Wednesday, October 3, 2012

Circumcision: If Evidence is Not Required, Why Should a Little Bit of Fraud Matter?

The Clearinghouse on Male Circumcision for HIV Prevention reassuringly states: "Conclusive research shows that medical male circumcision substantially reduces men’s risk of acquiring HIV infection through vaginal sex". However, the studies cited show that the research is not at all conclusive, as no effort was made to demonstrate that all new HIV infections in either the intervention or the control group were a result of vaginal sex. Some of these new infections could have been a result of unsafe healthcare, unprotected, receptive anal sex, intravenous drug use, even circumcision itself.

It has also been pointed out to me that new HIV infections in men who were in the control group, and who remained uncircumcised in the years following the randomized controlled trial, increased substantially to 1.93%, compared to 1.3% in uncircumcised men in Rakai at the time of the trial (many in the control group opted to be circumcised after the trial finished). So in addition to not showing how men were infected, whether through heterosexual sex or some other mode of transmission, it remains to be shown why taking part in the trial would have increased risk of HIV infection among those who did not get circumcised.

The "comprehensive package of HIV prevention services" includes "risk-reduction counseling, provision of condoms and instruction in their use, the offer of HIV counseling and testing, and screening and treatment for sexually transmitted infections". These have been made available to those who were circumcised and to those who remained uncircumcised, without being of much benefit, it seems (bear in mind also that many of the recipients of these 'packages' are not sexually active and may not become sexually active until many years later). But they all relate to sexually transmitted HIV, not to any other mode of transmission. Perhaps the continued failure to identify how people are becoming infected with HIV should now be addressed as a matter of urgency.

One often hears that circumcision is uncommon among Luos and that HIV prevalence is higher than among other Kenyan tribes, most of whom practice circumcision. But it's less common to hear that HIV prevalence among the 21.5% of circumcised Luos is almost the same as among uncircumcised Luos. Why would circumcision only protect non-Luo men from being infected with HIV? And why bother circumcising hundreds of thousands of Luos before answering this question? It is also claimed that HIV prevalence among women will be reduced 'indirectly' by mass male circumcision. But HIV prevalence is higher among women than men in almost every Kenyan tribe. Among the circumcising Luhya tribe, HIV prevalence is nearly 6 times higher among women than men.

Rather less reassuringly, an article on the safety of the voluntary medical male circumcision (VMMC) program finds that those carrying out the circumcisions (mainly nurses and clinical officers, not so many doctors) apparently only receive two to three weeks of training and a relatively brief supervision period. Also, while clients are given written instructions on wound care and the "42 day sexual abstinence period", it is not clear what illiterate people receive. Only 39.4% had completed secondary school. It is completely unclear how those who live on the street or in slums, or those who don't have regular access to clean water and hygienic living conditions, the majority of people in Kisumu, are supposed to care for their hygiene needs, either straight after the operation or in the longer term.

Just over one third of those undergoing circumcision were tested for HIV and prevalence was 3.4%, compared to 17.1% in the general Luo population, so it sounds like many of those being circumcised are less likely to be infected.

The vast majority, almost 90% of circumcisions, were carried out by the Nyanza Reproductive Health Society (NRHS), which is a bit mysterious as their domain name is currently for sale, but it is said to be an 'NGO'. At least one of the authors of the article on safety is a senior person connected with NRHS (although no competing interests are declared). I met someone who worked for this NGO and he felt that NRHS was very keen to gather and disseminate positive things about VMMC and discouraged employees from finding or alluding to negative aspects.

But an article in the Kenyan Standard is a bit more explicit. The NGO has had its funding cut from 500 million shillings (over five million dollars) to less than 100 million shillings for "widespread misappropriation of funds" and "massive financial impropriety". 250 workers have been dismissed or (it seems) invited to reapply for their position, which makes one wonder how this gap in the VMMC program will be filled. The US Centers for Disease Control (CDC) has categorised the organization as 'high-risk', and it won't be the first to receive massive sums for HIV related activities that later turn out to have been spent on things that have little to do with disease control.

Given the millions of dollars being spent on what is effectively a vertical health system to carry out medical male circumcision with the aim of reducing HIV transmission from women to men, one would expect high levels of safety, but the operation is not as risk free as some claim. Also, fewer than half of those circumcised ever return for follow-up, which makes one wonder about those living on the streets and those living in slums and in distant areas, for whom returning to the clinic may take up a lot more time and/or money. Also, much of the safety data is collected from clinics that do little other than circumcise men, so safety of circumcisions should reach higher levels than that found in clinics where other health procedures are carried out. But useful comparative figures are not available.

The intention is that VMMC 'messages' will spread virally (or evangelically?) throughout uncircumcised populations in Africa, and Kenya is being held up as an example to other countries (regardless, it seems, of what the outcome of VMMC there will be). A Zimbabwean journalist goes for the operation, where 55,000 are said to have undergone the procedure, out of a planned 2 million by 2015. Apparently, part of the process to ease expressions of fear and concern is to be laughed at by female medical staff for their weakness. So that's certainly encouraging.

But this poor journalist (and his female friends) has either been deceived by the pre-circumcision sales pitch or he's not very good at doing research. He says his female friends "realise the obvious health benefits, including a lower risk of HIV infection. For women especially, if their boyfriend or husband is circumcised it lessens the chance he will infect them with HIV should he stray outside the relationship." As mentioned above, the stated aim of VMMC is to reduce HIV infection from females to males, nor do the randomized controlled trials show that all HIV transmission was sexual.

The intrepid reporter does point out that even circumcised men are at risk of being infected with HIV, and of infecting others. But he doesn't mention that this campaign doesn't address the problem of already circumcised men thinking they are 'safe'. Nor does it address the problem that many women think circumcision is an indication that a man is less likely to be infected with HIV. On the contrary, not only can circumcised men be infected, but infected men can also be circumcised under the VMMC program. They can be tested and keep their status to themselves, or they can refuse to be tested or to be informed of their status. This could increase the risks that women face unless the program makes the precise implications of mass circumcision clear (although the implications are not clear to anyone yet).

The reporter concludes that his "scar is permanent and hopefully a daily reminder of the cost of faithfulness and real commitment to family, partnership and marriage" (compare his use of the word 'scar' to various definitions of the word 'stigma'). But his circumcision will not bring about his faithfulness and commitment. They are required among circumcised and uncircumcised alike to reduce heterosexual HIV transmission (and useless when it comes to reducing non-sexually transmitted HIV). More poignantly, if he and his wife really are faithful and committed, the circumcision will not give him any additional protection; unless he thinks his wife is not...

Accepting circumcision as a means of reducing the risk of being infected with HIV is also tacitly (or even explicitly) accepting that HIV is almost always transmitted heterosexually. While those remaining uncircumcised may find themselves thereby further stigmatized (they are already stigmatized as Luos and as Africans), those who are circumcised under the VMMC program are reinforcing the view that they and others around them are highly promiscuous, or that they may engage in promiscuous behavior in the future. Those who are circumcised for other reasons may engage in either safe or unsafe sexual behavior, but they will believe that their HIV risk from heterosexual sex is lower than that for uncircumcised men, and that non-sexual risks are not even worth considering.

UNAIDS tries to justify their strenuous efforts to ignore non-sexual HIV risk, especially through unsafe healthcare, by saying that it would confuse people to tell them about more than one risk, and that it may make people more cautious about attending healthcare facilities when they are sick. It is hard to imagine greater confusion that that found among people in non-circumcising populations, and even among circumcising populations. If the aim is to reduce HIV transmission, people must know about all risks, sexual and non-sexual. This will allow them to put a public health intervention such as mass male circumcision in perspective; HIV is not all about sex; therefore VMMC may give little benefit and may do a lot of harm. But hey, it's worth millions!


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