New book throws doubt on circumcision as a useful strategy against AIDS in Africa
David Gisselquist and several colleagues have long been critical of the proposition that nearly all HIV cases in Africa and other underdeveloped countries are spread by sexual contact. On the contrary, they have argued that at least a third of new HIV infections are the result of unsafe medical procedures, such as unsterilised needles or scalpels, and contaminated blood supplies.
These arguments have not been accepted by the AIDS industry - at least not in relation to men. Western agencies seem to have had no trouble acknowledging that non-sterile procedures such as genital cutting spread AIDS and other infections when performed on women. It is not clear why female circumcision should thus be acknowledged as a potential source of transmission and male circumcision ignored - until you appreciate that the agencies want to stop circumcision of women but promote circumcision of men and boys. This is the well-known double standard by which circumcision of women is known as female genital mutilation while male genital mutilation continues to be downplayed as circumcision.
In his intriguing new book, David Gisselquist exposes the unsafe health care system as a significant factor in HIV transmission in Africa and other regions with generalized HIV epidemics. While he spends little time discussing the issue of circumcision directly, his book is another nail in the coffin for the theory that promoting circumcision will significantly reduce HIV infections. According to Gisselquist's evidence, the introduction of more health care services, in the form of mass circumcisions, is more likely to place Africans at greater risk of HIV. Health care practices are simply too unsafe to cope with the existing surgical burden, let alone a massive increase.
Gisselquist makes a strong case that exposure to infected blood through health care services (particularly contaminated equipment and unsanitary practices) is responsible for about a third of HIV transmission in Africa, and criticizes the way in which the forces in charge of public policy are ignoring this evidence and sweeping this problem under the rug. While WHO and UNAIDS publicly claim that exposure to contaminated blood in health care settings account for a tiny percentage of HIV transmissions, Gisselquist presents convincing evidence to the contrary. After Points to Consider, nobody could doubt that unsafe health care is a major factor in HIV transmissions in Africa and other underdeveloped countries. He may be exaggerating to argue that more surgical services, such as circumcision, will place Africans at greater risk of HIV, but Gisselquist certainly makes a strong case that the current obsession with circumcision as the key strategy against AIDS is hopelessly misguided.
David Gisselquist. Points to Consider: Responses to HIV/ AIDS in Africa, Asia, and the Caribbean. London: Adonis and Abbey, 2008. $25. Available from Amazon.
South African Medical Journal attacks WHO-UNAIDS circumcision push
Clutching at straws to control the African HIV/AIDS epidemic has included strident advocacy for circumcision of males (MC) from some (mainly American) quarters, especially following three trials held in South Africa, Kenya and Uganda in 2006-2007. These seemed to show that circumcision did have a limited protective effect, and they were quickly hailed by the circumcision lobby as justifying an immediate "roll-out" of a massive circumcision campaign. Three contributions in the October 2008 edition of the South African Medical Journal, including an editorial, vigorously contest the usefulness, cost and ethics of circumcision in the prevention of HIV and condemn the indecent haste with which the WHO, under pressure from American money, has sought to enforce mass circumcision on African men.
The three articles are available here.
Intercision-circumcision:
Golden Compass movie raises spectre of genital mutilation
If you type intercision AND circumcision into Google you will find lots of links to Internet discussions of Philip Pullman's fantasy trilogy His Dark Materials, the first volume of which (Northern Lights) has been adapted into a brilliant movie called The Golden Compass. Quite a few readers and movie-goers have picked up on the possibility of a parallel between the variety of child cutting that goes on at Bolvangar (intercision - separating a child from his or her daemon) and the variety that is common in the United States, the Middle East and Africa (circumcision - separating a child from part of his or her genitals). The similarity is in fact drawn explicitly by the witch queen Ruta Skada in The Subtle Knife: explaining why they should join the forces opposing the Magisterium, she says that the forms of child cutting common in the south lands (cutting children's sexual organs) is different from what is done at Bolvangar, but that they are "just as horrible".
Read more about the parallels between intercision and circumcision in His Dark Materials.
*****
Several recent articles by prominent scholars have added to the growing chorus of doubt as to the effectiveness, cost, ethics and general propriety of male circumcision as a solution to Africa’s AIDS problem.
Writing in the American Journal of Preventive Medicine, Dr Laurence Greene and colleagues argue that the three clinical trials that provide on which the circumcision programs are based do not provide sufficient evidence for the effectiveness of circumcision as an HIV preventive. Even more seriously, there is no evidence that a protective effect observed in the artificial or “laboratory” conditions of supervised trial will be replicated in the real world – neither in Africa and certainly not in the developed world.
In the Journal of Medical Ethics, Marie Fox and Michael Thomson argue that on the evidence so far it is premature to promote circumcision as a reliable strategy for combating HIV. They point out that both the sponsors and the media, both popular and scientific, have exaggerated the protective effect of circumcision suggested by the clinical trials, and that questions of medical ethics, human rights and personal choice have been swept aside in the rush to roll out circumcision programs.
Meanwhile, several new papers by British and American researchers have confirmed the conclusions of many other studies that circumcision would have little or no protective effect on sexual transmission of HIV among men who have sex with men. It has further been well established that male circumcision does not protect women against HIV transmission.
Circumcision not so effective in the real world
Writing in the American Journal of Preventive Medicine, Dr Laurence Greene and colleagues argue that the three clinical trials that provide on which the circumcision programs are based do not provide sufficient evidence for the effectiveness of circumcision as an HIV preventive. Even more seriously, there is no evidence that a protective effect that is observed in the artificial or “laboratory” conditions of supervised trial will be replicated in the real world. Thee study concludes:
Recommending mass circumcision by generalizing from the particular RCCTs to the diverse populations of Africa highlights problems of external validity identified in several areas of preventive medicine and public health research. Studies published since the RCCTs show that (1) male circumcision is not correlated with lower HIV prevalence in some sub-Saharan populations; (2) circumcision is correlated with increased transmission of HIV to women; and (3) male circumcision is not a cost effective cost effective strategy. This new evidence warrants caution and further study before recommending circumcision campaigns. In addition, ethical considerations, informed consent issues, and possible increase in unsafe sexual practices from a sense of immunity without condoms must be weighed.
The global health community understands that the most important modifıable factor in sexually transmissible HIV is human behavior. 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.
Lawrence W. Green, John W. Travis, Ryan G. McAllister, Kent W. Peterson, Astrik N. Vardanyan, Amber Craig. Male Circumcision and HIV Prevention: Insufficient Evidence and Neglected External Validity. American Journal of Preventive Medicine, Vol. 39 (5), November 2010, 479-482
Ethical and human rights issues ignored
In the Journal of Medical Ethics, Marie Fox and Michael Thomson argue that on the evidence so far it is premature to promote circumcision as a reliable strategy for combating HIV. They point out that both the sponsors and the media, both popular and scientific, have exaggerated the protective effect of circumcision suggested by the clinical trials, and that questions of medical ethics, human rights and personal choice have been swept aside in the rush to roll out circumcision programs.
Abstract
In April 2009 a Cochrane review was published assessing the effectiveness of male circumcision in preventing acquisition of HIV. It concluded that there was strong evidence that male circumcision, performed in a medical setting, reduces the acquisition of HIV by men engaging in heterosexual sex. Yet, importantly, the review noted that further research was required to assess the feasibility, desirability and cost-effectiveness of implementation within local contexts. This paper endorses the need for such research and suggests that, in its absence, it is premature to promote circumcision as a reliable strategy for combating HIV. Since articles in leading medical journals as well as the popular press continue to do so, scientific researchers should think carefully about how their conclusions may be translated both to policy makers and to a more general audience. The importance of addressing ethico-legal concerns that such trials may raise is highlighted. The understandable haste to find a solution to the HIV pandemic means that the promise offered by preliminary and specific research studies may be overstated. This may mean that ethical concerns are marginalised. Such haste may also obscure the need to be attentive to local cultural sensitivities, which vary from one African region to another, in formulating policy concerning circumcision.
Marie Fox, Michael Thomson. HIV/AIDS and circumcision: lost in translation. Journal of Medical Ethics 2010;36:798-801
Circumcision has no protective effect in male-male sex
Several recent papers have confirmed that circumcision has little or no effect in lowering the risk of HIV transmission among men who have sex with men.
Chongyi Wei, H. Fisher Raymond, Willi McFarland, Susan Buchbinder, Jonathan D. Fuchs.
What Is the Potential Impact of Adult Circumcision on the HIV Epidemic Among Men Who Have Sex With Men in San Francisco?
Sexually Transmitted Diseases. Vol. 37 (12) December 2010, 1-3
Abstract: With the help of a community-based survey, we assess the potential effect of circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco. Only a small minority of MSM would both derive benefit from circumcision (i.e., were uncircumcised, HIV-negative, predominantly insertive, and reported unprotected insertive anal sex) and be willing to participate in circumcision trials (0.7%) or be circumcised if proven effective as a prevention strategy (0.9%). Circumcision would have limited public health significance for MSM in San Francisco.
Conclusion: public health significance for MSM in San Francisco. High existing rates of MC, coupled with low rates of predominant IAI and lack of interest in undergoing the procedure for HIV prevention limit the potential impact of this intervention, even if it were found to be efficacious. Although our results may have limited generalizability, the parameters that affect the utility of circumcision for HIV prevention are not expected to vary greatly among MSM in other US cities. Both national samples of US men and MSM have found similarly high rates of circumcision.13,14 Moreover, there is little reason to believe that sexual behaviors of MSM in other US cities would differ significantly from that of MSM in San Francisco. Therefore, it may be likely that MC among MSM would have little effect on HIV transmission throughout the United States.
Kristen Jozkowski, Joshua G. Rosenberger, Vanessa Schick, Debby Herbenick, David S. Novak, Michael Reece.
Relations Between Circumcision Status, Sexually Transmitted Infection History, and HIV Serostatus Among a National Sample of Men Who Have Sex with Men in the United States.
AIDS Patient Care and STDs. August 2010, 24(8): 465-470.
Abstract: Circumcision’s potential link to HIV/sexually transmitted infections (STI) has been at the center of recent global public health debates. However, data related to circumcision and sexual health remain limited, with most research focused on heterosexual men. This study sought to assess behavioral differences among a large sample of circumcised and noncircumcised men who have sex with men (MSM) in the United States. Data were collected from 26,257 U.S. MSM through an online survey. Measures included circumcision status, health indicators, HIV/STI screening and diagnosis, sexual behaviors, and condom use. Bivariate and regression analyses were conducted to determine differences between HIV/STI status, sexual behaviors, and condom use among circumcised and noncircumcised men. Circumcision status did not significantly predict HIV testing ( p>0.05), or HIV serostatus ( p>0.05), and there were no significant differences based on circumcision status for most STI diagnosis [syphilis, gonorrhea, chlamydia, human papilloma virus (HPV)].* Being noncircumcised was predictive of herpes-2 diagnosis, however, condom use mediated this relationship.** These data provide one of the first large national assessments of circumcision among MSM. While being noncircumcised did not increase the likelihood of HIV and most STI infections, results indicated that circumcision was associated with higher rates of condom use, suggesting that those who promote condoms among MSM may need to better understand condom-related behaviors and attitudes among noncircumcised men to enhance the extent to which they are willing to use condoms consistently.
* Translation: There were no significant differences based on circumcision status for most STI diagnosis, namely, syphilis, gonorrhea, chlamydia, human papilloma virus (HPV).
** Translation: Circumcised men were more likely to use condoms, and it was condoms, not being circumcised, that protected them from herpes. This suggests that being circumcised increased their risk of the other STIs.
This is why circumcision has no place in efforts to control AIDS in Australia, where nearly all sexual transmission of HIV occurs during male-male sexual activity.
McDaid LM, Weiss HA, Hart GJ.
Circumcision among men who have sex with men in Scotland: limited potential for HIV prevention.
Sexually Transmitted Infections, Vol 86 (5), October 2010, 404-406
Abstract: Objective Male circumcision has been shown to reduce the risk of HIV acquisition among heterosexual men but the impact among men who have sex with men (MSM) is not known. In this paper, we explore the feasibility of research into circumcision for HIV prevention among MSM in Scotland. Methods Anonymous, self-complete questionnaires and Orasure oral fluid collection kits were distributed to men visiting the commercial gay scenes in Glasgow and Edinburgh.
Results: 1508 men completed questionnaires (70.5% response rate) and 1277 provided oral fluid samples (59.7% response rate). Overall, 1405 men were eligible for inclusion in the analyses. 16.6% reported having been circumcised. HIV prevalence was similar among circumcised and uncircumcised men (4.2% and 4.6%, respectively). Although biologically, circumcision is most likely to protect against HIV for men practising unprotected insertive anal intercourse (UIAI), only 7.8% (91/1172) of uncircumcised men reported exclusive UIAI in the past 12 months. Relatively few men reported being willing to participate in a research study on circumcision and HIV prevention (13.9%), and only 11.3% of uncircumcised men did so. Conclusion The lack of association between circumcision and HIV status, low levels of exclusive UIAI, and low levels of willingness to take part in circumcision research studies suggest circumcision is unlikely to be a feasible HIV prevention strategy for MSM in the UK. Behaviour change should continue to be the focus of HIV prevention in this population.
Male circumcision does not protect women from HIV
Maria J Wawer et al, Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet, Vol. 374 (9685), 18 July 2009, 229-237
Background: Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. We assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners.
Methods: 922 uncircumcised, HIV-infected, asymptomatic men aged 15-49 years with CD4-cell counts 350 cells per ?L or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. Men were randomly assigned by computer-generated randomisation sequence to receive immediate circumcision (intervention; n=474) or circumcision delayed for 24 months (control; n=448). HIV-uninfected female partners of the randomised men were concurrently enrolled (intervention, n=93; control, n=70) and followed up at 6, 12, and 24 months, to assess HIV acquisition by male treatment assignment (primary outcome). A modified intention-to-treat (ITT) analysis, which included all concurrently enrolled couples in which the female partner had at least one follow-up visit over 24 months, assessed female HIV acquisition by use of survival analysis and Cox proportional hazards modelling. This trial is registered with ClinicalTrials.gov, number NCT00124878.
Findings: The trial was stopped early because of futility. 92 couples in the intervention group and 67 couples in the control group were included in the modified ITT analysis. 17 (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up (p=0·36). Cumulative probabilities of female HIV infection at 24 months were 21·7% (95% CI 12·7-33·4) in the intervention group and 13·4% (6·7-25·8) in the control group (adjusted hazard ratio 1·49, 95% CI 0·62-3·57; p=0·368).
Interpretation: Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed. Condom use after male circumcision is essential for HIV prevention.
For further analysis, see coverage at Circumstitions
Men circumcised as children at greater risk of HIV
A study in Mozambique has found that men circumcised as children are 2 or 3 time more likely to be infected with HIV than uncircumcised men. The study, by Dr D.D. Brewer, confirms earlier research in Kenya, Lesotho and Tanzania that young people without sexual experience were more likely to be HIV-positive if they had been circumcised or if they had gone through traditional cutting rituals such as scarification. The results confirm the argument of David Gisselquist and others that a significant number of African AIDS cases are not the result of heterosexual intercourse, but of non-sterile medical procedures. The increasing evidence of non-sexual transmission of HIV casts further doubt on the value of mass circumcision campaigns as the magic bullet against AIDS.
Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth
Background: In sub-Saharan Africa, significant numbers of children with seronegative mothers are HIV infected. Similarly, substantial proportions of African youth who have not had sex are infected with HIV. These findings imply that some African children and youth acquire HIV through blood exposures in unhygienic healthcare, cosmetic care, and rituals. In prior research, male and female Kenyan, Lesothoan, and Tanzanian adolescents and virgins who were circumcised were more likely to be infected with HIV than their uncircumcised counterparts.
Methods: I examined the association between male circumcision, scarification, and HIV infection in Mozambican children and youth with data from the 2009 Mozambique AIDS Indicator Survey. I excluded from analysis children under age 12 who had HIV seropositive biological mothers. I coded children and youth as exposed to circumcision or scarification only if it had occurred within the prior 10 years.
Results: Circumcised and scarified children and youth were two to three times more likely to be infected with HIV than children and youth who had not been circumcised or scarified, respectively. Circumcision and scarification were each associated with HIV infection for both virgins and sexually experienced youth. Males circumcised by medical doctors were almost as likely to be infected as those circumcised by traditional circumcisers. Circumcision and scarification were also independently associated with HIV infection in males.
Conclusions: To determine modes of HIV transmission with confidence, researchers must employ more rigorous research designs than have been used to date in sub-Saharan Africa. In the meantime, Mozambicans and other Africans should be warned about all risks of blood-borne HIV transmission, including scarification and medical and traditional circumcision, and informed about how these risks can be avoided.
Source: Brewer D.D. Scarification and Male Circumcision Associated with HIV Infection in Mozambican Children and Youth. WebmedCentral EPIDEMIOLOGY 2011;2(9):WMC002206
Economists slam African circumcision programs
In recent months the African circumcision programs have come under strong attack from leading economists, who warn that the programs are not cost effective and are distorting the health budgets of recipient countries. The circumcision programs were introduced after three clinical trials appeared to show that circumcision could reduce a male’s risk of acquiring HIV through unprotected sexual intercourse with an infected female partner. The degree of risk reduction is estimated by the authoritative Cochrane Review as somewhere between 38% and 66% – which has not prevented circumcision advocates and an uncritical media from bandying a mythical “60 per cent protection” as though it was the same thing as immunity. The excessive stress on HIV control, and within this on circumcision as the best tactic, is criticised in a paper by Michael Grimm and Deena Cass, published by the German Development Bank; while Bjorn Lomborg and economists at the Copenhagen Consensus Center have criticised the African circumcision programs as too expensive, and far less effective than cheaper interventions that have the additional advantages of being both less risky and less controversial.
Economists say circumcision not the best way to fight HIV-AIDS
Some of the world’s most prominent economists have criticised the African circumcision programs as far less cost effective than other methods of prevention. The criticism was made Bjorn Lomborg and a group of Danish economists at the Copenhagen Consensus Center, a Danish think tank focused on cost-effective public spending. They conducted a cost-benefit analysis of circumcision as an HIV control measure, comparing the costs of prevention and treatment options per lives saved, and found that it was far less effective than other strategies, such as preventing mother-to-child transmission, ensuring that blood transfusions and other medical procedures were safe, and putting more effort into developing a vaccine.
The economists estimated the cost-benefit ratio for adult male circumcision at 23:1, while preventing mother-to-child transmission by treating HIV-positive pregnant women with medication had a cost benefit of 95:1, and ensuring a safe blood supply a ratio of 393:1. Such interventions were so much cheaper and more effective than circumcision that they “jumped to the top of the list”, Lomborg said. He criticised the notion of circumcision as a “surgical vaccine” as misleading and likely to encourage high risk behaviour.
Need for healthy balance in AIDS fight
Lomborg’s criticism of the African circumcision programs comes hot on the heels of a critique by Michael Grimm and Deena Cass, published by the German Development Bank in June. They suggest that the massive funding for HIV-AIDS control in Africa is based on inaccurate and exaggerated assessments of the extent and impact of HIV infection, and an unproven assumption that nearly all infection is through unprotected heterosexual intercourse. In fact, there is good evidence that a significant proportion of infections are the result of non-sterile medical procedures.
“More experts accuse [leading world health organisations, such as WHO and UNAIDS] of a biased presentation of the facts to distort priorities in favour of the treatment and prevention of AIDS compared to other disease and global health issues. Experts estimate that [HIV aid] receives 25% of international healthcare aid. In some countries HIV aid clearly exceeds total domestic health budgets.” This leads to poorer health outcomes overall, as other diseases are neglected or ignored.
Accordingly, they argue that the stress on circumcision programs is excessive, distorts the health budgets of the poverty-stricken countries in which they have been introduced, and leads to neglect of other diseases, some of which are more serious killers. “Infant mortality due to acute respiratory infections, diarrhoea, measles, malaria and malnutrition in general causes more than twice as many deaths as AIDS”, they write. “Despite these facts, UNAIDS is still calling for a drastic budget increase.”
The authors also criticise the way in which HIV has been regarded as a special disease, requiring separate programs, when it should be incorporated with other health problems within a general public health strategy. They call for a “rebalancing” of the effort against HIV, with less stress on circumcision, and greater attention to raising the general level of health among these underprivileged populations.
Michael Grimm is Professor of Applied Development Economics at the International Institute of Social Studies, Erasmus University, Rotterdam.
Source: The fight against HIV/AIDS must be brought into balance: Policy brief by Michael Grimm and Deena M. Class; published by the KfW, German Development Bank, in the series “Meinungsforum Entwicklungspolitik” (No. 3, 24 June 2011)
A copy of the full report in English can be downloaded from the Institute of Social Studies, Erasmus University.
Read the report at Think Africa News
Circumcision ineffective against AIDS in developed countries
VIENNA, Austria, July 22 – Adult circumcision has been proposed as a possible HIV prevention strategy for gay men, but a new study by the University of Pittsburgh Graduate School of Public Health presented at the XVIII International AIDS Conference suggests it would have a very small effect on reducing HIV incidence in the United States.
Circumcision is thought to reduce the risk of HIV transmission by removing cells in the foreskin that are most susceptible to infection by the virus. Clinical trials conducted in Africa have found it reduces the risk of HIV in heterosexual men, yet there is little evidence that it can reduce transmission among American gay men. The study was based on surveys of 521 gay and bisexual men in San Francisco. Findings indicated that 115 men (21 percent) were HIV-positive and 327 (63 percent) had been circumcised. Of the remaining 69 men (13 percent), only three (0.5 percent) said they would be willing to participate in a clinical trial of circumcision and HIV prevention, and only four (0.7 percent) were willing to get circumcised if it was proven safe and effective in preventing HIV.
The researchers extrapolated these findings to the entire gay and bisexual male population of San Francisco, an estimated 65,700 people, and determined that only 500 men would potentially benefit from circumcision. "Circumcision in the U.S. already is very common, making it applicable to a limited number of men as a potential HIV prevention strategy in adulthood,” said Chongyi Wei, Dr.P.H., study author and post-doctoral associate, Pitt's Graduate School of Public Health. “Our study indicates that any potential benefit may likely be too small to justify implementing circumcision programs as an intervention for HIV prevention.”
Circumcising gay men would have limited impact on preventing HIV
by EurekAlert
Do you like this page?