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.]



Simon said...

There's some additional material about VMMC here:


Anonymous said...

Too many circumcised American intellectuals and Israeli doctors have their professional and religious egos bound up in mass circumcision campaigns in the AIDS belt. Hence it will be exceedingly difficult to back off the "circumcision-prevents-HIV" message until the situation becomes a huge scandal.
A medical school prof who has drawn up a splendid indictment of the African clinical trials is Gregory Boyle of Australia. The challenge is to turn his critique into the conventional wisdom.

Simon said...

Thank you, I'm familiar with Boyle and Hill's paper and have discussed it here. But it was dismissed by the circumcision establishment. I guess that's how they remain the establishment.