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.]


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