Is it Already Too Late For People to Reconsider this Circumcision Farce in Africa?

According to an article on IRIN's PlusNews there is 'good progress' being made in the male circumcision program in Tanzania, which presumably means that they are going to get away with performing hundreds of thousands, perhaps millions of operations, knowing that the overall positive result will be small at best and there will be a lot of adverse events, perhaps even serious ones. It's clear that people pushing for these programs are not in the least bit worried that they will have to bear the costs of any adverse events. Who knows, perhaps they'll even profit from them.

But it's not unusual for circumcision 'experts' to make light of the subject. It is also claimed that the goal is to circumcise 2.8 million men by 2015 in a country where many people die of cheaply and easily preventable and treatable conditions every day. Many tens of circumcisions will need to be carried out just to prevent a single HIV infection, if the figures we are constantly blasted with are right. Where prevalence is particlularly low, hundreds of circumcisions will need to be carried out to prevent a single infection.

The program is being rolled out in Iringa at the moment, where HIV prevalence is much higher than anywhere else in the country. Yet it's certainly not the only area where circumcision rates are low. There are many areas within high HIV prevalence countries where circumcision and HIV are positively correlated, as well as areas where they are negatively correlated. In other words, we don't know what the connection is between HIV and circumcision and we certainly don't know why so many people are becoming infected in just some areas.

Are we supposed to believe that people in Iringa have amazing amounts of sex, unlike, say, the people in Arusha, Moshi or Kigoma, where HIV prevalence is far lower than the national average? Or perhaps we are supposed to believe that HIV prevalence in cities, particularly Dar es Salaam, are high just because of love levels of circumcision. In some places where birth rates are very high, such as the Northeastern province in Kenya, HIV prevalence is less than one percent. People there are clearly having sex, unless there has been a sustained outbreak of virgin births in the area. But the claim that there has been such an outbreak is no less ludicrous than the claim that HIV prevalence is high in some countries purely because of sexual behavior or, even worse, because some of the men are not circumcised. Circumcision rates are very high in Northeastern province, but they are also high in Western Kenya, where HIV rates are high too.

There is some evidence of mission creep in this program: originally these crazy claims were about adult male circumcision. Now, some articles mention infant circumcision and this one about Tanzania says that the 2.8 million people includes men from 10 years old to 34 years old. The cost of all this is estimated at between 28 and 47 million dollars, which would probably be enough to completely eradicate far more serious conditions, such as obstetric fistula, and still leave some change to train some much needed health professionals. By the way, nurses have been trained to do the operation in Tanzania and elsewhere, as there are not enough doctors.

It's worth bearing in mind that circumcisions are more common in urban areas, where HIV is less common. But that might change. Earlier circumcision programs suggested that some men could have been infected with HIV as a result of unsafe healthcare they received. This was very inconvenient and the embarrassing results were not published for journalists and other commentators to rant about, but I wonder if they would even have bothered. It's too late for the hundreds of thousands of Kenyans claimed to have already had the operation, probably unnecessarily, and the tens of thousands of people in other African countries. But there is still time for some African countries, or African people, to get some impartial advice about this subject, which is now top heavy with industry lies.

Doubts About Male Circumcision and the HIV Industry's View of African Epidemics

Even the title, 'Not a Surgical Vaccine', flatly contradicts the claims of circumcision enthusiasts; the term 'surgical vaccine' is rejected for being entirely unscientific. But it's in good company with many of their other claims. Authors Robert Darby and Robert van Howe look in particular at the issue of infant circumcision in Australia which aims to reduce heterosexual HIV transmission. They find there is no case for this intervention.

The authors question the 'robustness' of the three African trials constantly cited in favor of mass male circumcision and find that possible risks of such an intervention are being ignored. They also raise questions about the ethical and human rights implications of such programs, which are already well underway in a number of African countries. The authors recommend that Australia continues to discourage infant circumcision.

However, many of the reasons for finding the pro-circumcision arguments unconvincing are also relevant to African countries; they are also relevant to adult male circumcision. The authors ask if the incidence of heterosexually transmitted HIV is rising to a dangerous level and whether circumcision is the only effective way of countering this challenge. In high prevalence African countries it would be better to demonstrate how heterosexual HIV transmission is so much more common than elsewhere. As for the question of whether circumcision is the only effective way of countering HIV transmission, it is not particularly effective; but there are effective ways.

For example, condoms are very effective at reducing HIV transmission. But also, male circumcision only reduces transmission among men who also use condoms all the time. In other words, it is pointless unless men are going to use condoms on all occasions where they are not aiming for conception. The condoms won't just prevent conception and HIV, they will also substantially reduce the risk of transmission of all sexually transmitted infections (STI).

The authors list six reasons for disputing the proposal that all infant males be circumcised in Australia but with the exception of number two, they all cast doubt on the circumcision programs in African countries, whether for infants or for adults:

1 [The proposal] ignores doubts about the African evidence on which it relies and passes over numerous critiques of the clinical trials and the manner in which the WHO recommendations arising from them have been implemented.
2 It is irrelevant to the Australian situation and the specifics of Australia's HIV problem.
3 It departs from the principles of evidence-based medicine.
4 It underplays the harm and risks of circumcision.
5 It violates accepted standards of medical ethics and human rights.
6 It is marred by unscientific thinking and hyperbolic language, such as the description of circumcision as a ‘surgical vaccine’.

In addition to a whole host of criticisms of the randomized controlled trials, the authors say "Perhaps the most crucial flaw in these three studies is that the researchers assumed that all the men who became HIV positive during the course of the trials were infected through sexual contact." But that flaw can be found in many trials of HIV prevention interventions, perhaps most. The authors suggest that as much as half of the infections were acquired non-sexually. And the authors also note the lack of a convincing biological explanation as to how circumcision is supposed to protect against HIV and other STIs.

It's interesting that the authors combine scepticism about mass male circumcision campaigns with less than whole-hearted acceptance of the HIV industry view that serious HIV epidemics found in African countries are a result of high levels of sexual activity. They suggest that "It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures." I hope these researchers' findings are applied, as they should be, to countries other than Australia, where HIV rates are extremely high. Their findings have implications for the entire HIV industry view of HIV in African countries, not just the doctrinaire decision to fund mass male circumcision campaigns.

[For more about healthcare associated HIV infections, see the Don't Get Stuck With HIV site and blog.]

Sex Workers Face Sexual and Non-Sexual HIV Risks

A survey into HIV/AIDS among female sex workers (FSW), injecting drug users (IDU) and men who have sex with men (MSM) in Lebanon has found that prevalence was 3.7% among MSM but that no members of the other two groups were HIV positive. Whatever about IDUs, it is not too surprising that no FSWs were infected. In many countries where HIV prevalence has been monitored over a long period of time, prevalence among FSWs has been found to be low, even zero, unless they also face other risks such as injecting drugs.

This is what makes it so surprising that HIV prevalence can be extremely high among sex workers in some African countries. It has been claimed that prevalence reached over 80% among sex workers in Nairobi in the 1980s and over 70% in one region in Tanzania in the 1990s. It is often said that high rates of sexually transmitted infections STI make sex workers more susceptible to HIV. This is undoubtedly true, but rates of some STIs, which are an indication that those infected could have been engaging in unsafe sex, don't seem to correlate with HIV rates.

Programs that aimed to reduce STI rates have often been successful, but they have not usually resulted in any reduction in HIV incidence. Indeed, long before HIV was identified, STI prevalence among the entire male population of Leopoldville in the former Zaire in the late 1950s was extremely low. And it was in the years following this that HIV transmission rates were said to have increased as a result of extraordinary levels of 'unsafe' sexual behavior. What seems more plausible is that FSWs in Kenya and Tanzania were rounded up, perhaps routinely, to receive sexual healthcare that may not have been too sterile.

Sex workers everywhere can engage in high levels of 'unsafe' sex, but only in a few countries have sex workers been found to have such massive rates of HIV infection. And only in a few countries have up to 50% of the female heterosexual population in certain age groups been infected with a virus that can be transmitted sexually, but is far more efficiently transmitted through unsafe healthcare. Why should high levels of 'risky' sexual behavior among Lebanese sex workers result in no HIV infections when relatively low levels in some African countries result in high rates of HIV infection?

Pandemic HIV: Not as Perfect a Storm as we Have Been Led to Believe

In his review of Jacques Pepin's 'The Origins of AIDS', Peter Piot (Science 334 (6063):1642-1643, 2011) claims to have been "fascinated by the sometimes devastating consequences of medical injections" since the mid 1970s, following the Ebola virus outbreak in the Democratic Republic of Congo. That's strange, because I've never been able to detect that fascination in his papers. Perhaps his fascination is dormant, a bit like one of the HIV virus strains Pepin describes, which never get beyond infecting one or a handful of people.

Anyhow, now that Pepin has described the role of healthcare in spreading HIV, especially in the decades before the virus was recognized, maybe Piot will develop all those thoughts which never quite became papers. Perhaps his ideas will 'go viral', mobilize UNAIDS and the entire AIDS industry to relinquish their more evident fascination with the sexual behavior of Africans, and perhaps result in thorough investigations of the many suspected cases of healthcare transmission of HIV that have been ignored for so long.

But like Pepin himself, Piot jumps from high rates of HIV transmission as a result of unsafe healthcare to high rates of HIV transmission as a result of 'unsafe' sexual behavior, as if unsafe healthcare completely died out in the 1980s and ceased to play any significant role over the last twenty years or so. HIV transmission from unsafe healthcare did begin to reduce shortly after it was recognized as playing a part in spreading the virus. And in countries where healthcare practices were modified to avoid HIV transmission, HIV incidence, and eventually prevalence, began to drop.

But the massive increase in unsafe sexual behavior that was said to follow urbanization and various other (often rather vaguely described) changes in the 1970s and 1980s may never have happened, or may never have played as big a role in HIV transmission as the industry claims. Of course, sexual transmission of HIV occurred, and still occurs. But with healthcare producing large enough populations of HIV positive people, relatively normal (for human beings) levels of sexual behavior would have resulted in additional infections, much as sexual behavior continues to contribute to epidemics now, albeit far more modestly than is sometimes claimed.

The idea that healthcare related infections no longer occur, or hardly ever occur, is a matter for investigation. Piot and Pepin may be right, or even somewhat right; but there is a lot of empirical work to be done. The need for empirical enquiry into the possible extent of healthcare transmission has been obvious for many years, many people have called for the work to be done. But all that people like Piot have done is supported UNAIDS and the industry in denying a role for anything except sex.

Glass syringes are no longer used and disposable syringes, presumably, are not reused (very often). But how does the industry feel so confident that there are no practices in healthcare facilities which, if carried out without proper care, risk transmitting HIV and other bloodborne diseases? The 'perfect storm' metaphor that Pepin mentions and Piot echoes, one that is currently so beloved by journalists and other commentators, doesn't appear to be appropriate here. They both refer to a series of events that gave rise to the HIV pandemic, rather than concurrent events.

Pepin's Spectacular 'Origins of Aids'; Looking Forward to Part II

I have been reading Jacques Pepin's recently published book 'The Origins of Aids'. He has produced a huge amount of research and thinking on the issue of where HIV came from and how it spread all over Africa and beyond in a relatively short space of time. He also considers some competing theories and proto-hypotheses and effectively shows why they do not provide an adequate or comprehensive explanation, either because they are not borne out by evidence or because they don't show what they purport to show.

Few would disagree with Pepin's conclusions that unsafe medical practices 'kick started' what became the current HIV pandemic, a process that was required for a virus that was difficult to transmit sexually to eventually infect people who were not sexually active, or not particularly so. Also very clear is one of Pepin's lessons learned: that profound social changes resulting from colonization, urbanization and the like, were highly significant.

But this is where I start to feel less convinced by Pepin's further remarks on what 'profound social changes' is usually taken to mean for HIV: sexual behavior. Pepin speculates about how 'unsafe' sexual behavior could have reached levels that explain later explosions in HIV transmission, but he never shows that enough people actually engaged in the requisite quantities and types of this behavior to account for some of the very high, or even medium prevalence epidemics.

In fact, since detailed figures have been collected, the connection between sexual behavior, unsafe or otherwise, has never been very strong. This is not to say that sexual transmission of HIV has never occurred, just that it has never been shown how it could reach a creshendo and then, as if spontantously, reduce and drop to a very low and steady rate, at least in some countries. But the drop in incidence (and/or the drop in 'unsafe' sexual behavior) does 'appear' to have been spontaneous in some countries, occurring long before any serious HIV reduction programs took place.

Vulnerable groups, such as sex workers, are small. If they face very high risks, their clients face higher risks than they would if they stuck with a single regular partner; but they face lower risks than the sex worker. And partners of sex workers' clients face lower risks still. Prevalence in the general population in some countries, people who did not belong to any high risk group, has often been higher than prevalence in extremely high risk groups in non-African countries; how do extreme levels of transmission among those who face the highest risks also arise in those who don't face the highest risks? I've never been convinced by talk of 'bridging populations', people who have sex with high risk groups and spread the virus among low risk populations.

For example, HIV prevalence among sex workers in India is less than 10%, often a lot less. But HIV prevalence in one whole region in Tanzania and among one large tribe in Kenya is two or three times higher. In some countries, such as South Africa, Swaziland, Lesotho, Botswana, Zambia, Zimbabwe and others, prevalence in the general population is many times higher. In some African countries, ordinary people doing ordinary things are infected with a virus that is difficult to transmit sexually and it is assumed that most of them were infected sexually. Is this not illogical? Even UNAIDS produce figures showing that the majority of HIV transmissions in many African countries result among people who have no obvious sexual or other risks.

Pepin seems to go beyond his own evidence in concluding that although unsafe healthcare played the major part in the spread of HIV at one time, that it no longer plays a particularly significant role. He may be right, but I don't see how this conclusion is borne out by evidence. In fact, just as there is still a serious lack of convincing research into sexual behavior in African countries, there is an even more glaring lack of investigation into instances where HIV has clearly been transmitted in healthcare facilities and in contexts where sexual behavior is unlikely to have played a part.

Over thirty years, it has become quite evident that sexual behavior doesn't miraculously change because of some perceived threat, such as HIV. For several decades before HIV was identified, the bulk of health development spending was thrown at persuading African women, and the donor community, that birth control would solve all their development problems, poor health, poverty, malnutrition, drought, famine, flooding, etc; if only people would just have fewer children. Many still believe it, Bill Gates being no exception in that respect.

What can change very quickly is practices in health facilities, if the right training and other resources are available. The spontaneous event that resulted in a sharp reduction in HIV incidence early on in various African country epidemics (and elsewhere) is unlikely to have been related to sexual behavior; but changes in healthcare practices took place very early on, especially in countries where such changes were affordable. Even in Western countries, some of the largest groups infected were haemophilics and others who regularly needed various forms of skin-piercing healthcare.

I wonder why Pepin didn't answer the often asked question: 'What happened in Uganda'. He had the answer at his fingertips. Uganda reacted to advice that was still given to developing countries in the 1980s, but is considered unmentionable now: HIV can be transmitted most efficiently through contaminated blood. Pepin shows us how amazingly common non-sexual transmission was in the past but he doesn't appear to have looked into how common this mode of transmission might have continued to be for the last twenty years or so, or how common it is now.

[I have also written about Pepin on the Don't Get Stuck With HIV website and blog, where we are trying to collect together cases of nosocomial (hospital acquired) HIV outbreaks, unexpected HIV infections and investigations that have taken place around the world.]

Branding Duesberg is Easy But Refutation Seems to Elude HIV Industry

Nature notes the publication of Peter Duesberg's controversial article in an Italian journal, where it is claimed that there is no proof that HIV causes AIDS. The article was previously published and then withdrawn, but the publishers, Elsevier, still make it available for a fat fee.

Anyhow, Duesberg's claim is no stronger now than it was when he first made it. His arguments are partly based on data which he himself points out is often not available. But, instead of supplying the data on which, presumably, the contrary arguments are based, all we get is a few protests that Duesberg's article was published at all, and the predictable rantings of the HIV industry sponsored comment junkies.

The publicity conscious HIV industry should be well aware of how they are drawing attention to Duesberg's views, while failing to deal with them satisfactorily. But the industry is really not good at producing well-rounded data, which would allow convincing opposition to Duesberg and allow the industry itself to put together a coherent argument for their own position (or positions).

Apparently, one of the reasons for withdrawing the original publication of the article was that it contained opinions that "could potentially be damaging to public health". But that's not a reason for refusing to publish them in a journal that hardly anyone reads. In what way would public health be served by not publishing the article? At the very least, Duesberg has pointed to serious failures on the part of WHO and other institutions to collect and publish data that is vital to public health.

If public health is really the issue, evaluate the paper properly, publish the evaluation and get on with something more important. Otherwise you are just recruiting for Duesberg and the whole issue becomes a mere exercise in protecting various theoretical pitches.

How Low Would An NGO Go For the Sake of Money, Even Spite?

The first time I came to East Africa, in mid-2002, I wondered how I could be part of 'development', part of the efforts to change things for the better (despite knowing that some things that go under the name 'development' make things worse, often by design). The changes may be small, but they would make a big difference to some. Etc.

Like anyone else who had similar wishes, I needed to find out what was going on, what was so bad that it needed changing, how to bring about such change, why this sort of change was not already occurring, or if it was, how to do more of that and less of anything that was inimical to development...

I wanted to meet people involved in development, people from East Africa, people not from East Africa, whatever it took. I went back to Europe to save enough money to return and, at the same time, study for a Master's degree that included development, and perhaps some other areas, so I would have some kind of perspective, maybe even some useful skills.

That may all sound very naive, but in some ways I haven't changed that much. Since I've come back I've been working with individuals, community based organizations (CBO), non-governmental organizations (NGO) and the like, hoping to find that some were doing the right thing so I could learn about where I could fit in. Because, as I spend time trying to find out where I fit in, I have to do something. So I do many things, and I hope that continues.

But what do NGOs and others in the developing world do? Well most people know something about some NGO, what might have once been referred to as 'charity'. They do relief work following emergencies, education of various kinds, healthcare work, poverty reduction work and much else. Nominally, they do all the kinds of things that someone 'with a heart' would wish to do, or wish to know that others do or to support, financially and in other ways.

Well, some people do things because they 'have a heart', but not all do. Some make a living out of their work, some make a very good living, some make a fortune, etc. But one expects NGOs themselves to be run, driven perhaps, by 'a heart', whether it's the heart of a person, several people or some kind of community, perhaps a church.

Many organizations in East Africa doing development work are, to a greater or lesser extent, church-based. Now, we all know from experience that being church-based does not guarantee that the work is always well intentioned. Unless the people driving the organization have good intentions, the work will be of little benefit to people who are in need of, say, education, poverty reduction, healthcare, and the like. As I've said, some 'development' work is harmful, and the ideal of 'making things better', however naive-sounding, was never part of the plan.

Perhaps I'm rambling a bit; that is partly my want, but partly my intention, for the moment. But you do come across organizations who say all the right things, tick all the right boxes and go through all the motions, and all that just to survive as an organization. There is nothing else they can do but survive. They look for calls for proposals, find ones they think they can do or ones they can persuade the donor they can do, and apply. If they get money, they do the job, somehow or other, if not they collapse.

So take an organization I shall call whateverisexcellent.or.tz; they are a church-based organization, they do all of the above and everyone says that they are very good proponents of their church's teachings. They 'help' poor people, sick people, vulnerable and abandoned people, people with disabilities, people who are in some way stigmatized, they care for them and look after them, up to a certain point; they are unlikely to do so for the duration of those people's lives, unless those lives are short (and many are); projects are usually a few years and no more.

But that's something, because they are doing what they say they are doing, donors love them, they give them money and every few years, when a project ends, they can apply for more money and say 'look at these children and old people and orphans and vulnerable children and disabled people and stigmatized people, this is what we have been doing, if you give us more money we will keep doing it and even find some more beneficiaries'.

But when it comes down to it, the organization is just part of a bigger community, which is part of an even bigger congregation, which is part of a whole lot of congregations and overlapping groups. And it happens that whateverisexcellent.or.tz has a neighbour, which whateverisexcellent.or.tz's church was able to help out with some land, so that this neighbour could build another NGO, specializing in some of the above needy groups; let's call the neighbour ladlesoflove.or.tz.

Ladlesoflove.or.tz, as an organization, do very well. So well that the church sees the beautiful buildings and, maybe, they  'covet' them. Whateverisexcellent.or.tz may well tick all the right boxes when it comes to applying for grants and, eventually, reassuring donors that they have spent the money well (and asking for more, of course), but they covet the assets of ladlesoflove.or.tz so much that they ignore the vulnerable, poor, disabled, abandoned, stigmatized beneficiaries of ladlesoflove.or.tz; they threaten to evict their neighbours, to whom they were once so sympathetic.

For me, the question is, if whateverisexcellent.or.tz is so concerned about all needy people, some of whom ladlesoflove.or.tz is benefitting, how could they do something that would compromise every single beneficiary? And just for the sake of some assets (plus a fair amount of spite, jealousy, bloody-mindedness, prejudice or anything else that drives such maneuvers)? Shouldn't their donors say 'hey, why do you take our money but continue to impoverish the poor, stigmatize the stigmatized, abandoned again those who have been abandoned?'

If donors don't do that, they are simply accepting that development is just an exercise in identifying some projects that can tick the right boxes, and getting on with the job. So is that all development is? As a person still trying to figure out what development is, I certainly don't accept that it is, effectively, an administrative and PR effort entirely motivated by political and/or commercial interests, with no intentions worthy of a human being as a human being. If development is just another business, and just as unscrupulous as it needs to be, I think many people working in the field will be looking for another way of fulfilling their original intentions.

I'll return to this theme soon and I hope to be clearer about whateverisexcellent.or.tz; are their intentions honorable, or is all the 'we're a church-based organization and we follow the teachings of the bible' just posturing, just a way of keeping the donor funds flowing. Because I've heard many claims about 'following the teachings of the bible' and (sharp intake of breath), some of them sounded quite hollow. But that's just my view.