Saturday, April 18, 2009

Mixed Views About Male Circumcision for HIV Prevention

Has anyone come across evidence that access to adequate food supplies reduces acute malnutrition? How about access to good health services reducing illness or good education reducing illiteracy? Should we believe that good water and sanitation reduces water borne diseases or that a clean environment can help to reduce acute respiratory infections?

The answers to the above questions are all 'yes'; there is overwhelming evidence for an affirmative answer to each one. But does Kenya or any other developing country have any of these benefits? Well, no, that is why they are called developing countries. Underdevelopment and retrogressive development are not new and these issues have been discussed in one form or other for many decades.

But just recognising their desirability doesn't give rise to development. The knowledge that these are all good things, necessary for development and for the insurance of human rights, has not given rise to their promotion. So when I see an article entitled '[Male c]ircumcision does reduce the risk of HIV, say researchers' I am pleased to hear it. But which developing country has the facilities, resources and personnel to carry out millions of circumcisions safely and to continue to circumcise all newborn males (either shortly after birth or later, when informed consent is possible)?

Kenya does not have presently have the health capacity required. Evidence has shown that the level of adverse effects relating to circumcision is nearly 20% when the operation is carried out in a clinical setting and around 35% in traditional settings. Those who presently don't go for circumcision, usually for reasons associated with the traditions of their tribe, may be more likely to choose a clinical setting. But with statistics like that they could be forgiven for opting to remain uncircumcised.

Kenya does not have the capacity required to control most of the infectious diseases that are endemic in the country, diseases that kill more people and diseases that have been around for far longer than HIV. If Kenya had good health, education and other social services, the HIV epidemic would never have got so out of control and some of the expensive prevention measures that are being carried out might have achieved some success by now.

In fact, the problem here is not the Cochrane Collaboration publication, entitled Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men, it's the newspaper article that reports on the original publication. The newspaper article only adds in the final sentence that policy makers need to consider the culture and environment in which MMC is carried out. This is crucial and the Cochrane abstract makes this clear, asking if "[a]t a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."

One might conclude from the newspaper article that because male circumcision can reduce the risk of HIV, that mass male circumcision (MMC) is a good thing, especially in countries that have high HIV prevalence. Circumcision may also protect against herpes simplex virus (HSV), which increases susceptibility to HIV, human papilloma virus (HPV) and various other sexually transmitted infections (STI). But the Cochrane review notes that incidence of adverse events was low in the trials they examined. One would expect the incidence of adverse events to be low, these were randomised controlled trials! The review concludes that circumcision "under these conditions" is a safe procedure.

The Cochrane review may have found the evidence conclusive and that could eventually be very significant. But the studies they refer to still raise many unanswered questions. I will not rehearse the various problems with the circumcision trials in question. A quick search of other sites and blogs will give you as much information as you could possibly want. (I haven't had access to the full Cochrane paper, although I am familiar with some of the literature and trials involved.)

Mass Male Circumcision (MMC) will not be carried out in ideal conditions in Kenya, not given the present state of Kenyan health services. If there were ideal conditions in Kenya it is unlikely that the country would have need to implement such a huge and costly project as MMC.

But a second objection to MMC is the problem of 'disinhibition'. Some circumcised people think they are, more or less, immune to HIV. People have told me that they don't need to use condoms because they are circumcised or even that condoms don't work because they are circumcised. There is a worry that MMC could result in a large number of people believing that they don't need condoms or that they don't need to be careful because they are circumcised. This will not be an easy problem to deal with.

There’s often a ‘eureka!’ quality to articles about MMC as a means of reducing transmission of HIV. Why not the same cry with regard to development issues where the solutions are more obvious, such food and food security for the starving, healthcare for the sick and healthy, alike, education for all, safe water and sanitation and a healthy environment? The Cochrane report also concludes with a need for further research. Let's hope policy makers are not as selective as journalists in what they glean from scientific papers.



Tamaku said...

Cultural and tribal prejudices make MMC in Kenya unlikely to succeed on it's own. You make a brilliant argument for the strengthening of our health systems (nuts and bolts!- the science) to compliment these initiatives. Great stuff.

Caroline said...

Thank you! I have said (and heard) for years that the vast majority of deaths and disease in many African countries is due to lack of clean water, lack of food, lack of resources, and many other lacks! I'm pissed that our government has time and money to squander away on dumbass "studies" to justify genital mutilation, meanwhile the people in these countries (whom we COULD help) are just left to hang.

Thank you for going to Kenya, living with the people there, and sharing with us your FIRST HAND knowledge of what's going on there and how we can TRULY help. We need more people like you!

Simon said...

Hi Tamaku, thanks for your comment. Yes, I think any single issue programme on its own will run up against difficulties and any that depend on health services will run up against the problem that national and international policies over the last three decades have decimated the health sector.

Simon said...

Thank you Caroline! In fact, there are a lot of people doing good work here but well used sources of information such as mainstream media are more interested in other things. For them, HIV is (or should I say 'was'?) sexy, poverty, disease and other issues are only sexy every now and then, like when there is a tsunami, a famine or a war. And then, the issue is aired for a while before being replaced by some other story, as if the original problems just went away.

Maybe any issue could be made fashionable for a while, like when pampered celebrities get involved for some reason. But the nature of fashion is that next year it will not be fashion. In the words of Dickens, the poor will always be with us. So circumcision will be less fashionable soon and something else will take its place. But HIV, and the development problems that allow it to spread, will not go away so easily.

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