Circumcision Enthusiasts: Screw the Evidence, We're Going Ahead

HIV prevalence has been high in Kisumu since early on in Kenya's epidemic. Rates went higher there than anywhere else in the country and they are still about twice as high as the next highest area, and three times as high as the national figure. This meant that a lot of HIV research work has been done in Kisumu. But no explanation has ever been given of why rates should be so disproportionately high there.

Naturally, fingers were pointed at the fact that people in Kisumu must have a lot of unsafe sex. But what is it about Kisumu (or Luo) sex that makes it so different from sex in other parts of the country? Some people have more than one partner, a few have lots. Most don't use condoms very much and many have their first sexual experience when they are still teenagers.

But those things could all be said about most of the other tribes and cities and provinces of Kenya, and about some people in every country. Birth rates, a sure sign of unprotected sex, are highest in Northern, ethnic Somali inhabited areas. There isn't really anything extraordinary about Kisumu or Luo sex that anyone has been able to discover.

Also early on in the epidemic, it was pointed out that Luo men are not usually circumcised. It was suggested that this might make them more susceptible to HIV. Research has shown that HIV transmission can appear to be connected to circumcision status. However, though in some places circumcised men are less likely to be infected, in others uncircumcised men are less likely to be infected.

But this finding didn't make the people for whom mass male circumcision is their personal cursade very happy. The more research they did, the more ambiguous the effect of mass male circumcision appeared to be. But they are still at it. In fact, research suggests yet another thing that was recognised early on in the HIV pandemic: that HIV is probably not always transmitted sexually.

So part of the personal crusade involves explaining away data which suggests that not all HIV is sexually transmitted. A paper published in 2007 asking uncircumcised, sexually active young men about their sexual behavior found that 5% were HIV positive, which is higher than you would expect among people who have not been sexually active for very long, especially among males.

The risk factors are particularly interesting, not just because risky sex is likely to be driving a good deal of HIV transmission, but because some non-sexual risk factors are also likely to be involved. Both medical injections and traditional practices (saro, bloodletting) were implicated. Those who received injections in the last 6 months were three times more likely to be infected that those who had not and those who ever practiced bloodletting were twice as likely to be infected.

Another surprise was that men who reported washing their genitals immediately after sex were also less likely to be HIV positive. This gives some confirmation to the view that circumcision may not be necessary if men take measures to ensure penile hygiene. Little research has been done into this phenomenon but it is not clear why the authors of this research paper are still advocates of circumcision without knowing how and why HIV transmission appears to be correlated with circumcision status, sometimes positively correlated, sometimes negatively.

Catholics were more than twice as likely to be HIV positive as members of other religions and this was not related to condom use. In fact, condom use is not even a reliable indicator of risk.

The authors try to explain away the data about receiving injections by arguing "because this is a cross-sectional analysis, it is also possible that HIV positive men were more likely to report recent injections to treat HIV/AIDS related illnesses". But these are young men. Even the HIV positive among them are unlikely to be receiving injections related to their HIV status.

While 72% of eligible HIV negative people took part in the survey, only 22% of HIV positive people did so. This could skew the results considerably, though it's not possible to know in which direction they would be skewed. But despite this, and despite the indications that HIV is not always transmitted sexually (or 90%, as is usually claimed), the authors are still devoted advocates of mass male circumcision.

If Tanzania Had More Health Personnel, Would HIV Be More or Less Common?

Apparently "One-third of U.S. hospital admissions can expect a medical error, an infection or other adverse outcome". But sometimes up to 90% of these outcomes can remain undetected. This is in the country with the highest health spending per head in the world. What percentage of patients in Tanzania, say, could expect a medical error?

For a start, who is counting? There is generally no way of keeping track of such errors, even serious ones. There are too few health personnel, too few of them are trained and most hospitals don't have the capacity to keep such records or prevent such incidents.

On the plus side, if you could express it that way, most Tanzanians will never see a doctor and won't spend too much time, if any, in a health facility. The percentage of patients suffering adverse outcomes may be higher than in the US but the number of people involved is a hell of a lot lower.

An article about the pastor in Loliondo, Arusha Region, who claims to have a concoction that cures just about anything, points out that the people flocking to drink the potion are not just following the herd; they are desperate.

This is a significant observation. For people in rural parts of Tanzania, and that's over 80% of the population, all health services are elusive, requiring a lot of patience, faith and perserverence, perhaps even some money.

This magic potion is even said to cure HIV/AIDS. It costs less than a dollar, 500 Tanzanian shillings. Of course, people have to pay the costs of waiting for days, not working, paying for accommodation, food, transport, bribes and anything else that someone can screw money out of them for.

But this may not be so different from some antiretroviral (ARV) programs, where the drugs, if you can get hold of them, are free. And ARVs don't guarantee survival either. Under the right conditions ARVs are very powerful, but many Tanzanians don't live in such fortunate circumstances.

This article cites estimates that Tanzania needs 126,000 health workers but only has 35,202, a 76% deficit. The ratio of doctor to patient in some places is as bad as 1 to 62,000 but in Kigoma, that ratio is one to 308,000. Coincidentally (perhaps), Kigoma is also the region with the lowest HIV prevalence in the country.

Per capita health expenditure is $22 in Tanzania, 2.7% of the global average. Much of that, an estimated 75%, comes out of the pockets of people where the majority wouldn't earn much more than a couple of dollars a day. Most illnesses, clearly, go untreated.

When I think of health conditions in East African countries and then look at HIV prevalence, I wonder why HIV prevalence is not a lot higher. And I wonder why HIV prevalence is so much higher in other African countries where far more people have access to health care.

But looking at the figures for adverse outcomes in the US, I'm not so surprised. Good health facilities are dangerous enough, I hate to think of the uncounted hazards people face in bad health facilities. In countries with high HIV prevalence, health facilities could be among the worst places to go.

'Counterfeiting' is a Problem That Can Only Be Solved By Big Pharma

If a business produces something and sells it for a price that covers costs and also gives a decent profit, that's a good model. Others may make the same thing, so a business needs to make the best and work hard to make sure they are not undercut. But most people will pay for something good rather than something that isn't up to scratch, if they can afford it.

However, if a business produces something and sells it for a price that is a complete distortion of the above business model, it is worthwhile for someone else to produce the same thing and charge a lot less. They don't even have to cut costs, they can just accept a lower profit. And those who have no chance of affording the expensive product may well be able to afford the cheaper one.

This is an oversimplification, but it is roughly what the pharmaceutical industry does, charges an outrageous price for something because they can. In addition, the industry depends on a form of protectionism called 'intellectual property rights'. Arguably, this has its uses, even that it is vital, but it is still a form of protectionism.

Often, the research that pharmaceutical companies claim to spend so much on is done by publicly funded, or partially publically funded, institutions. But there is little or no return to the public. And the amount spent on PR and marketing far exceeds what is actually spent on research.

So when someone else makes the same product but demands less for it, the industry reacts by resorting to all sorts of tricks to make sure the competition is destroyed. Competition, when you don't have a high level of trade protection, is not appreciated by the pharmaceutical industry.

The word 'counterfeit', therefore, can mean all sorts of things. It can mean a generic version of a branded drug, a fake version of a branded drug, a substandard version of a branded drug and probably other things. But a generic version of a branded drug is not a counterfeit and claiming that it is one threatens to deny  lifesaving treatments to many people in developing countries.

If drug companies don't want generic versions of their drugs to be produced, they should produce affordable versions themselves. There is clearly a huge market for them and a very good profit to be made. Dropping the price to affordable levels would also make the production of substandard and fake drugs a lot less tempting, perhaps not even worth the effort.

But instead of encouraging the production of generic drugs, the EU and, of course, the entire pharmaceutical industry, want to make sure affordable versions of drugs are not produced. They are currently trying to rope India into signing a 'trade agreement' whereby it will no longer be possible for the country to produce cheap drugs. Yet another form of protectionism.

India is one of the main sources of affordable drugs for developing countries. Some drugs will cost many times, perhaps even tens or hundreds of times more, just because they are protected by the sort of regulation that big industry claims to detest.

There is no doubt that some drugs are fake, made of materials that have no effect or are harmless, and this is unacceptable. But as long as ridiculous profits are made from drug pricing models, people will always find ways of selling their versions, no matter how useless or dangerous. It's not as if copyrighted drugs are always effective, or that they are never dangerous, either.

The pharmaceutical industry, already protected and subsidised in so many ways, wants more public money to be used to 'regulate' drug supplies in developing countries. Multinationals refuse regulation for themselves, but they seem to love the idea of regulating any competition.

Big Pharma have effectively created counterfeiting and many other related problems themselves, it's how they keep their profits so inordnately high. So they should sort it out themselves. If people object to the danger to the health and lives of so many people, they should aim their objections at the industry, the problem, not the mere symptoms of the problem.

The Science and Development Network have a selection of articles on the subject of 'counterfeit' drugs and some of the many issues involved. But the article doesn't really point out that Big Pharma don't lose out from counterfeiting because most of those who buy cheap drugs will never be able to afford the expensive versions.

Can We Guarantee that Public Health is Truly in People's Interest?

There's been an outbreak of measles in Somalia and apparently it may be connected with rumours that the vaccine could cause HIV in children and interfere with their reproductive abilities.

What is your reaction to such a statement? Would you dismiss it as nonsense and say that public health programs aim to prevent and treat diseases, not spread them? Would you say that no one would try to influence the fertility of a whole population, for any reason, and even put their lives at danger while claiming that it is in the interest of public health?

That would be a naive reaction. Some of the wealthiest institutions in the world care a great deal about the fertility of whole populations, especially when those populations are poor. Let me name some: the US Government, the Bill and Melinda Gates Foundation, FHI, PSI, the World Bank, and there are many others.

We don't know what lengths these parties would go to for the sake of their agenda. The Tuskegee Syphilis 'experiment' may seem like something that happened a long time ago, but Ugandans taking part in more recent HIV research were followed to see how long it took for some of them to become infected and how long it took for some of them to infect others. Many of them are now dead, others are still suffering from the disease and transmitting it to others.

What does the WHO or UNAIDS care about who gets HIV, how many people they may go on to infect or how many people die, and whether painfully or not? UNAIDS still insists that HIV is almost always transmitted through heterosexual sex but an estimated 30% of HIV positive infants in Mozambique (who can be matched with tested mothers) have mothers who are HIV negative.

UNAIDS's response in such situations is to suggest that the infants were raped. It's pretty obvious what their attitude towards Africans is, when they know that infant rape is no more likely in African countries and that incidence of rape, even infant rape, could never be high enough to explain such massive rates of infant HIV.

Quarraisha Abdool Karim, one of the people behind the CAPRISA vaginal microbicide gel fiasco, is planning another way of influencing reproductive choices, in the interest of public health, of course. This time, the idea is to hand out sums of money 'to reduce HIV infection in High School Learners'.

This is interesting for public health experts working with TB. This disease if often caused by occupational hazards, such as mining. It might be too extreme to pay people not to breathe when they are working. But you could compensate them for not working on some of the more dangerous tasks. That would at least drive up the value of labour.

Karim's plan, by the way, is not without it's exclusion criteria. Those who are 'cognitively challenged' will be excluded. I wonder if those who could be considered morally challenged would also be excluded, but there's no mention in the brief details on WHO's site.

Several countries have reported involuntary sterilization carried out on people who were said to be HIV positive. But a program in the US, 'Project Prevention', plans to offer people money to be sterilized if they are drug 'addicts' or 'alcoholics'. If 'addict' or 'alcoholic' just refers to users of these drugs, this would be bad enough, though I wonder who is judging. But what if those judging are evangelical Christians?

And the project is hoping to move to South Africa where it will aim at HIV positive women. Why it won't aim at men, I don't know. There are far more male than female drug and alcohol users. But women are always an easier target. Project Prevention's final solution can eventually move on to men.

One of the people behind this 'initiative', Barbara Harris, says "How can anyone object to anything that can prevent innocent children suffering needlessly?" She could try asking UNAIDS personnel in Mozambique the same question. Apparently Project Prevention are already operating in Kenya, where people are offered $40 (about a month's wages, a fraction of what those in the US receive) to take long term contraception.

Doctors needn't worry, they are given $7 to perform the insertion. Let's hope they wear a new pair of gloves with each patient and avoid reusing single-use instruments. They haven't had a great record of taking such precautions in the past. Even simple procedures like this carry serious risks in countries with a miniscule capacity for health provision, one of those risks being HIV.

This charade reminds me a bit of the mass circumcision campaigns currently raging in Kenya. In a country where only a few dollars are spent per head on health, some institutions are willing to pay many times that to slightly reduce (if at all) the probability of infection with one disease out of hundreds.

Measles is a terrible disease and it is especially worrying that the outbreak in Somalia (and other countries) could have been avoided if it were not for some rumour, probably completely unfounded. But public health authorities do not have much credibility when it comes to being able to assure people that there is no hidden agenda. There usually is a hidden agenda and it looks as if global public health is busy sawing off the branch they are sitting on.

The article concludes: "it is sad that in this day and age our children must die because of ignorance and lies". But the rumours in Somalia are based on lack of information. Far worse are the lies and half truths based on thorough knowledge coupled with an unspoken (and unspeakable) agenda. Lies do not exclusively arise from ignorance; the most harmful lies are those from people who know the truth.

Promoting Female Condoms in Salons is Great But Don't Forget Non-Sexual Transmission!

Some people like to depict vaginal microbicides as being in the control of women, unlike male condoms and other methods of reducing HIV transmission. Pre-exposure prophylaxis (PrEP, the use of antiretroviral drugs by HIV negative people to reduce probability of infection) can also be depicted this way.

However, it is interesting to hear what many people say about contraceptive pills. Most women in East Africa opt for injectible versions of hormonal contraceptives because they say their husband or partner will not allow them to take the pills if they know they are contraceptives.

But if concerned people are interested in female controlled HIV prophylaxis and contraceptives, perhaps they should take a look at female condoms, a simple enough technology that has been available for over 20 years. They are not 100% female controlled, but they are another arrow in the quiver.

Whatever the HIV industry's feelings about female condoms, they are rarely discussed. And while male condoms are often discussed, the issue of women not necessarily having much control over the use of male condoms constantly arises.

Perhaps it's time to take another look at female condoms. There is convincing evidence that they would make an excellent complement to current HIV prevention programs. Maybe those expressing an aversion just don't know enough about them. I have asked a number of people and the ones who express an aversion, all of them, have never used female condoms. (Similarly, those who said male condoms sometimes burst have either said it never happened to them or it happened once or twice).

Apparently there is a program in Zimbabwe which aims to promote the female condom through hairdressing salons. This is a great venue for promoting knowledge of HIV transmission because so many women go to them and because hairdressers themselves need to know a lot more about HIV transmission than they currently do.

For example, most people who have been lectured, sorry, advised about HIV transmission have been told about sexual transmission, mother to child transmission and possibly something about intravenous drug use. Less likely, they'll have heard about transmission through blood transfusions.

It is unlikely they will have heard much about other forms of medical transmission, such as through the reuse of poorly sterilized equipment, such as injecting equipment, IV lines, dental equipment, etc, although such knowledge could reduce this kind of infection.

It is also unlikely they will have heard about the possibility of HIV transmission through unsafe cosmetic practices, such as tattoos, ear piercing, shaving (where cuts and abraisions can occur), hair straightening (where the relaxants can cause burning) and other practices.

Apparently PSI (Population Services International) is running the program, which makes it unlikely they will mention much beyond sexual transmission of HIV, but there is hope. And it's good to hear that they are promoting female condoms, it's time someone did.

If Mass Male Circumcision Fails, Will We Be Told?

In order to implement HIV prevention, treatment and care programs, countries need adequate health facilities, with sufficient numbers of trained staff and supplies of equipment and drugs. Most high prevalence HIV countries don't have these.

A quick look a health statistics for most African countries show that they can't even cope with the most basic health issues, such as clean water and sanitation supply, nutrition or prevention and treatment of common diseases, such as water borne conditions and acute respiratory problems.

It is said that Africa has 24% of the global disease burden but only 3% of the world's health workers. It's common for countries and regions to have only one doctor for every 50 or 100,000 people. There are too few health facilities, they are all short of supplies and service provision can not meet demand, or services are of very low quality, or both.

None of this is particularly new. A glance at health service provision assessments from Measure DHS shows that the countries who have the worst problems often have the worst health services.

So it's not surprising that Kenya's ambitions to circumcise 1.1 million men in the space of a few years is proving quite challenging. An assessment of the first year or two of this program, which claims to have already circumcised 230,000 men, should worry those who have gone through the operation, as well as those who are planning to do so.

There is no mention of the numbers of men who have been infected with HIV or any other sexually transmitted disease since undergoing the operation. This is worrying because the whole aim of the exercise is to reduce HIV transmission. Those who have opted to be circumcised will need to be followed up for some time, but HIV transmission rates in the intervention are are massive.

If the program is going well, releasing the figures could help with enrollment. But if it is not going as well as expected, perhaps some problems should be aired and ironed out now to limit the amount of damage that could be done.

The assessment of health facilities involved in the parts of Nyanza selected for the intervention is not wholly encouraging. One of the 'minimum criteria' for service provision was "Sterilization and infection control compliance." Only two thirds of the facilities have autoclave equipment. No mention is made of whether the equipment is used, or used properly. And going by other similar assessments, most facilities don't have written procedures for sterilization and infection control.

Out of the 81 facilities assessed, none of them possessed all seven of the criteria necessary to provide safe services. Most didn't have enough doctors or clinical officers to perform circumcisions, although they were the only staff authorized to do so prior to the mass circumcision program.

85% of hospitals had enough nurses, so they were trained to perform the operation. How these facilities managed to cope with routine, non-HIV emergencies is not made clear. Indeed, it is to be wondered if all this information about health facilities will have any impact on the health development agenda, or if non-HIV health issues will continue to be ignored.

So far, much of the resources and personnel required have been supplied by donors. Whether the program can be continued using existing capacity, whether the program is sustainable, is debatable. And whether it can be continued safely is something I wouldn't like to bet on. I'm sure those who are being offered the services would have the same worry, if they had access to unbiased information.

The efforts to make mass male circumcision rollout seem successful suggest that a lot more could be done to develop health services in resource poor countries. But the lack of effort to deal with non-HIV health development issues suggests that little will be done. Ultimately, the program could result in similar or even higher rates of HIV transmission. It just remains to be seen how long it will take before useful data becomes publicly available.

If Maternal and Child Health is Bad, Family Planning = Large Families

Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.

If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.

If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.

If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?

If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.

Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.

There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.

Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.

There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?

But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.

And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.

Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.

Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.

Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.