Unethical Tuskegee Style Trial Being Re-run in African Countries

The issue of male circumcision has cropped up on this blog because of claims that it can reduce HIV infection in men. It is not claimed that it reduces infection in women, though there is often that implication. In fact, circumcised men may be more likely to transmit HIV to women.

However, here's what one of the 'experts' and flag-waving proponents of mass male circumcision, Dr Maria Wawer, has to say: "Circumcision removes the foreskin of the penis, which is rich in immune system cells targeted by HIV and perhaps other viruses. Taking off the foreskin likely makes the penis less likely (sic) to carry a range of microbes."

The lack of certainty that I express using the word 'likely' stems from the fact that I am not a scientist, nor am I collecting and analyzing data directly. There is conflicting evidence, to a large extent because much of the research has concentrated on demonstrating the effectiveness of male circumcision, rather than considering if it is really going to reduce HIV transmission.

But 250,000 Kenyan adult men have been circumcised because Dr Wawer and her colleagues think the operation is 'likely' to be effective. They have no idea why it might be effective, if it really is. Worse still, the best that can be hoped for in terms of transmittion reduction is really nothing to get excited about.

The claimed 60% reduction in HIV transmission was achieved in groups of people who were 'counseled' (indoctrinated) at length on 'safe' sex, urged to use condoms and monitored regularly for a relatively short time. What was really established was that if people, circumcised or uncircumcised, used condoms consistently every time they have sex, HIV transmission issignificantly reduced.

Far from publishing critical analyses of these rather poor results, much has been made about the protective benefits of circumcision against other sexually transmitted infections, such as human papilloma virus (HPV), which can cause cervical and other cancers. Yet again, the figures are not that impressive. Their '28% lower rates of transmission' in field trials could be far lower in practice.

But supposing the protection was real and male circumcision does give some protection against some STIs, or even just one? Would this mean that those who seem so vehemently opposed to mass male circumcision, and that includes me, need to backtrack?

I'm not opposed to proven interventions that reduce HIV transmission, such as prevention of mother to child transmission (PMTCT). What I am opposed to is half-baked interventions that may appear to give some small benefit but may also be doing a lot of harm.

The trial Wawer is involved in like the Tuskegee syphilis trial, where the ultimate outcomes for those taking part is not the concern of those doing the research. They are not worried whether participants become infected with HIV or anything else, they just want to know the circumstances so they can develop interventions for Western countries.

Why circumcision is still of so much interest is not clear, it of no use among men who have sex with men and unless people use condoms during heterosexual sex, it is of no use to them either. It's big in the US and must make a lot of money for the healthcare industry.

But it doesn't appear to protect people much in the US, either. HIV prevalence in the US, especially in some cities, is far higher than in European countries, where circumcision is not very common. Other STIs are also more common in the US, sometimes 10 or 20 times higher than in many European countries.

In African and other developing countries, though, the risks associated with circumcision are far higher than they are in Western countries, with their good health services and fairly numerous health personnel. Countries like Tanzania, Kenya and Uganda have deplorable health services, chronic shortages of skilled personnel, inadequate supplies of equipment and a serious lack of safety and infection control processes.

Going for an operation, even getting a tooth pulled or receiving an injection in many African and other developing countries is a serious risk. The Tuskegee syphilis style trials mentioned above don't bother checking what non-sexual risks people face in their day to day lives, so obsessed are they with sex.

Those taking part in circumcision, vaccine, microbicide, pre-exposure prophylaxis (PrEP), treatment as prevention and other trials, many of whom eventually become infected with HIV, are not warned about non-sexual risks. Researchers don't check to see if those who become infected were infected non-sexually or sexually.

In short, most of these trial results are not even valid and certainly do not justify the green light that mass circumcision campaigns have received. Circumcision has not been shown to be of benefit and its safety has not been assurred. The health and even lives of millions of African people are being put at risk by a bunch of well financed Western researchers. Doesn't that bother anyone?

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.

HIV Institutions Need to be Frank About How Discordance Occurs

Some time back, a Ugandan woman who found out she was HIV positive shot dead her husband, who was HIV negative. This incident introduces an article about the urgent need to focus on HIV discordance, where one partner is positive and the other is negative. Sadly, the article doesn't shed any light on how discordance could occur.

There has been some research into discordance but much of it has gone no further than estimating numbers. Discordance occurs in about half of the couples where at least one partner is infected. And even among non-discordant couples where both partners are infected, there are quite a number where partners did not infect each other. This data is not collected very much, but it should be. How could it occur?

For a start, someone needs to be HIV positive to infect someone else through sexual intercourse. This may sound obvious, but I wonder if the woman who murdered her HIV negative partner knew. In Kenya, half of all married HIV positive women have a partner who is HIV negative. Far more women than men are infected with HIV and in Western Kenya there are more than five HIV positive women for every HIV positive man.

If you go along with the oft repeated orthodoxy, that most (some say 90%) HIV infection is sexually transmitted, you may wonder why women are so much more likely to be infected than men when plenty of data shows that men are far more likely to engage in 'unsafe' sex than women. Or you may simply dismiss this by saying that women are more 'susceptible' to infection through sexual intercourse.

This doesn't really explain differences between genders, especially in Western Kenya, where a large number of women must be having sex with a small number of HIV positive men. After all, as I've just said, 'unsafe' sexual behavior is higher among men. But you could, along with the orthodoxy, dismiss that with some other, equally unconvincing, argument.

Currently, guided by the orthodox wisdom, people who find out that they are HIV positive and their partner is not tend to be told that they must have had unsafe sex with someone other than their partner. There isn't really any other possibility, given the orthodox view. They could object that they have only ever had sex with their partner but the assumption is still made that they are probably mistaken or lying. Very often, that's the end of the partnership. Some people remain with their HIV positive partner, many don't.

It would be so much easier to admit that the figures suggest that a lot of HIV infections are probably not caused by 'unsafe' sex. Most women are not promiscuous. Nor are most men, despite all the spoken and written attestations to the sexual behavior of Africans, especially African men. Some men and some women are promiscuous, but that's true in every country in the world.

The assumption that high HIV rates can be put down to sexual behavior at levels that are not possible for human beings is institutional racism, because it informs most HIV policy and programing. The assumption is only made of Africans. In non-African countries, it is not assumped that most HIV transmission is sexual. There is more scope for actually believing what people say about their own sex lives.

It is also institutional sexism. The attested behavior of women, which makes up data collected by HIV institutions, is not used to inform policy and programing. On the contrary, the data is assumed to be lies because it does not accord with the current orthodoxy.

Bizarrely, the article concludes without mentioning non-sexual HIV transmission, the one mode of HIV transmission that might explain prevalence patterns but is rarely discussed by UNAIDS or any other HIV institutions. These institutions are tasked with preventing HIV transmission, yet they choose to ignore the possibility that appalling health services in countries like Kenya, Uganda and Tanzania could result in accidental transmission of HIV.

Another article goes through a similar process of describing some of the problems of discordance and also fails to say how such discordance could occur.

It is difficult to explain discordance without mentioning non-sexual transmission. But it is also unethical, for two reasons. Firstly, everyone has a right to know how they were infected, or how they may have been infected. Secondly, everyone has a right to know how to protect themselves and others from infection, whether it's sexual or non-sexual infection.

Africans are being denied their right to know how they were or may have been infected with HIV and they are being denied the knowledge they need to protect themselves. And it's not just adults that are at risk, infants and children are also at risk. Parents need to be aware of risks that their children face in order to mitigate those risks.

Where infants and children are found to be HIV positive, it vital to establish the source of their infection. It needs to be clear that they were not necessarily infected by their mother, who may not even be infected or may be infected with a different strain of the virus. This phenomenon has often been documented but it has yet to be investigated in African countries.

HIV discordance is a lot easier to explain when it is frankly accepted that not all HIV infection is a result of sexual intercourse. The many non-promiscuous people, virgins, infants, children and no longer sexually active people who find they are HIV positive have a right to know this. And we all have a right to know how HIV is transmitted and how to protect ourselves, especially in high prevalence countries with failing health systems.