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.]


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