Circumcision undermines anti-AIDS efforts?
As I blogged about earlier, there is some scientific evidence that male circumcision can significantly reduce the risk of contracting HIV-AIDS.
However, part of the medical community in Rwanda is concerned that the country's current circumcision campaign could actually harm anti-AIDS efforts. They fear that the campaign could lull people into believing that the procedure is tantamount to a vaccine against the disease, particularly in a country where knowledge of sexual health issues is low.
"Most of the difficulties relate to convincing men that circumcision does not exclude the use of condoms during sex," notes one general practitioner in the capital Kigali.
While circumcision may reduce the chances of the man contracting HIV by one half, a risk still remains. And obviously it does nothing for the women.
Labels: AIDS, male circumcision
posted by Brian @ Saturday, February 23, 2008
24 comments
24 Comments:
In Rwanda, 3.8% of circumcised men have HIV, compared to 2.1% of intact men, so what the heck do they think they're doing? That's nearly twice as many. I'm not (of course) saying circumcision promotes HIV transmission (though it might) but clearly something else is going on. These figures are from the 2005 Demographic and Health Survey ( http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf , p10 and p15).
Circumcision can only possibly help men who have unsafe sex with HIV+ partners, so why this bizarre obsession with genital surgery when we know that ABC works better than circumcision ever could? (ABC=Abstinence, Being Faithful, Condoms). The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Something is very wrong here. These people aren't interesting in fighting HIV, but in promoting circumcision, and their actions will cost lives.
Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.
"Reduces the risk by half" is a powerful claim, but this is all it amounts to:
In each of the three trials, where 1500-2500 men were circumcised, about forty of the non-circumcised control group got HIV, compared to about 20 of the circumcised experimental group.
But more than 100 of the circumcised men dropped out of each of the trials, their HIV status unknown to the experimenters. They'd been encouraged to be tested elsewhere - wouldn't the circumcised men who found they had HIV be more likely to drop out, since the painful and marking operation had failed to work for them?
It's assumed without proof that all the HIV was transmitted sexually, when significant numbers of the men say they had no sex or only protected sex in the relevant time, and we know that dirty needles and other transmission is common in that part of Africa.
Far too much faith is being put in these non-blinded, non-placebo-controlled trials, held by men who have a track record of promoting circumcision, on subjects who very much wanted circumcision to be effective.
Just a reminder that my blogs do not publish completely anonymous comments. If you're not a Blogger member and want to leave a comment, include your name (or at least your first name) or a consistent pseudonym.
(And to the anonymous noter who refuses to sign his comments: I don't know enough about this issue to have a strong opinion either way. I'd be happy for you to further the debate. Just sign your comments)
Interesting. People with an obvious vested interest accuse others of same.
Time for idle chatter is over, the jury is in.
The joint WHO /UNAIDS statement states:
"Conclusions and Recommendations
Conclusion 1: The research evidence is compelling
The research evidence that male circumcision is efficacious in reducing sexual transmission of HIV from women to men is compelling. The partial protective effect of male circumcision is remarkably consistent across the observational studies (ecological, cross-sectional and cohort) and the three randomized controlled trials conducted in diverse settings.
The three randomised controlled trials showed that male circumcision performed by well-trained medical professionals was safe and reduced the risk of acquiring HIV infection by approximately 60%.
The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention.
Recommendations :
1.1 Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
1.2 Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men."
New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications
http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf
I'm well aware of the WHO/UNAIDS statement, and I think they're very wrong. Quite why they'd want to promote circumcision in a country where the HIV rate amongst circumcised men is almost twice as high as the rate amongst intact men raises serious questions about their motives. I for one don't think the primary motive of this is to combat AIDS.
Latest news. Circumcising HIV+ men seems to increase the risk to women.
Old news. Safe sex still works far better than genital surgery ever could.
Well it seems your stats from Rwanda are not quite as up to date and as accurate as you would like to believe. But then some seem to place much higher standards of proof on information that they don't agree with while wildly embracing anything and everything from any source if it supports their agenda. Sad really.
Joshua: Since you didn't specify the 'you' in your remarks, I can only assume you're referring to me.
"My stats" are nothing more than a link to an article by IPS.
Since you're making assumptions about my position rather than having the courtesy of asking, I'll tell you it.
My inclination is that if circumcision helps, then there's nothing wrong with doing it. My main concern is to make sure it complements, rather than replaces, traditional AIDS prevention programs. As long as it's complementary, then I have no objection to it.
As I said before, I don't know enough about this issue to have a strong opinion either way. It's not my area of expertise which is why this debate is interesting to me.
However, your repeated accusations against everyone as 'having an agenda' does not advance your position one iota. I've published your comments and assertions unedited, just as I have the others, but please lose the attitude and make your case in a less whiny manner.
Or at the very least, stop beating around the bush and have the guts to come out and say what you mean. Who has an agenda and what is that alleged agenda(s)?
Joshua, do you have different stats from Rwanda?
Brian, actually I was referring to the first comment of 'ml'. Did you bother going to read table 15.11 of the cited document? Please do and see just how small to the extent of being unreliable the data sample for circumcised men was. And note that they also found that in urban areas "where prevalence among circumcised men (5.0 percent) is slightly lower than among uncircumcised men (5.7 percent)" which was deliberately not mentioned by 'ml'. My point to you is that you need to get to understand the fundamental intellectual dishonesty of the anti-circumcision zealots in the desperate way in which they try to promote their cause.
WHO and UNAIDS and a growing number of medical groups within countries are accepting and advocating or putting into practice mass circumcision programmes because it has been found beyond doubt that male circumcision reduces the risk of female to male HIV transmission by 60% or more. The jury is in, the debate is over ... but not it seems for the desperate last kicks from the dying horse which is the anti-male circumcision movement.
Joshua: My point is that you should make your arguments in a more dispassionate manner. Your angry accusations in these comments have done more to discredit you than the people you're attacking. Let your facts speak for themselves and go from there.
Talk about cherry-picking. Table 15.11 shows 3.5% of 449 circumcised men were HIV+, but only 2.1% of 4,287 circumcised men. You don't have to be anti-circumcision to find it strange that circumcision is being promoted in Rwanda to prevent AIDS.
Not mentioning a subset of the data which happens to suit your view is hardly "intellectual dishonesty", and you lose credibility by describing it as such.
Brian, lighten up. Mark Lyndon it really doesn't matter what your opinion of the joint WHO /UNAIDS statement is. You and your single issue group just got comprehensively trumped by science. Now what I really find hilarious is how you nit-pick the studies which find in favor of circumcision yet cling in utter desperation to weak stuff like you quote with regard to Rwanda. Do you really think that is the only data Rwanda has had on which to base their decision to roll out male circumcision on a massive scale? Sorry to see all your years of dedication to saving the foreskin coming to naught. It must be devastating for you.
Brian, if you were not aware before you should be now that there is a small but vocal group of true believers dedicated to saving foreskins at any cost. Take for instance the costs in lives and illness.
Researchers have calculated that if all men in the South African city of Soweto were circumcised then over the next decade 2 million infections and 300,000 deaths would be averted. http://allafrica.com/stories/200707250311.html
Little wonder then that WHO and UNAIDS are advocating mass male circumcision.
But think about the motivation of the rabid anti-circumcision zealots. They seem to be umoved by the thought of millions of HIV infections and hundreds of thousands of AIDS deaths. And they claim to be concerned with human rights. Obviously not they are concerned only with foreskins.
How many lives could be saved by condoms and safe sex?
If HIV struck people at random, then I'd be in favour of circumcision too, but like I said before, circumcision can only possibly help men who have unsafe sex with HIV+ partners. It also seems to make HIV+ men more dangerous to women. It seems likely to me that rolling out circumcision is likely to result in more AIDS deaths, as HIV+ men will infect more women, and there is also anecdotal evidence that some men see circumcision as an alternative to safe sex.
Like I said before, calling me and others "rabid zealots" diminishes your credibility.
Brian, this post is an excellent example of how the anti-circumcision zealots attempt to spread disinformation.
Take the supposed higher risk higher risk of HIV positive circumcised men infection HIV negative females during heterosexual sex.
Now first remember that WHO / UNAIDS finds that male circumcision protects men from becoming HIV infected through heterosexual sex with a HIV positive female by more than 60% when compared to uncircumcised men.
Note - female to male - heterosexual.
Now what our anti-circ activists refer to is this from the CDC statement "... A clinical trial in Uganda to assess the impact of circumcision on male-to-female transmission reported that its first interim safety analysis showed a nonsignificant trend toward a higher rate of HIV acquisition in women partners of HIV-seropositive men in couples who had resumed sex prior to certified postsurgical wound healing and did not detect a reduction in HIV acquisition by female partners engaging in sex after wound healing was complete."
http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm
Note: 'nonsignificant trend' and 'in couples who had resumed sex prior to certified postsurgical wound healing'.
Now you will be forgiven for interpreting what Mark Lyndon said as being a permanent higher risk of HIV transmission.
And then of course WHO / UNAIDS state clearly that "Promoting circumcision for HIV-positive men is not recommended".
http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf
Then the condoms in Africa issue.
Now this anti-circ zealots know that there is a massive condom gap in Africa.
http://www.bmj.com/cgi/content/full/323/7305/139
Provision of condoms to the countries with the highest levels of HIV infection is 17 condoms per man (15-59) per year or 4.6 per year across the whole continent.
Adding to this sad reality where even if they wished to African men could not get enough condoms to practice safe sex is that the Catholic church says "The spread of HIV and Aids in Africa should be tackled through fidelity and abstinence and not by condoms, ..."
So all round very bad news for the foreskin and its admirers.
Are you incapable of making a post without using the word "zealot"? It really doesn't help for reasoned argument.
There have been calls within the Catholic church to abandon opposition to condoms in Africa, and this seems to me very much the right thing to do. The current opposition to condoms has resulted in the deaths of hundreds of thousands of Africans, and I feel as strongly about that as I do about circumcision. Circumcised or not, condoms will save lives anyway.
The Catholic Church is also against circumcision btw (see www.catholicsagainstcircumcision.com) Only 5% of Catholics worldwide are circumcised, almost all of them in the USA.
The male-to-female study appears to have resulted in 8 more women acquiring HIV by the end of the study, than if their partners had not been circumcised. Even after the healing period was over, there was still a higher rate, though the difference was not statistically significant. Interestly, the researchers chose to ignore all the couples who started having sex less than 5 days before the healing period was over, which seems to indicate researcher bias. They were looking for a certain result, and when they didn't get that, they selected the data so that things didn't look as unfavorable for circumcision.
This isn't the first time that HIV in women has been linked with circumcision of their partners anyway. For instance, this 1991 study in Rwanda also made the link:
http://ije.oxfordjournals.org/cgi/content/abstract/23/2/371
As noted before, Rwanda is also the country where circumcised men are 66% more likely to be HIV+ than intact men.
If couples are presumed to be incapable of safe sex, then why would they be presumed to be capable of safe sex immediately following circumcision?
Did you know that circumcised male virgins, appear to be more likely to be HIV+ than intact male virgins? This suggests that some men are acquiring HIV as a result of traditional circumcision:
http://www.afrol.com/articles/24469
It is really sad to see desperately you anti-circumcision zealots cling to any scrap of information that you can apply spin to in support of your dubious cause. Should you not be talking to a professional about this problem you have?
The benefit of male circumcision is the 60%+ protective effect against HIV infection through female to male heterosexual sex.
It is not recommended that HIV males be circumcised as a means of reducing the risk of an HIV man infection a female. Therefore the potential for irresponsible people who have sex before fully healed should not be a factor even though it was clearly stated in the study that this was not statistically significant. But it is understood with sympathy that desperate anti-circumcision activists will cling to this like a Linus blanket. Sad to behold.
With regard to the spin on the Rwanda stats I need to repost this comment from earlier:
"Did you bother going to read table 15.11 of the cited document? Please do and see just how small to the extent of being unreliable the data sample for circumcised men was. And note that they also found that in urban areas "where prevalence among circumcised men (5.0 percent) is slightly lower than among uncircumcised men (5.7 percent)" which was deliberately not mentioned by 'ml'. My point to you is that you need to get to understand the fundamental intellectual dishonesty of the anti-circumcision zealots in the desperate way in which they try to promote their cause."
In addition to this (if it were not enough) the anti-circumcision zealots now chose to ignore the equally 'important' finding that in urban areas of Rwanda the incidence of HIV infection among circumcised men is 'lower' than for the uncircumcised. Why does anyone think that is?
Then of course having given the impression that they as a group of foreskin true believers can sniff out an agenda and a conspiracy they introduce information from people with an obvious agenda (who do these zealots think they are kidding?)
You see if there is an agenda it is that of Gisselquist and his cronies of which Brewer is one. There sole obsession is to prove (at any cost and, sadly, seemingly by any means) that unsafe injections is the major cause of HIV infections and not sexual contact. The issue of HIV infection during tradition circumcision is an offshoot of this obsession. These intellectually compromised individuals have now been comprehensively rebutted.
This of course does not mean that there is no risk from 'unsafe injections' or 'unsafe bush circumcisions' just these are nowhere near the level of infection that Gisselquist and his cronies or the anti-circumcision zealots claim.
You learn so much about the mindset of these foreskin true believers if you apply a little critical thinking to what they claim. Quite fun even though their intellectual dishonesty is a little too predictable nowadays.
Rwanda: Overall HIV infection rate among cut nearly the rate for uncut. Simple.
Condoms: UN *could* give them away for 3 cents each. It's simply a matter of political will. A $50 circumcision could be traded in for over 1600 condoms.
Virgin African boys are found more likely to ALREADY have HIV if they had been circumcised, so only the fancy expensive IMPORTED version of the proceedure could have any protective effect (IF the non-double-blind written-by-long-time-justifiers no-predictive-power-elsewhere studies could be believed).
Infants don't have sex. HIS body HIS decision. Simple.
Well here we have more unsubstantiated pronouncements. These anti-circumcision zealots just can't help themselves it seems.
In a newly published study it is found that: "Complete coverage by Male Ccircumcision could reduce HIV prevalence from 12 to 6% for an average population country in sub-Saharan Africa in 2020."
http://tinyurl.com/2uvbbq
This study confirms the findings of an earlier study, http://tinyurl.com/2azdv5
Joshua
Ok, I'm going to reject further comments that include the word 'zealot' or similar invectives, regardless of whether it's from a pro- or anti-circumcision person.
Joshua, you've made it very clear what you think of anti-circumcision people. The ad nauseum repetition of 'zealot' is getting really tiresome and does nothing to advance the debate. From now on, stick to facts and opinions, not name calling.
Brian, I hear what you say so may I ask you to provide a description for the anti-circumcision activists?
Read this article (and those I posted links to) and tell me if you will how should one describe people who rather than save millions of lives through a simple medical procedure would rather see these millions die with the attendant suffering for the additional millions in the families of the infected and dying rather than see the removal of millions of their beloved foreskins?
http://tinyurl.com/yrt4oq
Joshua,
You've made your description of them abundantly clear. I'm just tired of reading the same invectives in every
single
comment
you
leave.
Your position is compelling enough that you don't have to repeat the word 'zealot' 15 MORE times or other sarcasm.
Thank you for your cooperation.
If I thought that circumcision would really be a more effective way of combatting HIV in Africa than promotion of ABC, then I would support it. However, I believe that it will result in more deaths (even if funds aren't diverted from ABC).
I find it very sad that some people are so keen to promote male circumcision that they will sacrifice lives in Africa to achieve their aim.
Can you really imagine circumcision being promoted in Africa if it wasn't already considered acceptable in the USA?
Everyone's just going back and forth and nothing new is being said. Therefore I'm closing comments on this particular piece. Thank you all for your participation.
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