We do them in Black for 14.99

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself

The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don't Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act's definition of 'informed consent', which requires that people be given "adequate information including risks and benefits of and alternatives to the proposed intervention". Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn't always protect them from conviction.

Part one of section 45 reads: "All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification"; part three reads: "A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction...".

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else's blood, or how to avoid this.

The Don't Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else's blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don't Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don't know there is a risk and they don't know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO's 'Tool C', also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

"Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface...

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub...

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections...

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle...

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes...

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container."

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and 'traditional' practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

Kenya's HIV Prevention Revolution: Beating Swords into...Condoms

Kenya's recently published 'HIV Prevention Revolution Road Map - Count Down to 2030' presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country's epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned 'King of Condoms', with a paper crown on his head, demonstrating to the country's first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don't see that as an instance of crass infantilization? Perhaps they don't find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed 'Modes of Transmission' spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn't we start collecting empirical data to guide future efforts?

Why 'Reducing HIV Transmission' Must Never be an Excuse for Genital Mutilation

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

The English Guardian is calling for an end to FGM, of course. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials are have been used to justify a continuation of mass male circumcision, involving tens, even hundreds of millions of men, boys and infants and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to 'protect' against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret). In fact, it is assumed that FGM status is seen as irrelevant to HIV transmission, and that, even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds, not even the kind that leaves no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason, on infants, children, or even unconsenting adults. Quite right, too.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian's Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a 'population control' theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this 'eugenics'.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other 'population control' organizations certainly do promote that.

So promoting your favorite 'public health' intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, 'trials' of this operation on millions of people. The excuse is that it 'reduces HIV transmission'. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neo-eugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.

Biological Factors that May Contribute to Huge Disparities in HIV Prevalence

The brief summary at the end of an excellent article on 'Biological Factors that May Contribute to Regional and Racial Disparities in HIV Prevalence' really gets to the point about how HIV prevention should be approached, but generally isn't:

"To develop better prevention tools, it is critical that communities, researchers and policy makers come together to discuss and investigate these tremendous [racial disparities in HIV prevalence, both between regions and within regions] in an open and non-judgmental fashion."

Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."

The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.

Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."

Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.

Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.

Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.

Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.

Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.

But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.

Do Some Researchers Get Commission for Each New HIV Infection?

An article by Drs Robert van Howe and Michelle Storms entitled 'How the circumcision solution in Africa will increase HIV infections' brings together many of the arguments I have been putting forward about HIV and circumcision, but far more elegantly. And there are some arguments I haven't discussed as well.

The authors question the assumption that all HIV infections in the three often cited randomised controlled trials of male circumcision (in South Africa, Kenya and Uganda) resulted from heterosexual transmission. They argue that less than half resulted from sexual transmission and that therefore the majority of infections would not have been prevented by circumcision.

They argue that concentrating on mass circumcision will deflect attention and resources from effective HIV prevention work and may result in an increase in HIV risk. They recommend the promotion of correct and consistent condom use, which, unlike circumcision, is highly effective. If circumcised men think they don't have to use condoms, HIV transmission could increase considerably.

This argument also makes pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV negative people, said to reduce transmission by 44% when used by men who have sex with men, look like a very weak prevention strategy. PrEP also could lead to an increase in HIV transmission if it resulted in lower condom use.

The authors conclude that "a fifteen-fold increase in the circumcision rate would have the same impact as a 3.8% absolute increase in the use in condoms." So why not just concentrate on promoting the use of condoms and other complementary prevention strategies that actually work?

The authors also mention the barely mentionable iatrogenic HIV transmission which is clearly far more common in developing countries than UNAIDS and the HIV industry would like to admit. They comment: "Before Africans address sexually transmitted HIV, a concerted effort to eliminate the iatrogenic spread of the virus is needed."

They also note: "Condoms would be expected to be ineffective in regions where the majority of infections are from non-sexual transmission." Some authors, such as Drs David Gisselquist and Devon Brewer and Mr John Potterat have been writing on this subject for many years. But iatrogenic transmission is rarely mentioned in the official HIV literature and academic articles that discuss such concepts never seem to see the light of day.

Circumcision enthusiasts have concentrated their attention on populations where circumcision rates happen to be low and HIV prevalence high. But there are populations where circumcision rates are low and HIV prevalence is low. And there are populations where circumcision rates are high and HIV prevalence is high. It is hard to imagine why they have received so much attention, and presumably funding, when their overall stance is so unscientific.

But the vagaries of UNAIDS and the HIV industry have always been beyond comprehension to me. Meanwhile, massive rates of HIV transmission continue to occur in some of the most closely observed populations in the world. And yet those doing the observing don't seem to have figured out how HIV is being transmitted. Doesn't that ring alarm bells for anyone?

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]

Underlying Factors in HIV Transmission Are Not Causes

When I was researching for a grant proposal to address gender based violence (GBV) and female genital mutilation (FGM) in the Mara region of Tanzania, I was unsurprised to find that HIV rates there are relatively low. High levels of violence, even GBV and FGM, do not necessarily lead to high levels of HIV. On the contrary, high rates of FGM are often correlated with low HIV prevalence.

This does not, as far as I am concerned, make GBV or FGM any less repulsive. But low prevalence of HIV in an area can sometimes make it difficult to attract funding. Low levels of nutrition, food security, education and other basic human rights are often ignored until it can be shown that HIV rates are high, or that rates are connected with other developmental problems.

Any claim that something is the 'main' driver of HIV is suspect, including an article on AllAfrica.com today entitled 'Women's inequality Main Driver of HIV'. Like GBV and FGM, all inequalities need to be addressed, because they are symptoms of underdevelopment, not because they are more or less related to HIV transmission.

Of course the "relentless cycle of vulnerability affecting girls and young women" needs to be addressed. But the attitude of UNAIDS and other institutions contributes to that relentless cycle. Telling whole populations that HIV is almost always transmitted through heterosexual sex gives rise to the sort of disempowering social and cultural norms and attitudes that such institutions claim to find so abhorrent.

The article correctly refers to staggering infection rates among women between 15 and 24 years but it does not refer to the fact that many of these women have only one partner who is HIV negative. Fewer men than women are infected in many countries and in some regions, rates among women are several times higher than those among men. It doesn't take people long to work out that something about what they are being told is not true.

Apparently 80 per cent "of young people, aged between 15 and 24 years, living with HIV are female". But most men are not infected until they are a lot older, well into their 20s, perhaps even their 30s. Why wouldn't some people think that HIV is introduced to populations by women? People know more about their own sexual behavior than they are sometimes given credit for, and if they or their partner become infected, they have a right to question the HIV orthodoxy.

All the HIV industry has succeeded in doing is in disempowering women further and undermining their efforts to change their situation. The industry has also further alienated men from wanting to bring about any kind of change. They have been branded as the main culprits in HIV transmission, in addition to all the other things they are accused of. They may not be innocent, but that's no reason to condemn them for something they are not all guilty of. And condemning them, rightly or wrongly, will not help bring about change, either.

Apparently men will be targeted in HIV campaigns that have so far mainly targeted women. But if this means further accusations of promiscuity, strange sexual practices and widespread antisocial behavior, it will prove as fruitless as most prevention work that has taken place so far. It will not be a new strategy, just another way of beating people over the head with the old strategy.

Another 'leading cause' of HIV often mentioned is illiteracy. Again, continuing high levels of illiteracy and profound inequalities in education are disgraceful after so many decades of development work. But HIV transmission has usually been found to be higher among the better educated (and richer) people in high prevalence countries. That wouldn't justify the claim that education 'causes' HIV, but nor should it justify the claim that illiteracy is a cause.

If UNAIDS are interested in what causes HIV, they should re-examine data about sexual practices and sexual transmission. They will find that some of the data is anomalous if it is assumed that almost all HIV is sexually transmitted but the anomalies disappear once they allow that some HIV is transmitted non-sexually.

Reliance on mathematical models is unwise when it comes to estimating the contribution of various modes of transmission because this can lead to circularity. But HIV prevention will be a whole lot easier when it begins to target genuine causes, rather than mere underlying factors.

Circumcision: 1.1 Million Kenyans Tricked Into Being Human Guinea Pigs

Some of the highly dubious pronouncements about HIV programs can be taken with a pinch of salt and I certainly hope that's true of the mass male circumcision program taking place among the Luo tribe in Nyanza province, Kenya. About a year ago they were claiming to have circumcised about 100,000 men. Now the figure has risen to 250,000, 40,000 of them said to have taken place over the last few weeks.

The argument is that men are less likely to be infected with HIV if they are circumcised. There is little evidence for this and how, exactly, the process may work, is unknown. But on the slight chance that it may work, the program is going ahead. Aside from the fact that the HIV industry really wants to do it, it is not clear why this program was ever started.

We are constantly told it is 'cost effective' and will prevent hundreds of thousands of infections over the next 20 years. However, this projection depends on a lot of assumptions that are completely unsupported by evidence. And lots of things are 'cost effective', such as reducing diarrhea and intestinal parasite rates, which infect far more people, kill more people and cost even less to prevent and treat. But cost effectiveness doesn't seem to count in those instances.

Male circumcision is rare among members of the Luo tribe and HIV prevalence is high, so this is seen as a good argument for circumcision. However, female genital mutilation (FGM) is also rare. I don't hear anyone calling for mass FGM just because of this correlation. Not that I think FGM is a good thing, I don't. I think it is an appalling form of gender based violence that has none of the benefits claimed for it.

However, two other tribes in Nyanza province, the Kuria and the Kisii, have low HIV prevalence. And most of the men are circumcised. But many, perhaps most, of the women are victims of FGM. And the lowest HIV prevalence found in Kenya is among the ethnic Somalis, who also practice male circumcision and FGM widely.

Clearly, there are other circumstances that surround low HIV rates and high rates of FGM. FGM is most commonly practiced where levels of education are low, people are exceptionally poor and they are isolated from health and other public services. But there are other circumstances high rates of HIV and low rates of male circumcision, too.

Are these arguments for reducing education and health and increasing poverty? I wouldn't have thought so. But if you make projections using the figures for the Northeastern province, which has the lowest HIV rates in the country, you might find that such measures are 'cost effective' when it comes to reducing HIV rates.

Recent research in Tanzania has found that HIV rates are, indeed, lower among women who have undergone FGM of some kind. Indeed, the level of 'protection' given by FGM is curiously similar to that claimed for male circumcision. So if this is not a valid argument for FGM, maybe it's time to reconsider male circumcision?

Given current data, Kenyan Luos are being used in a large scale public health experiment that is undoubtedly unethical. As to the consequences of the experiment, it's too early to say. But if I was a Luo I'd be careful of people wielding scalpels. Just use condoms. You'll still have to do that when you are circumcised, anyway.

Circumcision Could Increase HIV Transmission But Strategy Will Continue

With all the publicity about mass male circumcision (MMC) and the great part it could play in reducing HIV transmission in high prevalence countries, little is said about the likely effect of such a strategy on women. After all, it is women who are most likely to be infected, women who are most susceptible, women who are said to have the least power in relationships, etc.

Well, something like a report, but without the balance you might expect, has been published on MMC and women. The fact that AVAC (a pharmaceutical industry front) and the Gates Foundation are involved means that, whatever the report finds, it will be used to support MMC. It certainly won't be used to slow things down and consider whether this is the right way to go about it.

The report finds that women lack detailed factual information about how MMC is supposed to play a part in HIV prevention. This is not surprising, considering the heavily biased reporting on the technique. The average of '60% protection' claimed on the basis of three brief trials involving small numbers of people doesn't stand up to scrutiny.

The fact is, it is not clear how circumcision protects men against being infected with HIV, if it really does protect them. What is clear is that HIV prevalence is only lower among circumcised men in some countries. In other countries, HIV prevalence is higher among circumcised men. How that problem will be resolved is not clear.

Also, MMC does not directly protect women at all. It could be argued that if fewer men are HIV positive, fewer women will become infected, so they are indirectly protected. But, in addition to the lack of clarity about how much it protects men, it is not clear than most women are infected with HIV through sexual intercourse.

Many HIV positive women have a HIV negative husband, yet many of these women only have one partner. Even if their husband is as sexually promiscuous as African men are said to be, something there is no evidence for, their husband didn't infect them if they are not themselves infected. If some people are not being infected sexually, circumcision will have no benefit for them.

But are circumcised men who are HIV positive less likely to transmit HIV to women, or more likely? There is evidence that they are more likely. Many HIV positive men are circumcised and many more will become infected. It needs to be clear whether MMC will also reduce transmission by men who are already infected or who have yet to become infected.

The 'report' finds that many women think they are directly protected from HIV transmission if their partner is circumcised. But many men also believe that they are protected and they will argue that they don't need to use other precautions, such as condoms. Even the circumcision trials advised those taking part to use condoms. Circumcision, even according to its most ardent advocates, does not guarantee against infection and the 60% figure refers to circumcision in conjunction with consistent and correct condom use.

When it comes to negotiating 'safe' sex, it will be even harder for women to negotiate for condom use if the man, and perhaps even the woman, think that circumcision obviates the need for condoms. And even if the man doesn't believe that he can safely have unprotected sex, he could still use the claim to support his case, if he wished to. If people associate circumcision with a lower likelihood of being infected with HIV, the operation could put women in more danger from unprotected sex, rather than less.

There is also the problem of circumcision performed in a non-clinical setting, which carries high risks of various kinds of infection, including HIV. Many men have been and many will continue to be circumcised outside of clinical settings, where the may not be tested, before or after, and the risk of transmission under such circumstances may be increased as a result of circumcision.

Some have even conflated male circumcision with female genital mutilation(FGM), whether inadvertently or otherwise. Even the promoters of MMC have not tried to promote FGM, but there are those who believe, or wish to believe, that it also reduces HIV transmission.

This is where things become more mystifying. Areas with high rates of FGM tend to have low HIV prevalence (such as the Kuria and Kisii tribes in Nyanza province). And some areas with low FGM rates have high HIV prevalence (such as the Luo tribe, also in Nyanza).

This is not because FGM reduces transmission, although the reason for the correlation is not clear. In other words, even if there is a correlation between high rates of FGM and low HIV prevalence, most people wouldn't claim that there is a causal connection between the two phenomena.

But then, advocating MMC on the basis of similar correlations seems particularly foolish. There is speculation about why removing the foreskin could possibly give some protection but there has been no explanation of exactly how this might work. And the assumed process is not just unclear, it is not even consistent if circumcised men in some areas show higher prevalence rates than uncircumcised men.

This report makes it clear that, despite evidence against the claimed benefits of MMC, including the finding that it will increase the vulnerability of women, MMC will go ahead. The findings of the report are profound, but not as profound as the stupidity of continuing with MMC under the guise of reducing HIV transmission. It is difficult to comprehend, but advocates of MMC have always intended to procede with the intervention, regardless of the consequences. Amazingly, this report confirms that intention, without explaining what advocates, or anyone else, has to gain.

This report claims to be opposed to stigma and advocates dispelling myths that support stigmatizing attitudes. But an MMC strategy ony lends support to the common belief that 'promiscuous' women spread HIV. The conflation of FGM with MMC also goes back a long way and is also being used to justify this and other violent acts against women. But the almost guaranteed failure of HIV prevention strageties has never put the HIV industry off in the past, so why should it do so now?

[AVAC and the Gates Foundation are also deeply involved in the CAPRISA 004 vaginal gel trial; more on my other blog]

The Choppy Logic of HIV Politics

"Circumcising infant boys could become part of Kenya's voluntary male circumcision programme...if an ongoing pilot project in the western province of Nyanza recommends it." Can infant boys become part of a voluntary program? Perhaps the author meant that parents could choose to have their infants circumcised, which is quite a different matter.

The pilot project is looking at the ability of medical staff to run an infant circumcision program that is acceptable to parents and safe for the infants. At least, that's how I interpret this rather garbled account. Words like 'successful', 'promising' and 'viable' also occur in the article (though some of the optimistic words are later qualified by words like 'reasonably', 'variable' and 'comparatively'), though the program hasn't finished yet.

The people being trained, apparently, are clinical officers and nurses, not doctors and surgeons. Kenya doesn't have anywhere near enough doctors or surgeons to take care of existing health problems, let alone get involved in tens of thousands of additional operations and follow-up care. Not that they are oversupplied with nurses or clinical officers, either.

The whole exercise involves what is sometimes referred to as 'task-shifting', whereby less well qualified, even completely unqualified people, are trained to do work that in wealthier countries would only be carried out by a highly qualified person.

Task-shifting may be safe enough when it involves doling out drugs and the like (though that also has its risks), but carrying out operations? I can't see it being popular in a Western country. There are hairdressers who have more training than some clinical officers but no one is suggesting that hairdressers should circumcise anyone.

The article suggests that infant circumcision is 'preferable' to adult circumcision, for various reasons, including being more cost-effective. But does that make it ethical to decide on behalf of infants that they should have an invasive and potentially dangerous operation, rather than waiting till they reach an age where they can give their informed consent? And purely because it may give them some protection against HIV?

Does the fact that parents make the decision on their behalf make it ethically sound? What sort of information are the parents being supplied with in order to make the decision? This operation may, the argument runs, reduce the risk of the children being infected with HIV when they become sexually active, but the evidence is slim and needs very careful manipulation to make circumcision sound like a good idea.

Even if circumcision were guaranteed to protect against HIV, or give a high level of protection, I would still question the ethics of carrying out such an operation on infants. They could decide whether or not to have the operation when they are adults. After all, there are many things these children will face, most of them preventable or curable and many of them deadly.

Up to 20% of the children will die of water-borne diseases and another 20% of respiratory problems. The majority will suffer from some form of intestinal parasite, possibly all their lives, and a large percentage will endure various forms of malnutrition and vitamin deficiency, the effects of which will almost definitely last for the rest of their lives (if they live). Most will, at some time, suffer from malaria and a host of other controllable diseases.

Indeed, quite a large number will be infected with some disease or other, hepatitis B, hepatitis C, possibly even HIV, as a result of their contact with a health facility. Some will even die from the disease, or suffer severely compromised health as a result. Health resources are not just scarce in Kenya, they are also potentially dangerous. The risk of HIV and the protection that circumcision may give seem quite diminished compared to the realities of Kenyan health care.

The trend towards 'treating' healthy people with drugs and other procedures is extremely worrying. Health is not just the absence of disease. Although sick people need drugs and other things, healthy people do not. Especially in a country where the most basic needs, clean water, sanitation, food, housing and education, are lacking. If the country doesn't have the wherewithal to treat all its sick people, why do some appear so anxious to use up scarce resources on those who are not sick?

Some Statistics Are More Equal Than Others

I recently wondered out loud why those who were baying for mass male circumcision in high HIV prevalence African countries didn't seem to be as interested in the possibility that washing with soap and water might be just as effective. Well, one Thomas J Coates has received 800,000 dollars to evaluate the feasibility of a "post-coital genital hygiene study among men unwilling to be circumcised" (compared to an estimated $50 million to circumcise just over a million members of the Luo tribe).

If this 'genital hygiene' involved something as basic as soap and water, that might be worth celebrating. But I doubt if it is. It's more likely to involve 'penile wipes' or some other technology. (Nothing wrong with technology, but let's just keep it appropriate.) And the study is not to establish if such measures would protect as well as circumcision, better or less well. It is to establish if men would find the practice acceptable, convenient, practicable and if adherence is high.

The project information says "If we find that men are able to practice consistent washing practices after sex, we will plan to test whether this might protect men from becoming HIV infected in a later study." It's surprising that they are going ahead with the plan to circumcise a million people, even though penile hygiene may be all that's required!

But I am not sure what they mean by 'able'. I assume most men are able to wash their penis, whether circumcised or not. I'm also wondering why pre-coital hygiene is not also being observed, with a view to reducing male to female transmission of HIV (and other sexually transmitted infections), not just female to male transmission, which is often less of a risk.

If "adherence is high" (and if men are 'able'), genital hygiene might then undergo randomized controlled trials to be considered as a HIV prevention intervention. If adherence is not high, some serious questions would need to be raised about the way the research was carried out. Personal cleanliness is considered extremely important everywhere I have been to in Kenya, Tanzania and Uganda, whether running water is available or not. But by the time the results are available, many more men will have been circumcised, possibly unnecessarily, possibly at considerable risk to their health.

Male circumcision is, all things considered, an odd HIV prevention intervention in a country with relatively low health care standards and low levels of access. Outside of the Luo tribe, circumcision rates are between 90 and 100%, yet HIV prevalence ranges from 0.8% among the ethnic Somalis to 7.9% among the Luhya and Maasai. That's nearly 10 times higher. And among the Embu, Somali and Meru tribes, men are just as likely to be infected as women (see table below).

In contrast, men are far less likely to be infected with HIV than women in most other tribes. Only three Luo men are infected for every four Luo women. But only 1.6 Luyha men are infected for every 10 Luyha women. So circumcision may protect men, but to widely varying degrees.

In some tribes, circumcision may not be giving much protection at all. It's hard to compare, because there are very few uncircumcised sexually active members of most tribes, but that information would hardly increase confidence in the effectiveness of circumcision, would it? In fact, it has never been clear what sort of protection male circumcision gives, if any. There is even evidence that Luos are more susceptible to HIV infection for reasons unrelated to their circumcision status.

But the passion with which mass male circumcision is advocated as a HIV prevention intervention smacks of an almost religious fervor. After all, lower HIV rates are found among those who practice female genital mutilation (FGM), too, mutilation of the worst sorts. Thankfully, none of the circumcision enthusiasts are advocating for FGM. But the highest rates of HIV are found among the people who don't practice FGM in any form (Luo and Luhya). Perhaps we shouldn't be so easily swayed by the promise of 'up to 60% protection' against HIV, or any other opaque statistics.

Tribe	HIV+	Female HIV Prev	Male HIV Prev	Ratio	HIV+ Male Circ'd	Male Circ'd
Embu	3.0	2.7	3.2	118.5	3.3	97.8
Kalenjin	1.8	2.1	1.4	66.6	1.5	93.8
Kamba	4.1	5.5	2.4	43.6	2.5	99.2
Kikuyu	4.1	5.9	1.7	28.8	1.6	98.0
Kisii*	4.7	5.1	4.3	84.3	4.4	97.0
Luhya	7.9	12.0	1.9	15.8	2.0	95.9
Luo	20.2	22.8	17.1	75	16.4	21.5
Maasai	7.9	8.2	7.8	95.1	8.8	90.1
Meru	5.3	5.3	5.4	101.9	5.1	91.6
Miji/Swah	3.2	3.5	2.7	77.1	2.7	98.9
Somali*	0.8	0.8	0.8	100	0.8	99.2
Taita/Taveta	2.7	3.7	1.4	37.8	1.4	100
Other	3.1	5.0	1.1	22	1.1	72.8

*FGM rates almost 100%

Figures from the Kenya 2008-09 Demographic and Health Survey.