Thursday, January 24, 2013

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

Only a few weeks ago, the owners of the company that makes PrePex 'bloodless' circumcision devices (effectively, a plastic ring and a rubber band) were happily plugging their ware, a difficult process of persuading journalists to regurgitate an entire press release without any research or criticism. This time, the press release was set in Uganda and a researcher, presumably one not versed in the skills of PR, claimed that "We have so far tested it on about 50 clients but we need 250 more to confirm its acceptability but so far it has worked properly with those who used it". No need for any Ugandans to worry, then.

But alas, some of the main proponents of circumcision, who are also some of the main recipients of the copious millions of dollars available for the mass male circumcision programs in Africa, have announced that "The PrePex Device Is Unlikely to Achieve Cost-Savings Compared to the Forceps-Guided Method in Male Circumcision Programs in Sub-Saharan Africa". They were even generous enough to make the findings available in a free peer-reviewed source. This is all the more remarkable when you consider how most research relating to mass male circumcision is made available: selectively, at the convenience of those who collected the data, rather than that of anyone who may wish to scrutinize it.

Of course, this may be just a bit of a spat between those who prefer to know that scalpels are used (who currently receive the lion's share of funding) and those who don't give a toss how the operation is carried out as long as they make lots of money out of it. The paper by Walter Obiero, Marisa Young and Robert Bailey claims that at $45-50, the PrePex method is "unlikely to result in significant cost-savings". The authors declare no competing interest, unless the fact that at least one of them is a founder of the Nyanza Reproductive Health Society, which provided some of the funding for the research, represents some kind of competing interest.

The $45-50 figure is interesting. According to an article from the UK's National Secular Society, hospitals in Sheffield are going to start charging for non-medical circumcision. They carry out fewer than 200 per year, which is surprising enough, but they expect to save nearly $1,600 per operation. Could it really cost 32 times more to carry out a circumcision in an English hospital? I can imagine costs are lower in African countries, for lots of reasons, but I wonder what, exactly, will be excluded from the mass circumcision campaigns to keep the costs so low. I wonder also if Sheffield could be induced to reconsider their decision if they could offer the operation so cheaply, and how many people would then take them up on it.

One person commenting on Sheffield's decision feels that this may give rise to 'backstreet operations'. But in African countries where circumcision is already carried out for tribal reasons, almost all circumcisions are 'backstreet operations', carried out by someone with no medical training, often without sterile instruments. The several billion dollars on offer for mass male circumcision programs in African countries are mainly available in areas where circumcision is not routinely carried out already.

A spokesperson for the National Health Service said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need." A spokesperson for the National Secular Society said "We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent." These guys have evidently never heard about the US government's plans for African males.

Most articles promoting mass male circumcision for high HIV prevalence African countries claim that "results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent". This is not what the trials showed. HIV transmission was lower in the group that was circumcised than in the group that was not. But the trial did not show that all transmission was a result of sexual contact. Some may have been through unsterile healthcare, reused medical equipment, etc. Perhaps more importantly, at least one of the trials suggests that HIV transmission increased in the control group, rather than decreasing in the intervention group.

It seems hard to believe that current interest in promoting mass male circumcision to reduce HIV transmission from females to males could be based entirely on the evidence for the effectiveness of such a strategy, because the evidence is extremely mixed so far. It seems equally hard to believe that the whole thing is just a money earner for those competing for funding. But there is a lot of money involved. You might expect the Nyanza Reproductive Health Society to be unworried about whether PrePex is used, or some other method. But the difference in cost could be about 10%, some $100,000,000. So how much does something have to be worth to be a 'competing interest'?

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



Joseph said...

Aren't circumcision promoters planning to circumcise 20 million men?

This from an NYTimes paid ad by PrePex:

"PrePex’s ultimate cost is still being negotiated with donor agencies and foundations, Ms. Fuerst said, but may end up in the $15-to-$20 range, about the same as a surgical circumcision kit."

Let's see, at 20,000,000 men, that's $300,000,000 at minimum, and $4,000,000,000 at most.

For a useless, extraneous device looking for a purpose, not bad.

Not bad at all.

Simon said...

Thanks Joseph, you're quite right, the amount they stand to make is eye-watering. I was just calculating the figure Robert Bailey and friends was saying was "unlikely to result in significant cost savings". Some have said the target population is more like 38 million, so the profits for churning out little plastic rings and rubber bands could be well worth the effort.

I assume the biggest effort is getting the money sorted out now as it is becoming obvious that the vast majority of men are not agreeing to be circumcised. Not only are the numbers agreeing to it falling fast, but the remainder will be harder to persuade, as they have already probably decided not to go through with it. PrePex probably feel that the only way they can pull this trick is to get in and out before anyone notices the sleight of hand.

But I really wonder if there is some competition between Bailey and his crew, on the one hand, and the PrePex bunch on the other hand. I would have expected them to be in cahoots, but perhaps not. Bailey is well aware that it's going to be a hard slog so perhaps he doesn't want anyone else cashing in on it. It is not a foregone conclusion, but some country may wake up and realize that HIV prevalence is higher among circumcised men, which would really mess things up for Bailey and PrePex.

Joseph said...

"I would have expected them to be in cahoots, but perhaps not."

I think it becomes more and more obvious what this is about; money and extraneous agendas, and NOT actually disease prevention as they purport.

Regarding countries waking up, haven't some leaders like the Ugandan president simply never bought it? The statistics of countries where HIV transmission is more prevalent among circumcised men is out there.

It is mind-boggling to me why nobody has noticed it.

Perhaps it's the money signs in their eyes getting in the way...

Simon said...

I agree with you, but I'm sure it's not beyond the ingenuity of Baily and his friends to gloss over results that don't fit their PR. So PrePex must be disappointed that they missed such a massive endorsement. You're right about Museveni, but I don't see him turning down money for his country. And development by big donors and NGOs seems to be something apart from governance, beyond oversight, without so much as a sniff of democracy.

I've tried, over and over again, to point out that the program is being carried out in countries where HIV prevalence is higher among circumcised men but very few seem to react in any way. Is it that difficult to understand? What should I do, draw a picture? Ideograms?

Joseph said...

"It is difficult to get a man to understand something, when his salary depends on his not understanding."
~Upton Sinclair

The people you explain things to cannot bite the hand that feeds them.

If they are told that in order to get funding, donations, a paycheck etc., they must say circumcision prevents HIV, and dismiss evidence to the contrary, then that is precisely what they will do.

They can't risk losing funds from say, PEPFAR, Bill Gates etc.

It has got to be money making people ignorant to reality.

I can't see any other reason why people would just ignore the fact that circumcision has already been shown to fail in the massive circumcision experiment that exists in human history.

"Insanity: doing the same thing over and over again and expecting different results."
~Einstein (Attributed)

Simon said...

Sadly, the people who are in favor of circumcision must be well aware that there are many areas where HIV prevalence is higher among circumcised men. Even people like Bailey doesn't deny that, he just fails to address it.

No, I'm talking about people who have no interest in circumcision, it's nothing to do with their job or their income; but telling them seems to have no impact. Just as people seem happy to assume that almost all HIV transmission in Africa countries is a result of heterosexual behavior, they seem to think that circumcision is, by definition, a good thing for Africans, or at least nothing to object to.