidence suggesting that they may be more likely to transmit HIV, especially if they resume sexual activity before the wound heals (and HIV negative men with HIV positive partners are more likely to be infected if they do so).

It's hard to estimate what proportion of the 450,000 people said to have been circumcised under the current program legitimately contribute to the target. Perhaps those running the program know, they may even make the data available. But it's very handy that those who are most likely to take precautions against being infected are going to be among the first to be circumcised. It's also useful that many of those already circumcised actually face low risk of being infected sexually; it means that they will make up a group that, for a number of reasons, is pretty much guaranteed to have lower HIV prevalence than the Luo population as a whole.

Yet another HIV 'intervention' will fail to find out how people are being infected with HIV and will fail to prevent HIV infection to any appreciable degree. In order to bring about the result they claim to be able to achieve, the vast majority of those circumcised will be those known to be at least risk of being infected through heterosexual sex in the first place. Indeed, the best way to get 'good' results is to target those who least need such an intervention. That this is unlikely to have much benefit is irrelevant to the fact that there will be a big group of people who are circumcised and a lower percentage of them will be HIV positive, not because they were 'protected', but because they were not at high risk.

Worse still, those who are currently at high risk remain at high risk; they are not agreeing to be circumcised in large numbers. The fact that they are sexually active will be taken to indicate that they must have been infected through unprotected sex. Non-sexual risks tend not to be investigated. This may sound like a complete failure, but it's a success to the VMMC program because many of them will be uncircumcised. Not only will a lot of money have been spent on the program, but it can be assumed that vast amounts will be made available for countries that still have large uncircumcised populations.

How many reasons do people need to question this program? Though the evidence for its effectiveness is slight at the moment, even those in favor of VMMC agree with this, the program itself seems designed to result in a group of uncircumcised men among whom HIV prevalence is high and another group of circumcised men among whom HIV prevalence is lower, perhaps much lower. HIV transmission could be entirely uninfluenced by circumcision status, and yet the results of the program could be used to make it look extremely effective. A match made in heaven.

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


Wednesday, September 19, 2012

HIV and Circumcision: Too Many Answers, Too Few Questions

When asking people why they think HIV prevalence is so high among the Luo population of Nyanza province in the West of Kenya, they give all sorts of explanations that have been hypothesized over the years. Wife inheritance is one of the most common, although some say this doesn't happen so much except in rural areas and is on the decline. Some blame it on poverty and lack of economic opportunity, even though HIV prevalence has often been more closely correlated with wealth than poverty. And even still, HIV prevalence tends to be more closely associated with people who are formally employed than those who are unemployed or who subsist in some kind of informal economy. Which suggests that 'being idle', a commonly heard explanation of high rates of HIV transmission, is not really an explanation of high HIV prevalence.

The latest Ugandan Aids Indicator Survey (AIS) results have not been released yet, even though they were collected in 2011. A preliminary summary has been published, but other bits of data are being drip-fed to journalists, it seems, and released in newspaper articles every now and again. Certain groups that are favorites among those forming hypotheses and speculating about how the virus is spread have sometimes claimed that house girls are infected in large numbers and that they can transmit the virus to the father, who can transmit to his wife, and then the house girl can also infect sons in the house. I remember seeing a HIV drama enacting this very scenario in 2002. I have never seen any evidence that it could account for a substantial proportion of transmissions. But the results from Uganda find that those in domestic employment are one of the lowest prevalence occupational groups, at just under 7%.

Many early articles on HIV, and a lot of the policy documentation still going around, point the finger at long distance lorry drivers and others involved in the transport sector. But the Ugandan AIS estimates HIV prevalence to be 7% in this group, similar to prevalence in the country as a whole. It's also similar to prevalence among those working in real estate, which is estimated at 8.6%. Prevalence among those working in the hotel and restaurant industry is estimated to be 10.3%, which is a bit higher than the national figure. But some of the earlier literature claims that a lot of women working as waitresses or 'bar girls' are generally sex workers or engage in sex work some of the time. Perhaps they do, but it sounds like they don't do so as often as the official view of HIV would have it.

But one of the top explanations given for high HIV prevalence among Luos is the fishing industry: one can often read of a practice whereby women who sell fish have to sleep with the fishermen before they get the first choice of which fish to sell. While this practice may exist and may be deplorable to some, it seems it may not account for as much HIV transmission as we have been led to believe. The Ugandan AIS estimates that prevalence among those in the fishing industry is only 7.1%, which is not extraordinarily high. Looking at all these figures, it is tempting to suggest that the sexual behavior explanation of HIV transmission may sometimes lack explanatory power, that a significant proportion of HIV transmission is non-sexual.

The highest figure by occupational group that I have seen is for those working in public administration, which stands at 16.3%, well over double the national figure; also around the prevalence figure for Kenyan Luos in Nyanza province. If unsafe sexual behavior is the explanation for high prevalence among Kenyan Luos, is unsafe sexual behavior also the explanation for people working in public administration? And what sort of sexual practices exist in the Ugandan public administration sector that could account for this very high figure? Or is there another explanation entirely, one that is not purely about sexual behavior? As I haven't seen the complete AIS, I don't know how these figures are to be reconciled with the received view of HIV transmission. But I'm sure those collecting the figures have a whole slew of epidemiologists at their disposal to explain away anything that looks anomalous, anomalous meaning in any way inimical to the theory of the African who does little but engage in unsafe sex with as many people as possible, for as much of the time as possible.

Having followed newspaper articles and other documentation about HIV over the years, I'm not surprised that, as I go around interviewing people, the same explanations of HIV transmission appear with alarming regularity. People are mystified and if it wasn't for these explanations, which often have a certain exotic quality, they might just resort to equally exotic, but equally implausible, explanations of their own. But each of the much loved explanations, that depend on the belief that most HIV is transmitted sexually and that Africans have lots of sex, collapses if you start to look for evidence. And like other stereotypes, biases, myths and various kinds of pseudo explanation, they then continue under their own inertia, no less loved for being entirely without foundation.

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


Monday, September 17, 2012

Pay the Piper; Circumcise Him; Never Mind the Tune

When I ask people why they think 450,000 men have agreed to be circumcised under the voluntary medical male circumcision (VMMC) program currently being carried out in Kisumu, I am told that it's because they are convinced that it will work, that they will be '60% protected', that they will be less likely to be infected with HIV. (Some have even said that they will be less likely to transmit HIV if they become infected, but this has not supported by evidence.) That may sound reasonable enough, people choosing to benefit from a public health program with (allegedly) proven benefits.

But another person who promotes VMMC has suggested that the vast majority of the people who have been circumcised, he estimates about three quarters, are not sexually active men in long term relationships, those who are considered to be most at risk of being infected with HIV. Indeed, people in the areas with some of the highest prevalence rates in the country, areas such as Suba, Homa Bay and Asembo Bay, have been the most difficult to 'recruit'. The easiest to recruit are teenagers, the younger the better.

Another good source of stuffing for the 450,000 figure is people from tribes who already circumcise, but would like to avail of the free and safe operation, something they would otherwise have to pay for. I don't know if those providing circumcision are collecting information about tribes, whether the person would have been circumcised anyway or even if they are getting people who are young to confirm their exact age. Perhaps they are. But the original plan was to target people who are at risk of being infected and who would not normally be circumcised.

Young boys do not face a very high risk of being infected with HIV, especially when they are not sexually active. Any protective benefit that can be expected must wait for another five, ten or perhaps more years. But, apparently, it is easy to 'recruit' whole groups of people who are young, perhaps too young to have had any sexual experiences whatsoever. It seems their parents are willing to give their consent. Even that sounds quite remarkable, but I have yet to ask any parents who have given consent.

This man who was 'recruiting' said that the program has probably now circumcised the bulk of those they can expect to recruit in this way. Others running the program have also confirmed that numbers are slowing down now that they have got the 'low hanging fruit'. But there is another group that will not be protected from HIV through VMMC: people who are already HIV positive. People don't have to agree to be tested for HIV before being circumcised. About 8% refuse to be tested. But HIV prevalence is high even among men in this part of the country (it tends to be lower, sometimes a lot lower, among men in other parts of Kenya). In excess of 15% of men may be infected. This percentage should be lower in the 450,000 if the majority of them are teenagers, of course.

So what percentage of the figure we are given are even considered to be likely beneficiaries of circumcision? It's unlikely to be even half of all those circumcised. Earlier work has shown that the number needed to treat to prevent a single HIV transmission is about 76. But if half or more of those treated are not at risk, the number needed to treat to prevent a single infection must also be far higher. We don't know how high it is. If it is necessary to circumcise 76 people to prevent one infection in randomized controlled trials, that will probably cost around $9000. But if the number is twice that, or higher, then the cost is also much higher than we have previously been led to believe.

One of the people I spoke to was employed to collect data about circumcision for a specific communications/publicity/marketing related project. But the institution funding the research made it quite clear what sort of data to collect and what sort not to collect. It was made clear to this researcher that his job was to find out positive things about circumcision. He pointed out that it very easy to find people who will say that sex is better for them after they have been circumcised, that they are very happy and that their sexual partner also enjoys sex more. But it's also easy to find people to say the opposite. All the researcher needed to remember was which to report and which not to report.

Few people really know how to explain what '60% reduction' means, how to express it to people who actually ask, who are not content just to repeat the phrase whenever asked. Several who are involved in rolling out the program have wondered what the phrase means, not just how to express it or explain it. Clearly, they haven't answered these questions. Over and over again, I hear people saying '60% reduction', as if on cue. Even those speaking in Swahili or in the Luo language use the exact English phrase, which is the usual way with unfamilar terminology, such as 'abstinence', 'faithfulness' and other terms that people trot out with alarming regularity.

In addition to the evangelical fervor and the ready repetition of campaign mantras, the VMMC program approached Luo political leaders very early on. I have talked to Luo elders (who are cultural rather than political leaders) and they did not wish to say whether they thought Luo politicians agreed to be circumcised themselves to persuade their people it was a good intervention, or for political reasons. But the tribe as a whole does appear to have been persuaded. Even though adult men who are in long term relationships, those who are most likely to be infected, seem to be staying away in droves, there are a lot of parents who are giving their consent to their teenage sons being circumcised. One Luo elder felt the program was not well implemented and should be rethought. Another felt that he and his fellow Luos may not have been told the full story about circumcision or about HIV.

VMMC proponents are fond of pointing out that those who agree to be circumcised are also given various pieces of information about 'safe sex', abstaining, being faithful, using condoms, etc. This sort of behavior change communication (BCC) has been around for some time and it doesn't appear to have been very successful. Indeed, the lack of success of BCC is sometimes used as a reason for trying VMMC, even though VMMC itself may not have much impact. Why the two in combination should be worth all this effort and money when there are other priorities is not clear. But there is a clear get out clause here.

When something like pre-exposure prophylaxis (PrEP) or vaginal microbicides or treatment as prevention or anything else doesn't work very well, those pushing the programs blame the participants. They say that adherence wasn't very high or that people didn't use the drugs properly. This may, of course, be true. But in the case of VMMC, you either buy into it or you do not. So if it doesn't work, the proponents can simply say that participants did not adhere to the various pieces of BCC that were employed: they didn't abstain, they had more than one partner, they didn't use condoms, etc. We know in advance that many people will not take much notice of BCC if they haven't done so in the past. So any HIV infections among men circumcised during the program can easily be explained away. And, naturally, any reduction in infections, or anything that can be presented as a reduction in infection (many of those being circumcised are not at very high risk anyway) can be claimed as evidence that the program was brilliant.

HIV programs have been run by foreign donors since the beginning. Otherwise, we might know a lot more about why some people, especially Luos, are infected in such high numbers. We might not have depended on programs that sounded quite stupid when they were first mooted (BCC, for example). And we might never have seen a program that is doomed to failure, but has been dressed up to look like a success before it has even been completed by forms of false accounting that proponents have been developing, unchallenged, over the years. Driven by greed, ambition and a large amount of bigotry, it is a long shot to get Kenya to take another look at the HIV epidemic and question the emphasis on sexual transmission, and to question the VMMC before it goes any further. But it would be a good start if Kenyans themselves started to ask questions.

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


Sunday, September 16, 2012

Why Circumcision? Because it Gets Funded, Stupid!

The received view of HIV in African countries is that almost all transmission is a result of unsafe sex between heterosexuals. But HIV transmission through penile-vaginal sex is not particularly efficient. Only extremely high levels of unsafe sexual behavior among most adults in a population, most of the time, could possibly explain some of the worst epidemics, even some of the medium level epidemics found in East African countries.

By extremely high levels, I mean a large proportion of the population would have to have sex many times a week, some perhaps many times a day, with several different partners a year, and much of that sexual activity would need to be quite unsafe, for example, engaging in sexual intercourse without condoms with people whose HIV status is unknown. Evidence that large numbers of people engage in such high levels of sexual activity, unsuprisingly, is in short supply.

Therefore, models of sexual transmission that purport to explain high rates of transmission need to latch on to the few studies that appear to have found the right sort of evidence. But, while incredible levels of unsafe sexual behavior have been reported, it doesn't seem credible that most people in a population could have the inclination, the time or the strength to do so for a lengthy period of time. But without ridiculously high levels of unsafe sex between most people in a population, the various models of HIV transmission would not explain either high or medium prevalence epidemics.

Some people have wondered about how the received view could become so pervasive. Do most people believe that HIV transmission in African countries is mostly a result of heterosexual sex? If they know that heterosexual sex is a relatively inefficient means of transmitting HIV, they must believe some version of the 'behavioral paradigm', the belief that HIV in Africa (but not in most other countries) is a sexually transmitted virus. So, who is having all this sex, where, with whom, and what is it about this sexual activity that results in very high rates of HIV transmission?

I've asked some people, but they usually trot out the tried and tested reflexes about not using condoms, concurrent relationships, lack of circumcision, bits on the side, migration, intergenerational relationships, lack of empowerment, gender inequality, etc. But I can't find the people who are having lots of sex. I'm sometimes told that it is 'idle people' who spread HIV. But I wonder if this is not a kind of moralistic reaction. After all, many people are 'idle', in the sense that there is very little employment in some areas. And HIV prevalence tends to be higher, often a lot higher, among people who are employed, rather than people who are unemployed.

Other explanations say that employed people have more money and so they can have more sex, paying for it, of course. Where they find the time, I don't know. But who are these people, and is all unsafe sex paid for? Thankfully some people here say they also wonder how people could find time to have sex so frequently, perhaps every day, perhaps even several times a day. But they are surprised to find that there is this received view about HIV transmission, and that it applies to Africa only, that Africans are seen as somehow different.

Disturbingly though, many people accept the explanation. Which makes it easier to argue that 'voluntary' medical male circumcision (VMMC), and various other HIV 'interventions' seem to be so easy to sell to people. It is claimed that as many as 450,000 men have been circumcised in the last four years under the current program. They must believe that circumcision will protect them, at least to some extent, and also that the main risk for HIV infection is sex.

I spoke to a man who is the head of a clinic that does this operation, among other procedures. He is from a non-circumcising tribe, he has been circumcised under the program and he is happy; he says it is 'easier' in bed, that it is easier to put on a condom. I had no idea lack of circumcision made putting on a condom so difficult to some people, but he insists it can be a problem. We discussed the program at length, with me asking questions and even objecting to some of the answers I got, and him laying out all the usual reasons for VMMC. He seemed entirely convinced and nothing I said appeared to shake his faith.

But he and others involved in the program make a potentially very worrying point: the program in Kenya is, in reality, a very big experiment. The randomised controlled trials (RCT) that are often trumpeted as proof that VMMC reduces HIV transmission enough to make the billions to be spent on circumcising tens of millions of men worthwhile, did not really provide strong evidence. The current program is due to last 10 years, which means it has another six years to go. It is expected that the evidence from this 10 year exercise will support the decision to circumcise between 22 and 38 million African adults and possibly tens of millions of infants and children. In other words, it is hoped to be shown that the intervention works after it has been carried out, because there's isn't yet enough evidence for its effectiveness at the community level!

That could mean that Kenyans who are consenting to be circumcised may not be consenting to take part in a trial to demonstrate that VMMC actually works. In other words, an experiment is being carried out on enormous numbers of people without their consent. Even though the Kenyan, Ugandan and South African RCTs suggested that circumcision may provide some protection against HIV, if people also take other precautions, it is even clear to the researchers involved that the results from a trial will generally be better than the results from a program that is not so closely monitored, than the effects of the intervention at the community level.

But it seems the VMMC program is another trial, even though it's not an RCT. It is not known whether the results will be better or worse, or whether there will be other consequences, good or bad. Will VMMC also achieve the sort of changes in sexual behavior it hopes to achieve? Or will the program adversely affect sexual behavior? By the time the program has run for 10 years, around one million more Kenyans will have been newly infected, if current transmission rates continue. If transmission rates decline, will that be attributed to VMMC, just as a decline in transmission rates in the early 1990s was attributed to ABC and other programs that never actually took place?

The man running this clinic asked me what I thought they should be doing, and that's a good question. For a start, I think we should be tracing contacts. For every person found to be infected, identify their risks, identify the people with whom they have had contact, sexual or otherwise. This exercise needs to go beyond sexual contacts because some people, believe it or not, either don't have sex, don't have unsafe sex, or only have sex with their long term partner, who is very often HIV negative. We don't yet know that all or most HIV transmission is sexual, therefore we need to find out first, before implementing programs that assume we already know.

Despite being convinced that VMMC is the way to go, several arguing for it have told me that it requires that people also use condoms, yet they argue that just running programs to increase condom use will not work, because most people don't use condoms. But they can't really say what it is about being circumcised that will increase condom use if most people don't already use them. Behavior change programs that included condoms have been going on for years without having much impact on behavior, the VMMC proponents agree with that. But according to them, VMMC won't work unless behavior change also occurs. It sometimes sounds as if even proponents of VMMC don't really believe it will work, but that it may have some slight benefit. Some even admit that if there is any benefit, it will be slight.

There is also the issue of this program being donor driven. Even the clinic director with the cogent arguments in favor of VMMC, when asked about other health and development priorities, said: 'it is you donors who decide what money is spent on'. And this is no secret. But it makes one wonder what else would be done in the name of HIV transmission reduction if donors were willing to pay. Another health worker was even clearer, saying that people apply for grants to do whatever the grant is offered for. If it is offered for reducing sexual transmission of HIV, it will not be paid to those working with non-sexual transmission.

Several people have told me that Kenyans (presumably they were referring mainly to Luos, amongst whom HIV prevalence is highest) have sex before everything, before going fishing, when they return with their catch, before ploughing, planting, harvesting, etc. I don't know what this means or how it differs from other populations all over the world. But when carrying out research into what it could possibly mean, researchers may need to spend less time concentrating on bars, hotels and other places reputed to host inordinate levels of sexual activity.

Because even people who are not employed need to work. Research should also take in people in fields, down by the river, in markets, workshops, on the sides of roads where work is done and things bought and sold, places where evidence of great sexual prowess may be harder to find. The oversexed Kenyan or African may exist, but is unlikely to be in the majority. And high levels of sexual activity has not been shown to be high enough to result in major HIV epidemics. If VMMC programs are being implemented, ultimately, because there is funding for them, and because they may reduce HIV transmission slightly, this does not justify carrying out an invasive operation on millions of people who seem unaware they are an insignificant guinea pig in a massive human experiment.

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


Saturday, September 15, 2012

Saving Lives or Saving Condoms? It Shouldn't Be a Choice

By David Gisselquist and Simon Collery

It has become popular to present HIV as if it is now manageable if we would just spend more money, usually more money on drugs. In addition to the new drugs that continue to be produced, the real changes involve how those drugs are used. Instead of being targeted at those most in need, the aim seems to be to sell as many of them as possible. At one time, those selling drugs (and 'solutions') seemed content just to increase the number of HIV positive people taking the drugs once they have reached what is considered to be an appropriate clinical stage. But, as we shall see below, there are now plans to keep pregnant women who are HIV positive and on mother to child transmission programs on antiretroviral treatment (ART) for life, to start treatment early for those who have not yet reached an appropriate clinical stage and even to put HIV negative people on a treatment program called pre-exposure prophylaxis (PrEP).

Donor aid for ART expanded from low levels before 2004 to save millions of Africans from dying of AIDS. As of December 2010, an estimated 5.06 million Africans were taking ART (this is the latest available estimate from WHO).  Treatment is for life. As of 2012, donors pay for most ART in Africa, with the US putting up the lion’s share of aid through the President’s Emergency Program for AIDS Relief (PEPFAR).

A lot has been achieved. Even so, as of December 2010 only 49% of Africans who needed ART to stay healthy (whose CD4 cells fell below 350 per cubic centimeter [cc] of blood before starting on ART) were getting it. The untreated 51% have not been tested for HIV, have not tried to get ART, or have tried but failed.

Although donors have made a big contribution to ART for Africans, the donor-pay-for-ART model is not the long-term answer. Let’s play out some numbers to 2020.

Because an estimated 2 million Africans were newly infected with HIV each year during 2000-10, the number progressing to low CD4 cells and thereby needing ART to stay healthy will increase by an estimated by 2 million per year through 2020. Over 10 years from 2010 to 2020, that’s another 20 million needing treatment. If we suppose that 70% of these 20 million people will be alive and treated in 2020, that’s 14 million to be treated. In addition, if 4/5ths of those already receiving treatment in 2010 are alive in 2020, that’s another 4 million to be treated. The total receiving treatment (because they need it to stay healthy) would reach 18 million by 2020.

The WHO has also advised that all HIV-positive pregnant women take ART during pregnancy and for as long as they breastfeed. If HIV-positive women do so, and if they stop breastfeeding after 6 months, less than 5% of their babies would be infected vs. 35% with no treatment. With results like that, ART for pregnant and breastfeeding women is a priority. If all pregnant women take ART from their 14th week of pregnancy through 6 months of breastfeeding and then go off ART, that would add roughly 1 million women to the total needing treatment at any time over the next decade, for a total of 19 million on treatment in 2020.

Nineteen million Africans on ART in 2020 is almost 4 times the number treated in December 2010. A significant percentage of this 19 million people on ART will have passed from first to second and third line drugs, which are currently many times more expensive.

Will we get to 19 million Africans on ART in 2020? I see three options: (a) drug company revenues from ART in Africa go up at least 20% per year; (b) far less than 19 million people will be treated; or (c) prices for generics will drop, and more ART drugs will be available as generics. The first option is unrealistic. So the choice is between: option (b), which would represent a return to the late 1990s scenario with Africans dying of AIDS while Europeans and Americans live with treatment; or option (c), more and cheaper generics.

Considering mounting deaths with option (b), I suspect option (c) will be achieved. Africans will get access to more and cheaper generics than are available today, despite reprehensible efforts by US and European pharmaceutical companies and governments to prevent it.

What’s involved in option (c)? Much cheaper generic drugs for ART could become a reality if more companies in more countries produce and sell them through competitive international trade to private as well as public buyers in low and middle income countries. With competitive trade in ART drugs into Africa, a lot of drugs could go through private pharmacies for private doctors to prescribe and patients to buy, without going through government, donor programs, or NGOs.

With this option, treatment costs could be brought so low that a majority of people infected in even the poorest countries could pay out of pocket for drugs and treatment from private providers. That would leave only the poorest along with priority populations (especially pregnant women, to prevention mother to child transmission) to depend on ART and treatment provided by their own governments, NGOs, or donors.

In this scenario, donors could continue to contribute for AIDS care at the current rate, but they would be paying for ART for not more than 10%-20% of those who need it. African governments and patients would pay for most treatment. Donor aid and government budgets would go further, since they, too, could buy cheaper drugs from competing generic producers.

From the above estimates, it will take major changes in trade policies and health aid programs for ART to reach 19 million Africans in 2020 in order to keep HIV-positive people alive and healthy and to stop mother-to-child transmission. But instead of focusing on this challenge, many influential AIDS experts during 2012 diverted attention to proposals to extend ART to healthy Africans under the banner “ART as prevention.”

Advocates for ART as prevention propose several interventions:

1. The most conservative proposal for treatment as prevention is to continue women on ART after pregnancy and breastfeeding, no matter the level of their CD4 cells when they began ART. WHO designates this as the B+ strategy, where B is ART during pregnancy and breastfeeding, and B+ continues ART for healthy women after breastfeeding ends. This would add about 4 million women to ART during 2010-20. Treatment would reach 23 million people by 2020. The proposed benefit from this B+ program is protection for HIV-negative husbands. There is no evidence that women who start ART when they have more than 350 CD4 cells per cc of blood get any health benefit, and they may even be hurt.

2. A more ambitious proposal is to treat all adults who are HIV-positive no matter how many CD4 cells they have. It takes an average of about 7 years after infection for someone’s CD4 cells to fall below 350 per cc of blood. WHO estimated 22.9 million Africans living with HIV in 2010 of which 10.4 million needed treatment and 12.5 million had enough CD4 cells to stay healthy. If we assume that the annual number of new HIV infections in Africa continues steady at 2 million during 2010-20, the number of Africans infected but not yet needing treatment will tend to stay steady over 2010-20 at about 12.5 million. Suppose that ART as prevention reaches 56% (7 million) of the 12.5 million who do not need it to stay healthy (this includes women in the B+ program): treatment would reach 26 million by 2020.

3. The third proposal for ART as prevention is to put HIV-negative people considered to be at high risk to get HIV on daily treatment with a combination of two anti-retroviral drugs that goes by the brand name Truvada. In multiple trials in Africa, the Truvada has been inconsistently effective, reducing the rate people get new infections by nothing on one trial  to as much as 83% in another.  It comes with rare but serious side effects. Even if it were free, who should take it in Africa? Ignoring these concerns, suppose that approximately 10% of HIV-negative adults in the 9 countries with the worst HIV epidemics in southern African take ART as prevention, this would add another 10 million adults on ART. Treatment would reach 36 million by 2020.

How much would giving ART or Truvada to healthy people cut HIV transmission? Considering condom use as an alternate or additional protection, treating HIV-positive people would have only a minor effect on sexual transmission. Similarly, HIV-negative people who take Truvada to prevent HIV have the option to use condoms, with or without Truvada. If people taking ART or Truvada are less likely to use condoms, the added prevention is minor and may even be negative.

Another factor that must be considered is the impact of treatment as prevention on non-sexual HIV transmission – through skin-piercing procedures in health care and cosmetic services. Although not much is known about the risks and scale of blood-borne HIV transmission in Africa, evidence from other countries suggests efficient and rapid transmission through unsafe health. In hospitals and clinics with unsafe procedures, HIV has been observed to spread from one to more than a hundred patients in less than a year. Such rapid transmission through hospital-based outbreaks would not be found or stopped by treatment as prevention. Aside from outbreaks, people on ART with low viral loads would be less likely to transmit through bloody instruments. But a much more effective strategy to reduce blood-borne transmission is to educate and warn the general public about risks, trace unexpected infections to find and stop outbreaks, and strengthen infection control in health care and cosmetic settings. Once that’s done, how much blood-borne transmission will remain to be reduced by ART as prevention?

Overall, these various proposals for treatment as prevention would add 4-17 million people on ART (including Truvada) on top of the 19 million needing ART to live or to prevent mother to child transmission. None of these numbers are realistic without much cheaper generics for Africans. Once that’s solved, will healthy HIV-positive Africans buy and take drugs to protect others, despite the threat to their own health? Will discordant couples choose ART – with all its side effects – rather than condoms?

First things first – let’s figure out how 19 million Africans who will need ART to live and to prevent mother to child transmission by 2020 will be able to get it. Given limited donor and government funds, it’s hard to imagine that 19 million people will be treated without a large proportion of them buying low cost generic ART drugs and treatment from private providers at full cost with their own funds.

If donor and government funds fall far short of treating all those who need it – which seems likely – does it make sense for donors to subsidize treatment as prevention (ART and Truvada) for people who do not need it for their own health? If the cost of generics can be brought so low that people who need ART for their own health are able to afford it without aid, then it is reasonable to leave treatment as prevention to private trade and patient choice as well, and with their own funds. Even then, unless and until we get new information or better drugs, treatment as prevention is not something to recommend, except in rare situations for limited periods (such as a discordant couple wanting to conceive).

So there are plenty of alternatives to putting more and more people on high cost ART. For a start, the cost of drugs could be lowered substantially. Generics are cheaper than the branded versions, but they are not cheap enough yet. And many of the people who would be on ART under some of the above proposals will benefit more from measures such as reducing non-sexually transmitted HIV in healthcare facilities, increased condom use, and various other measures. Indeed, in many instances where risk of HIV infection is high and drugs are being presented as the only option, drugs are unlikely to have much impact; and in many instances where people's risk is low, again, drugs are unlikely to have much impact.

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


Friday, September 14, 2012

Is Mass Male Circumcision a Crime Against Humanity?

I went to a village in Western Kenya earlier this week because someone I'm in touch with said there was a young man there who had been forcibly circumcised by a mob who claimed to be 'kicking AIDS out of Kenya'. I also had a video camera, as someone else wants filmed interviews about circumcision. I felt so bad for the young man who had undergone forcible circumcision that I wondered what right I had to film him and ask him to tell his story. But what he experienced, though extreme, is just one partial consequence of the current received view that circumcision reduces HIV transmission.

Most tribes in Kenya practice circumcision and an estimated 85% of men are circumcised for cultural reasons, rather than for any claimed hygiene or disease reduction reasons. But some do mention hygiene and disease reduction, especially HIV and sexually transmitted infections, when asked. However, the Luo, a large tribe, along with several smaller tribes, do not circumcise. The village I visited is mainly inhabited by people who are circumcised. There are Luos and others who are not circumcised, but they are in a minority everywhere except in part of Nyanza and perhaps a few slum areas in Nairobi (they can also be found close to Lake Victoria in Tanzania and Uganda).

The young man who underwent forcible circumcision was from a small tribe that does not circumcise. However, during circumcision month, which was August, some people apparently decided that they would circumcise him. As the incident only happened four weeks ago, the man was visibly upset and also said he was still in pain. He started to relate his story, with someone translating from the Luhya language into English. But when he got to the bit about being circumcised, he said he couldn't continue. His cousin, who witnessed the whole event, told the story instead, in Kiswahili, with a translator.

Forcible circumcisions do occur, but sometimes the target is a member of a circumcising tribe who has not been circumcised. But other times, the victim is a member of a non-circumcising tribe. This sort of violence has been said to have been carried out during the post-election violence in 2008, and on various other occasions over the years. The man I spoke to, though, was not just a victim of forced circumcision. The mob beat him, stripped him in public, humiliated him, marched him several kilometers naked, stole everything he had and then left him to fend for himself.

He was brought to the river where traditional circumcisions take place and covered in mud, apparently the usual practice in the area. On the way, some of the mob collected money from passers by on the road. It is said they collected about 15,000 Kenyan shillings, more than $150, which would represent many months of wages. It is customary for the circumcised youth to be given money for their coming of age, so many people contributed. But that money, also, was stolen. In other incidents, the mob has taken the victim to hospital and even paid for treatment. But in this case, this was not done.

The current enthusiasm in the HIV industry to get as many Africans as possible to agree to be circumcised did not 'cause' the above incident. It simply gave the mob another excuse for what was an extremely violent act, involving a number of crimes, none of the which the police are investigating. But does that mean the mass male circumcision programs do not involve violence? Perhaps it could be argued that they don't involve violence, but they do involve aggressively selling an invasive operation that it is well known will have little positive impact on HIV transmission at a population level, and may even have a negative impact.

The mass male circumcision program or 'voluntary medical male circumcision' as it's called (VMMC), amounts to an attack on the rights of men to decide whether to be circumcised or not; an attack, because men are not being given clear and accurate information. They would be shocked to know that appropriate penile hygiene would give them better protection from HIV; some would even be shocked to hear that they will still have to use condoms. But even the HIV industry knows well that VMMC will have little impact. So why are they so keen to spend lots of money on this program, at the expense of cheaper programs that will benefit more people?

Ironically, much of the negative impact may be more noticeable in the circumcising tribes than in the currently non-circumcising tribes. If you talk to people who currently circumcise, they will tell you that they don't need condoms, even that condoms don't work. They will tell you that they are protected from HIV. Some will qualify that and say they are partially protected, but many will not. They are not being targeted by the VMMC campaigns, which claim to be enforcing the message about partial protection.

Women also may suffer more than men from the negative impacts of the campaigns. They are not being consulted, but also, it is likely that circumcision will increase transmission from men to women. It is only claimed to reduce transmission from women to men, which makes up a smaller proportion of all transmissions, about 40% in Kenya. But many women think, or believe it when they are told, that circumcised men are less likely to be HIV positive and that there is less need for them to use condoms.

I can't help thinking that Kenyans and other Africans are being tricked, just as they have been lied to and abused by the HIV industry since the beginning of the HIV epidemic. Mass circumcision seems to be a physical attack by a group of well funded international institutions on entire cultures, between 22 and 38 million Africans, it has been estimated. The HIV industry appears to be putting the (American) culture of male circumcision forward as being superior to cultures where male circumcision is not practiced. The forcible circumcision described above is sickening, but the number of victims of VMMC, men, women and children, sound as if it would fit the definition of a crime against humanity.

Perhaps it's too strong to use the explicit term 'crime against humanity', I don't know. Those pushing the VMMC campaign don't look like an angry mob, beating and stealing from the victim. But they have financial and political strength, coupled with the sometimes violent support of some of the circumcising tribes. The Luo are politically weak, internationally and in Kenya. The Luo Prime Minister, Raila Odinga, and some other Luo politicians have apparently agreed to be circumcised to promote the campaign. But was this for the sake of their fellow Luos or for the sake of their own careers, after generations of being told that an uncircumcised man is not fit to run the country?

Of course, circumcision is not exclusive to American culture. But almost all the money behind VMMC is from the US. Many of the arguments appear to be based on the sort of American prudishness about sex and hygiene, especially sex and hygiene among Africans, that has driven the bulk of 'philanthropy' for much of the 20th century, continuing up to the present day. The programs are even being carried out by organizations that have roots in eugenics, 'social hygiene', population control and various other notions that differ little except in terminology. This theme will be continued in the next few days.

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


Thursday, September 13, 2012

Tensions Between Discovery and Creation in Circumcision Research?

When it was discovered that, in some African populations, HIV prevalence was lower among circumcised men than among uncircumcised men, did this represent a great advance in epidemiological research? Was it the sort of 'discovery' that eventually gave rise to the current mass male circumcision programs in Kenya and other high and medium HIV prevalence African countries?

In a sense, I would argue in just a limited sense, the answer is yes. Because at the same time as the discovery was made, it was also found that in some countries HIV prevalence was lower among uncircumcised men than among circumcised men. Taking the data from all the countries, the overall benefit of circumcision was roughly zero.

So, a body of data was collected and certain things were discovered through analyzing that data. But presenting this and similar data to support mass male circumcision (MMC) programs required some hefty marketing and publicity work. For a start, it was necessary to ignore data showing that HIV prevalence was, in different places, either positively or negatively correlated with circumcision status. (In other places, unsurprisingly, there was no correlation, either positive or negative.)

Are the current MMC programs supported by an act of discovery, creation, or both? What is fairly clear is that the arguments in favor of circumcision are not based on science. The science is currently highly ambiguous. It is even likely that circumcision status itself is irrelevant, because no clear protective mechanism whereby circumcision could protect against HIV transmission from females to males has been demonstrated (it doesn't reduce transmission from males to females, and may even increase it). There are hypotheses but even preliminary evidence for these is still wanting.

Surely, you might object, the point of doing research, and a fair bit of research has been carried out, is to be able to present the arguments for and against such a program. But so far, proponents of circumcision appear to ignore the arguments against and even to exaggerate the arguments for. Could it be that those arguing for circumcision are paid to do so? I'm not just talking about the politicians, bureaucrats, NGOs, consultants and others, I'm talking about people who collect and analyze the data and publish their 'findings'.

One scientist I spoke to in Kenya's Nyanza province put it a different way: there is funding to carry out research into sexually transmitted HIV, but there is no funding to carry out research into various forms of non-sexually transmitted HIV. Proposals to carry out research into transmission of HIV and other diseases through unsafe healthcare, for example, even articles on the subject, are unlikely to see the light of day. Circumcision is proposed as an intervention to reduce HIV transmission through heterosexual sex, not through anal sex, nor through any non-sexual route. Indeed, an MMC program should require that health facilities be safe. Yet it is well known that most are not particularly safe; some are particularly unsafe.

Research requires scientists, but it also requires money. If you get funding to investigate the benefits of mass male circumcision, that's what you are expected to find. I'm not suggesting that scientists have to make up results. Some research has produced abysmal results, but it has still been used to plug for MMC. There have even been highly questionable practices employed during some scientific trials. But since the data has been used to shore up arguments for MMC, the money continues to flow. Another scientist I spoke to in Nyanza took a different tack: the evidence is indeed weak, but it is still evidence for, rather than against, and it is getting stronger as time goes by and as more and more men are circumcised. Presumably these men think this will protect them from being infected with HIV, along with a host of other diseases that have been added in as a kind of healthcare goody bag.

I spoke to someone who used to be involved in HIV and health research in Nyanza, but who is now running his own construction business. He is opposed to MMC because he feels it will not have much positive impact on HIV transmission and may have some negative impact. But his most strongly expressed views are against infant circumcision. He asks who will be held responsible if people grow up demanding to know why they were circumcised without their consent, a question I don't believe current research aims to address. But he does not raise strong arguments about the fact that Luos are culturally opposed to circumcision, despite being a Luo.

Perhaps some Luos are opposed on cultural grounds; perhaps some are not. But why should weak scientific evidence for MMC be used to trump the culture of not circumcising? There are alternative HIV prevention interventions; it has not been shown that it is circumcision that reduces HIV transmission at a population level, even where HIV prevalence is higher among uncircumcised men; there are areas where HIV prevalence is higher among circumcised men; it's a very expensive program (probably about four times the annual government health expenditure per head), etc. Indeed, the same weak evidence used to dismiss cultural arguments for not circumcising is sometimes used by circumcising tribes to argue for their cultural superiority, to justify prejudice against Luos and other non-circumcising tribes and even to justify forced circumcisions carried out by mobs.

Tomorrow I'll mention some other views relating to HIV and circumcision, and about forced circumcision. But what is remarkable about the three people mentioned above, something shared by some people who are opposed to the mass male circumcision programs, is that neither side seem to be claiming that their point is very strong; those who work on programs which assume that HIV is almost always transmitted through heterosexual sex, sometimes called the 'behavioral paradigm', don't claim to have all the cards. In fact, they simply have all the funding, and some are scarily frank about that. One can only wonder why an expensive program for whose effectiveness there is little evidence would go ahead, even if there are no arguments against it.

But, even those who would object to the behavioral paradigm and who think the mass male circumcision program will not reduce HIV transmission are not exactly screaming from the rooftops. Of course, they have strong objections to clear abuses, such as forced circumcision, lack of consent, infant circumcision, lack of information and clarity, possible political interference, the disproportionate amount of money being spent on circumcision programs, the lack of money being spent on alternative programs, etc. But they just think the mass male circumcision program is not going to have the effects it is claimed it will have. They are demanding an end to abuses but not always to the program itself.

That's worrying because the program is going ahead, regardless of what people think. And it is going ahead because it seems to be the sort of thing that gets funding. Those advocating for change, for an end to abuses, for human rights to be respected, are not getting funding. Most of those I spoke to who are not in favor of the program are not in a position of power or influence, they live in rural areas and they are involved in other things aside from HIV, circumcision and the like; for example, most have to earn a living. Someone running a long-standing indigenous HIV organization also confirmed that certain things get funded, and whoever supplies the funding decides what it should be spent on; local need is entirely irrelevant.

So the question of whether mass male circumcision programs should go ahead, and that of whether other development programs should even be considered, is decided by those who issue calls for proposals, grant giving bodies. Those who oppose such programs, especially if they live in rural areas and need to spend most of their time on other matters just to survive, are unlikely to be heard. Tomorrow, I'll post up notes about some conversations I had with people in rural areas who do not believe MMC is necessary, and that it could do a lot of harm; yet views like theirs do not appear to have any influence where large amounts of foreign donor funding is involved.

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


Wednesday, September 12, 2012

Most Information Doesn't Trickle, Down or Up

There are some severe problems relating to information here in East Africa, even lifesaving information about healthcare, nutrition, water and sanitation, infrastructure and education, you name it. For a start, access to information is not particularly good; books are expensive and scarce, especially recently published and highly technical books. Journals are even less accessible, unless they happen to be available free of charge online (the majority are not), which means some are accessible to those who can use the internet, can access the internet and can select, evaluate and utilize the information.

Aside from the many logistical problems, even the issue of low educational standards which renders most information useless to many people, how does information get to influence people's lives, in any way? Health information relating to mass male circumcision is easy enough to find at the moment. But if you're a parent, guardian, teacher, peer educator, community health worker, volunteer or otherwise engaged in the field, you will probably be bombarded with fairly one-sided 'information'. You may be aware that things are not straightforward, but what can you do about it?

The newspapers interview top politicians, bureaucrats, heads of NGOs, doctors and other professionals, but they rarely mention dissenting views. When they do mention them, it tends to be a long way through the article, often juxtaposed with views that seem to contradict, rather than disagree with the dissenting views. So any opinion or even data opposed to the mainstream may possibly become known to people working in the field; but what would the status of that data or opinion be?

Over the years, I have talked to a mixture of people working in various fields that somehow relate to HIV, healthcare or even circumcision, along with people whose connection is on a personal level, or on a level that relates to family, friends and associates. But circumcision goes beyond being a mere medical procedure, especially in countries where some groups circumcise and some don't. Kenya is such a country; many of the tribes circumcise boys when they are in their early teens. But there are some groups who don't traditionally circumcise, such as the Luo, who make up one of the biggest tribes in terms of numbers.

Despite the issue of mass male circumcision programs being potentially very thorny, culturally, medically, politically, etc, a number of foreign donors have weighed in with funding for research, advice, manpower, equipment and anything else required to carry out their aim of circumcising between 800,000 and a million Kenyan (Luos) and between 22 and 38 million Africans (depending on which figures you use). In other words, those supplying finance and anything else have already decided that mass male circumcision is going to go ahead; they seem to be steaming through men in Kenya as if they are afraid the whole thing will lose momentum.

As the money is behind doing research that shows MMC is the right thing to do, that it will, definitely and unquestionably reduce HIV transmission (from females to males, male to female transmission may increase as a result), who is in a position to carry out research that may not find what the donors want them to find? Who will fund research that verifies previous research, that even investigates how that research was carried out and how current campaigns are being carried out? I doubt if anyone will.

So if a health professional, NGO worker, professional of any kind or anyone else wishes to express a dissenting view, it is unlikely anyone will be listening. If they receive public funding, which many do when their work relates to HIV or even health, they risk losing their funding. And if people in positions of even some slight influence are unlikely to say anything, those with no influence at all, and that's most people, are even less likely. And it's highly unlikely that anyone will take any notice if they do say anything. If we are going the wrong way, how will we know and when? And what will be done about it, if anything?

Over the next few days I hope to be able to write up some notes from talking to people about HIV, healthcare, circumcision and development in Western Kenya and Nyanza province.

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


Monday, September 3, 2012

HIV Finger-Wagging Exercises Are Bad for the Recipients' Health

The education Millennium Development Goal (MDG), number two, is to achieve 'universal primary education'. The target is to "Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling". School fees have been abolished in many countries, including Tanzania, and this has led to very high levels of enrollment according to the MDG website. But it goes on to say that this has "brought a new set of challenges in providing enough teachers and classrooms."

There are other challenges not mentioned. For example, many teachers don't spend a lot of time in the classroom, many have receive poor training, many of the pupils who have enrolled hardly ever turn up for classes. And worst of all, the majority of children in Tanzania, Kenya and Uganda fail literacy and numeracy tests. In other words, (almost) universal enrolment is not universal education; and even relatively high levels of attendance do not lead, in the cases of Kenya, Uganda and Tanzania, to high levels of attainment.

A report by an initiative called Uwezo shows that enrolment and attendance figures are noticeably lower for people in lower income brackets and in public schools, while those for dropping out are higher; the overall enrolment figure is far lower than that cited in the MDG document, above. Performance was generally very low, especially in Uganda and Tanzania. In fact, Tanzania scored lowest in English (not so surprising, given it's not as widely used as in the other two countries), numeracy and even Kiswahili (Uganda was not scored for Kiswahili).

So, to return to my last blog post, about a paper called "Changes over time in sexual behaviour among young people with different levels of educational attainment in Tanzania", the authors raise questions about the relationship between educational attainment (the three levels of attainment being 'none', 'primary' and 'secondary', so not a very finely grained measure) and sexual behavior, and how these change over time. A number of countries have shown that higher HIV prevalence was often found in those with higher levels of education and lower prevalence in those with lower levels of education, but the correlation has changed over time.

To understand why these and other researchers should go to so much trouble, it's important to look more closely at the highly simplistic, probably rather racist and clearly empirically unfounded theory they have of HIV transmission. They believe that high levels of HIV prevalence mean that there are (or were) high levels of sexual risk taking (or 'unsafe sexual behavior' or 'promiscuity', or whatever you wish to call it). On the contrary, high levels of sexual risk taking exist in many places where HIV prevalence is low; and HIV prevalence has been found to be high where levels of sexual risk taking are not high.

The relationship between sexual behavior and HIV prevalence is not clearly understood. It can be presented as being a fairly direct relationship and it is often concluded that unsafe sexual behavior *causes* HIV transmission, that this is not a mere correlation. As a result, HIV interventions involve wagging fingers at people about whom to have sex with, how often, how many people, what kind of sex to have, etc. Of course, there's nothing wrong with good sex education; there's just no evidence that recipients of these finger-wagging exercises have ever received good sex education (or good education of any kind, if Uwezo's data is to be believed).

To be clear, unprotected sex with people whose status you don't know is risky. There's the risk of sexually transmitted infections, HIV and unplanned pregnancy, for a start. But HIV is not always transmitted sexually; we just don't know the relative contribution of sexual and non-sexual HIV transmission. We have no real idea of how much transmission occurs in health facilities, through unsterile procedures such as injections, in cosmetic facilities, through tattooing, traditional practices and other skin piercing practices.

So what relationship should one expect between education or socio-economic group and sexual behavior? What relationship between sexual behavior and HIV transmission? And what relationship could there be between various HIV educational campaigns and behavior given the current situation in Tanzanian, Kenyan and Ugandan schools? Those are difficult questions to answer. They are also empirical questions which can only be answered by collecting and analysing good data, not by casting aside data that doesn't fit the preconceived views and hypothesizing data that has no basis in reality.

In a report entitled "Integrated biological and behavioral surveillance survey among migrant female sex workers in Nairobi", there are some curious findings. While HIV prevalence is high, at over 23%, STI prevalence is relatively low, the highest being syphilis, at 2%. But HIV prevalence of over 20, 30 and even 40% can be found among women who are not sex workers, for example in Kenya, where overall HIV prevalence is probably less than 7%.

If the women are sex workers, what are their risks? Or, to put it a different way, what are the risks for women who are not sex workers and among whom HIV prevalence is far higher? The immigrant sex workers, who are said to face even higher risks than indigenous sex workers, have an average number of sex partners per month of 21.6. This is nowhere near the kind of figures we have heard in the past for sex workers, with client numbers running to the 20s and 30s per day. Things have changed for the better, you may think, but massive rates of HIV transmission through heterosexual intercourse alone requires numbers of sexual encounters that are probably not achieved, or even achievable, by many.

When it comes to 'knowledge' about HIV transmission among sex workers, "there is a trend of increased prevalence of HIV among participants who know the correct answers to the knowledge questions, the exceptions being participants who know that sharing needles puts one at risk, and that a healthy looking person can have HIV." Those who 'know' the 'correct' answers after all the finger-wagging are often more likely to be HIV positive. In some ways, this is hardly surprising. There is a photo of a flip-chart headed 'Modes of Transmission': "(a) Unprotected intercourse (sexual) with an infected person (80%)", along with all the others, with 20% of transmission to share among them. Perhaps one of the risk factors is attending finger-wagging exercises purporting to teach commercial sex workers and others how to protect themselves from HIV?

Perhaps HIV related education does little to reduce HIV transmission because people are not being told about important non-sexual risks, because they are being told or led to believe untrue things about sexual transmission, because the recipients of the programs are very badly educated, often by badly trained teachers. Besides, there is no clear correlation between good education and low HIV prevalence; the relationship is probably often inverse because those who can afford a good education can also afford healthcare at a facility where they would certainly have faced a high risk of being infected with HIV in the early days, before HIV was recognized and before anyone got around to doing anything about it.

Educational HIV prevention interventions have had limited success because they are one-sided, concentrating on sexual risk and ignoring non-sexual risk; it's not all about sex and it never has been. In addition, they probably don't even constitute good sex-education. But educational standards among the recipients are also low, among adults, high risk or otherwise, or children. This has little to do with HIV and the right to education should not be tied to public health messages, however well meaning. Few public health campaigns will ever succeed in countries where both the health and education sectors are in as deplorable condition as they are in East African countries.

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