Friday, December 15, 2006

Soon to disappear along with the white rhino: the African foreskin

Big, big news in HIV prevention research: clinical trials in Uganda and Kenya have indicated that male circumcision reduces risk of HIV transmission, from women to men, by about 50%. These results confirm the findings from last year's trial in South Africa, and will almost certainly move the WHO and UNAIDS to officially endorse the promotion of male circumcision in high HIV prevalence countries, particularly in non-circumcising regions of sub-Saharan Africa. With its vaccine-level protectiveness, male circumcision could potentially prevent millions of new HIV infections, and thereby save millions of lives.

Potentially. Research is one thing, implementation of research findings into real world situations is another, as one of the researchers in the Ugandan trial soberly points out. If men come to believe that circumcision offers them immunity, and they engage in more unsafe sex, then the protective effect will be lessened. It will also be lessened if men and boys have sex too soon after the operation, or if the operation is performed in unhygienic circumstances by under-skilled practitioners. There are many unknowns, such as unknowns about the acceptability of male circumcision or its wider cultural impact among traditionally uncircumcising groups, or the acceptability of circumcising at early ages among traditionally circumcising groups. The underlying biological mechanisms to explain how male circumcision prevents transmission of the virus are not entirely clear. But the Ugandan and Kenyan studies should greatly increase confidence in the idea that being circumcised helps protect a man somewhat from getting the virus from an HIV positive woman.

It is strange to see how many news reports make reference to what the findings mean for the USA, as if the story that male circumcision could save millions of African (or Asian) lives is not interesting enough. Given that most men and boys (some 77%) in the US are circumcised already, the effect of male circumcision on male to male transmission is unknown, that it does nothing for injection drug users, the new findings won't help the US epidemic much. But there are still some fascinating twists. These results are yet another blow to the 'intactivists', those who regard male circumcision as genital mutilation, something only permissable (but still frowned upon as irrational) when an adult male consents to it. Until last year, the intactivists were helping to slowly roll back the practice of routinely circumcising infants in the United States. Now they are on the ropes. Given that the rate of new HIV infections has not dropped in the US over the last years, it is possible that the American Academic of Pediatrics could start recommending routine neonatal circumcision again, and insurers start covering the operation again. It is amazing how many effects this faintly comical flap of skin is capable of producing.


Anonymous Anonymous said...

As in intactivist, I do not feel the least bit "on the ropes."

The discussion this news has generated can only help Americans notice that over 80% of the world does not circumcise (and some of the lowest AIDS rates are in non-circumcising nations). I see and hear quite a bit of outrage at the arrogance of the US administation's abstinence-only anti-condom policy, without which these studies by long-time circ justifiers probably would have never even been funded.

There are studies identifying that female circumcision (hood removal only) has a protective effect against HIV. Imagine an African nation officially declaring that all American women should have normal sensual parts amputated.

Notice how the study authors (e.g. Bailey) and those working the PR spin machine (e.g. Halperin) are quick to point out that traditional African techniques won't do. It must be done the American way. But, as the reports all point out, condoms must still be used. So why not just use a condom and skip the circ? Oh, yeah,... because then nobody gets to bill for the procedure or for the tools.

11:49 AM  
Blogger Stuart Rennie, Editor said...

Thanks for your response. I would like to hear comments from others who happen to visit this blog on this particular topic.

I was unfamiliar with the idea that some of the lowest AIDS rates are in non-circumcising nations; certainly some mostly non-circumcising nations have some of the highest (Botswana, Swaziland, Malawi, etc.). But there are so many confounding factors, it does not help to map HIV on whole regions in terms of circumcision/non-circumcision, and hope to show correlation/causation. That is why randomized controlled trials were done, to minimize confounders. Perhaps the best way to argue against the trials is to question its methodology -- but the details have not been published yet.

I personally don't think there is a substantial body of scientific evidence in favor of hood removal for women, analogous to what exists for men. If there was, you are right, it would cause some serious issues. But even if a correlation was found, I doubt that anyone (African or not) would strongly recommend male circumcision in the US, because the US prevalence is too low to justify it on those reasons. That is probably why male circumcision won't be pushed too hard here, but more strongly promoted in Africa.

As for the idea that traditional African techniques won't do, I personally don't buy into a conspiracy theory. In South Africa, quite a few boys have died from botched circumcisions, and elsewhere in Africa, the multiple use of the knife on different initiates is a vector of HIV transmission. If it is done, it should be done safely, with follow-up for possible infections etc. There is a danger that the news about the trials will have men and boys looking for cheap and dirty circumcisions, and put themselves at risk.

Why use a condom and skip the circumcision? Good question. One answer is that condoms are, and have been, underutilized. Of course, recent US policies have not helped, but condom use in many parts of Africa was never great. Condoms are often considered immoral (partial thanks go to the Vatican) and unnatural. The thing about circumcision is, that if it offers some protection, there is no problem with adherence; once the foreskin is gone it is gone. If US agencies promote circumcision, then they better drop the anti-condom policy -- it would be irresponsible to do otherwise.

Don't take this as an endorsement of male circumcision as HIV prevention method. I think this is one of the riskiest ventures in HIV prevention ever, and I don't see that people in the highest reaches of public health have carefully thought through all the issues.

2:16 PM  
Blogger TLC Tugger said...

You mentioned Malawi as a high-incidence region, but in Malawi it is the CIRCUMCISED who have the highest prevelence of HIV infection.

Non-cutting Japan has a lower AIDS rate than 97%-cut Israel. The mostly-cut US - with its excellent education and health systems - has 3 times the AIDS rate that Europe (where cutting is rare) has.

The Africa trials were conducted and promoted by long-time circumcision justifiers, and as such should have been laughed away for being neither placebo-conrolled nor double-blinded, let alone even logical. If they really wanted to fight AIDS, the first response to a finding of fewer new HIV infections in cut men should have logically been "What's goig on here?" "Can we get this beneficial effect without amputation, for example by having men wear their foreskins retracted (rolled back off the glans 24/7)?"

The only explanation sought for the findings was one they made up out of thin air; that Langerhans cells attract HIV. Other research shows Langerhans cells fight HIV. Still other research shows that the clitoral hood (rich in Langerhans cells) can be amputated to reduce HIV infection rates. "Can be" not "should be" of course. None of this has any bearing on children, who don't have sex, and who have a basic human right to keep their whole bodies until they can make their own informed adult decision.

All the time and effort and education progress lost promoting condom use is the real tragedy of these useless results. No study investigating amputation of healthy normal body parts should ever have been allowed. We don't fight other diseases by pre-emptive amputation of valuable tissue except in cases of strong genetic evidence of disease inevitability.

AIDS is not inevitable, it is easily thwarted by a condom. The UN can give away condoms for 3 cents. One billion dollars buys 4 condoms per week for every male adult in Africa. Believe it or not that's a fraction of present AIDS funding.

Foreskin feels REALLY good. HIS body HIS decision.

12:07 PM  
Blogger rich winkel said...

The american experience with circumcision and HIV presents a problem for those pushing for circumcision in africa: the US has the highest HIV rate and the second highest rate of circumcision (second only to israel) in the industrialized world. The question is why. Here's the answer: the african studies only address the question of female->male HIV transmission, not the other direction. This is of course a glaring omission, particularly in light of the fact that circumcision increases vaginal abrasion during intercourse, which can be expected to break down the natural barrier to HIV presented by intact vaginal mucosal tissue:
a hypothesis which is borne out in empirical findings:

Please reevaluate your position. Circumcision may in fact exacerbate the african HIV problem.

6:00 PM  

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