Wednesday, March 14, 2012

HIV and Circumcision: the Emperor's New Condom

It may seem like the issue of male circumcision crops up a lot on this blog. But if there was ever an intervention ostensibly intended to reduce HIV transmission whose time had not come, circumcision is it. It may, under certain circumstances which have yet to be identified, reduce HIV transmission from females to males. But it is very likely to increase transmission from males to females. Females in African countries where mass male circumcision campaigns are being carried out are far more likely to be infected with HIV than men. Therefore, females face the greatest risks if these ill-advised campaigns go wrong.

One prominent study intended to show that circumcision was effective in reducing transmission unfortunately suggested that the operation actually increased transmission from males to females. The trial was stopped early; this was clearly the wrong result. But even some studies that are openly in favor of the intervention also raise serious questions. A mathematical model of transmission where mass circumcision has been achieved looks at some potential effects, including behavioral disinhibition, where behavior can become less safe, or revert to being less safe, because people think circumcision protects them from infecting others, or from being infected themselves.

The long term population effects for males and females investigated by this model are found not to be strongly linked and "there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females." Despite such potential drawbacks, the authors seem happy for these campaigns to continue, with some minor adjustments. Let's hope that those baying for mass male circumcision can find funding for the modifications the authors recommend in the estimated $1.5 billion figure being bandied about for a campaign that promises (threatens?) to circumcise 20-30 million African men.

 Before it was acknowledged that male to female transmission might increase, it was assumed that females would be indirectly protected because there would be fewer HIV positive males in the population. But, in addition to facing increased direct risks from circumcised males, the indirect benefits hoped for may also be eroded by changes in sexual behavior, presumably influenced to some extent by people's beliefs. Some circumcised men already think they are protected from HIV; some women think circumcised men are protected; some men are only willing to be circumcised because they think it confers very high levels of protection; and women seem to have been railroaded into persuading partners to be circumcised under the misapprehension that it will mean the men will be protected.

The highly dubious but often repeated arguments in favor of circumcision were originally concocted for scenarios where it was adult males being circumcised, and those opting for the operation were HIV negative. But it's a game of moving goalposts and now, HIV positive men are also offered free circumcision in case denying them the operation might lead to 'stigma'. The arguments are also now being used for those who are too young to give consent for the operation and even for newborns, for whom even the dubious benefits are known not to be relevant. But at least the authors of the above paper admit that their simulation shows a relatively small overall effect of circumcision rollout.

An article entitled 'Male Circumcision and HIV Prevention - Insufficient Evidence and Neglected External Validity', asks if research carried out so far really does support the rapid scale up of mass male circumcision programs. The three trials used to argue for circumcision suffer from a number of biases and one of the issues circumcision enthusiasts don't seem keen to discuss is the fact that many of the participants who seroconverted don't appear to have been infected as a result of their sexual behavior. Male circumcision will not protect against non-sexually transmitted HIV, such as through unsafe healthcare (or during the circumcision operation), tattooing, dentistry, body piercing, etc.

Those arguing for questionable HIV reduction and reproductive health strategies often claim that circumcision, pre-exposure prophylaxis (PrEP), injectable Depo Provera, microbicides and others benefit women, or even that they are 'women controlled'. But in reality, control is being wrested from people, male and female. Circumcision seems to increase the risks that women face in several ways. The extraordinary folklore that has grown up around the strategy shows that African men and women have been taken in; how will ordinary people ever be in a position to question something that seems to have so much academic, institutional and financial clout behind it? It's a bit like the mythical 'cloak of invisibility', which leads wearers to do things they wouldn't otherwise have done, not realizing that they are fully visible.

Maybe all or most African men will rally to the HIV industry's call, lining up to be circumcised and then returing home to use condoms for as long as they are sexually active. Maybe women will be galvanized into compelling men to use condoms, something they haven't been able to do so far. But the authors questioning circumcision as a HIV reduction strategy conclude that: "The policy questions to be considered are not whether a link exists between male circumcision and reduced rates of HIV infection, but, rather, whether mass circumcision is (1) an ethical and safe public health choice, and (2) the most cost-effective use of limited resources." At best, the answer to these questions is 'not yet', at worst, a resounding 'no'.

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]



Devon Osel said...

Common rhetoric surrounding the drive to modify male genitals included terms like "gender equality" and "protecting" women and girls.

As those anticipated and hoped-for benefits fail to materialize it becomes even clearer that priority number one-- is circumcision itself.

Simon said...

It's bizarre such excuses are used. Those who support circumcision sometimes talk about hygiene, as if uncircumcised men are unable to wash their penises. But then, those defending female genital mutilation also talk about hygiene, as if unmutilated women are unable to maintain the same levels of cleanliness. 'Protection' is reminiscent of the colonials and their 'protectorates'.

Petit Poulet said...

Recently released data from the Kenyan RCT (completed in 2006) found that the men who were circumcised in the trial were significantly less likely to report using condoms all the time than the men who were not circumcised at the beginning of the trial. As much as Bailey's group wants to obfuscate this finding, it suggests that condom use is decreased after circumcision. It is easily demonstrated that a small change in condom use can undo the impact of large increases in circumcision prevalence.

What I think is telling is that propaganda is more about everything other than what these studies think they demonstrated.

Simon said...

Similar remarks apply to the Depo Provera and injectable contraceptive issue: people using these are less likely to use condoms, yet they are even more in need of them than those who use safer birth control methods, or who just use condoms!