Saturday, December 1, 2012

HIV and the Open Secret of Mass Male Circumcision

An article that begins "[The Zimbabwean] government is considering making neo-natal male circumcision compulsory as a long-term strategy for HIV prevention" may not raise an eyebrow if you have been subjected to the biased coverage in the mainstream press about mass male circumcision programs. The fact that some randomized controlled trials have shown that circumcision may reduce HIV transmission has certainly convinced a lot of people. The problem is that circumcision clearly doesn't always protect against HIV transmission and one of the countries where it does not is Zimbabwe (others are Cameroon, Malawi, Burundi, Ethiopia, Ghana, etc).

Another problem is that the randomized controlled trials did not show that circumcision protects against sexual transmission of HIV. Some people on the trial may have been infected through unsafe healthcare, or one of several other routes. This could mean that circumcision is even more effective than previously thought, of course. But it also means that we don't have a clue why or how circumcision may protect against the virus. What we do know is that the operation is unlikely to reduce transmission from HIV positive men to women, and that it probably even increases transmission. HIV positive men may already be circumcised. If they are not, they are eligible for the mass circumcision programs; so the net benefit may be negative.

But back to Zimbabwe, where HIV prevalence is higher among circumcised men. Why would circumcising anyone be beneficial? If 'the science' is behind circumcision in Kenya, Uganda and South Africa, where the randomized controlled trials suggest that the operation may be beneficial, shouldn't Zimbabwe recommend that parents do not allow their infant boys to be circumcised? Shouldn't plans to circumcise millions of Zimbabwean people, at a cost of hundreds of millions of dollars, be shelved? A spokesperson said infant circumcision was 'more sustainable' than adult circumcision. But does that mean it's cheaper? Because that is not the same things as sustainability.

The HIV industry finds Zimbabwe's HIV epidemic quite mystifying anyhow. HIV prevalence figures were estimated to be among the highest in the world in the late 90s, at almost 30%, but dropped to half that in the following 10 years. Of course, much of that drop could probably be explained by massive death rates. But it is likely that incidence, the annual rate of new infections, also dropped. The industry claims that almost all transmission is a result of 'unsafe' sexual behavior. Therefore, they are forced to believe that levels of 'unsafe' sexual behavior were reduced radically at a time when the country was experiencing political, social and economic turbulence.

There are probably several reasons why incidence declined. Radical changes in sexual behavior seem unlikely to be a result of the HIV industry's interventions because the same interventions have never been shown to have had much impact elsewhere (though the industry is loath to admit that), also because there is little evidence that Zimbabwe (or any other country) ever followed the industry's 'advice' particularly faithfully. The puzzled authors of the PLOS Medicine article above can do little but scratch their heads, but they don't even mention the possibility that health facilities may have been responsible for a significant proportion of transmission at one time in Zimbabwe and that this reduced as health facilities became less accessible.

That may be unfair to Zimbabwe health services. After all, transmission in health facilities may have reduced because conditions were improved. These are empirical questions, and ones unlikely to be answered by the HIV industry because they simply refuse to ask them, or to allow others to do so. Perhaps we'll never know. But it would seem like a smart question to ask. If HIV transmission is sometimes a result of unsafe healthcare, and it may almost never be, as UNAIDS claim, will circumcising adults make any difference? Will circumcising infants? Wouldn't it be better to reduce unnecessary operations in health facilities and concentrate on more urgent matters?

Tomorrow is World AIDS Day and one of the industry's offerings is a rather sickening song from 'Champions for an HIV-Free Generation'. It asks us what we are waiting for, tells us that circumcision is cool and clean and protects lives, that it's what the smarter generation does and advises us that if we are champions we should get circumcised. The song even mentions Zimbabwe and several other countries where HIV prevalence is higher among circumcised than uncircumcised men. This is not about whether people should or should not circumcise for religious or any other reasons, it's about the ethics of aggressively marketing circumcision for its protective benefits against HIV in countries where HIV prevalence is higher among circumcised men.

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



Unknown said...

If the states is where they get their info, then baby's will be circumcised with NO pain meds with is clearly unethical even IF it were protective. At any rate, I am tired of the US working to harm others rather than help. Food, healthcare, clean water, and education are what our African brothers and sisters need if they have no already got it. With recent news of the UN trying yet again to extinguish FGM, they may not realize it but the only way to do that is to also extinguish MGM.

Simon said...

Thank you for your comment. The money is all coming from the US at the moment and even if other countries are not contributing to it because they feel it is pointless or wrong, they don't appear to be opposing it. But the issues do differ between infant and adult circumcision. Infants are not yet sexually active and their parents can easily wait till they can make up their own minds. Adults are being bullied into this and women are proving an easy target when it comes to filling them up with incorrect information about hygiene and the belief that the operation will protect them. Most sexually active men are saying no, but the majority of those who have had the operation are teenagers. It seems to be a grey area where the ethics and legality are questionable, but not as clearly as they would be with infant or adult circumcision.

Joseph said...

"Some people on the trial may have been infected through unsafe healthcare, or one of several other routes. This could mean that circumcision is even more effective than previously thought, of course."

I don't understand why the former would necessarily mean the latter. Could you please clarify? Thanks.

Simon said...

Hi Joseph, the operation is supposed to protect against sexually transmitted HIV, in fact, transmission from female to male, penile-vaginal sex. If men who underwent circumcision were infected because they had receptive sex with another man, injected drugs with a shared syringe or received unsafe cosmetic or health procedures, this would not mean that circumcision couldn't protect against sexually transmitted HIV. But such possibilities were not considered.

Of course, the same possibilities would have to be considered for those who were not circumcised and who became infected, but the randomized controlled trial should have been comparing sexually transmitted HIV instances and excluding non-sexually transmitted instances.

As a matter of interest, it seems likely that incidence, the rate of new infections, increased among the control group during the Ugandan trial. Those running the trial did not say why incidence increased among them when they were the control group. They should be able to explain this for the results to be valid. What did those in the control group have to do to comply with instructions? Were they told to vigorously wash their penis after sex, or before and after, or something like that? This could have increased transmission, which would also invalidate the RCT results.