Saturday, July 25, 2009

This Will Not End Well

I often browse The New York Times every few days because I generally hold their professional journalistic ability in high regard. However, every now and then, I come across an article that I greatly disagree with.

Earlier this week I came across the article South Africa Is Seen to Lag in HIV Fight. The title wasn't really news but the moment I began reading the it, the epidemiologist in me bristled with indignation. The article focused almost exclusively on the low rate of male circumcision in South Africa as a major factor for the nation's high HIV rate. It barely mentioned the importance of condoms (and combating the Pope's erroneous statements about condoms), access to HIV testing, access to HAART drugs, safe sex education and behavior, LGBT rights, women's rights, and mother-to-child transmission of HIV - all necessary and greatly lacking in South Africa (and verily, most sub-Saharan African countries). This will not end well.

The purpose of this post is singular: to dispel the belief that male circumcision will make a significant dent (if at all) in lowering HIV rates.

The argument for male circumcision hinges on 3 studies (all of which were ended early) that seemed to indicate that being circumcised might decrease a guy's risk of getting HIV by 50-60% from woman-to-male transmission. It should be important to note that this is a relative risk. On an individual scale, the absolute risk is closer to a 2% decrease according to the studies. It's simple math and statistics. A risk reduction from 4% to 2% has a relative risk decrease of 50%, but the absolute risk reduction is 2%. It's critically important to use the words "risk reduction" as opposed to "prevention" because circumcision does NOT prevent HIV/AIDS. I had already discussed this briefly before in a previous post here.

There have been many criticisms of those studies. All sexual encounters were self-reported. Female partners were not tracked. It isn't known if any of the men engaged in homosexual sex (will be important later). Hygienic practices weren't assessed, as good and proper genital hygiene does help lower the risk of contracting STDs. There is no solid biological/physiological reason why male circumcision would confer this risk reduction.

But let's assume male circumcision is the wonder bullet that some health officials have made it out to be. In one recent model, increasing access to antiretroviral drugs and increasing condom use will have a much greater impact on HIV rates than circumcision. In fact according to their model, increasing both antiretroviral drugs and condom use could reduce new HIV infections by 64% to 90% by 2025 and could reduce mortality by 10% to 34%. In contrast, focusing on increasing male circumcision would only reduce new HIV infections by 3% to 13% and reduce mortality by 2% to 4%. Of course there are several assumptions that must be held in this model, as in all models. But the difference is still quite striking. The article could be found at aidsmap.

If you read the aidsmap article, you'll notice that their model does not increase access to antiretroviral drugs, condom use, and male circumcision. Why? It probably boils down to cost. Funds are a limited resource - the more you focus funding on one thing, it necessitates that you must reduce funding elsewhere. South Africa does not have the health care infrastructure nor enough health professionals trained to circumcisions safely and under sterile conditions. It costs a lot of money to update the health care infrastructure and to train more health professionals. Now think how many antiretroviral drugs, condoms, and safe sex pamphlets and ads will that same amount of money buy? Two words: A LOT.

Even if male circumcision continues to be promoted, there are several foreseeable problems. The first is that if you tell guys that getting circumcised will reduce their risk of getting HIV, it's only a matter of time until people misinterpret being circumcised as preventing HIV. While these men are still counseled to use condoms, if they think they're protected against HIV they will use condoms less. (Note: proper condom use reduces the risk reduction conferred by male circumcision to negligible or near-zer0.) Furthermore, they may use their circumcised status to "negotiate" unsafe sex with women, posing a greater of HIV infection to women. Circumcision Is a Red Herring, a must-read article.

In addition, because clinics and hospitals are becoming overwhelmed by men wanting to get circumcised, it's only a matter of time until they seek traditional healers or witch doctors with little/no medical training to perform unsafe circumcisions. Each year in South Africa, several hundred teens and men are maimed and disfigured due to seeking circumcisions outside the formal health care system, and many also die as a result. Read more about it in an article here, but be warned: it's not for the faint of heart.

Lastly, several studies have concluded that circumcision makes no difference in reducing HIV rates where homosexual sex is concerned (article here). Anyone who thinks circumcision offers a risk reduction against HIV in gay sex is simply wrong. With this in mind, the number of gay/bi men in Africa have long been underestimated and the role of gay sex in HIV transmission in Africa has been ignored. Because homosexuality is illegal and punishable by death in several African countries, gay sex is kept secret and underground. Little/no safe sex info is targeted towards homosexuals and gay/bi individual often face discrimination and lack access to care. To maintain the appearance of normality, many male-male sex networks often overlap with male-female sex networks. This is how homophobia fuels Africa's AIDS crisis.

In summary, male circumcision is not an effective means of reducing new HIV infections. It's entirely possible that it may actually do more harm than good. Money going towards male circumcision should be directed to strengthening proven methods (e.g. condom use and safe sex education/behavior) and increasing access to retroviral drugs and HIV testing. Pregnant mothers should be tested for HIV and have access to antiretroviral drugs to reduce/prevent mother-to-child transmission of HIV. There should also be campaigns to promote women's rights and LGBT rights. A lot of money, and a lot of people, hinge on a single decision. I only fear that Africa (and perhaps health advocates) might be making the wrong one. This will not end well.


Tyler said...

ugh. i so with i could write like that...

and now... how on earth would a cut dick decrease the chance of contracting in std... i dont get that... like... i dont see how cutting off a chunk of skin will change anything :/ like... i thought that u get the std is the dick touched the contaminated vag... whether if its got some xtra skin or not... its still touching the std-vagina : /

like, even if circumsition does not change anything... why would anyone think it : /

Randy said...


Anonymous said...

I agree with you whole-heartedly. I wish those involved with preventing the transmission of HIV in Africa could also see things your way.

Aek said...

Tyler: Awww, thanks! In 11th grade my English teacher had a law degree, so we were subtly taught how to think like lawyers when we wrote essays. In a way, lawyers, scientists, and doctors all think somewhat similar - you must build your case/hypothesis with evidence/facts.

There are several guesses as to how a cut penis "might" decrease HIV/other STDs. One is that the foreskin provides a moist and conducive environment for STDs to infect the body. Another is that the foreskin is prone to damage and microscopic cuts and tears allow STDs into the body. And lastly, there are special immune cells called Langerhans cells that target viruses in the foreskin (and actually, in all skin on the body - though at a lower concentration).

None of these 3 "hypotheses" hold very well. The first is negated by good genital hygiene (which, unfortunately, is something Africa lacks due to limited/no running water). The second one doesn't make sense, as the foreskin's there to make sex easier and trauma less likely to happen to the penis. And the third one is contentious, because some studies indicate that Langerhans cells traps and destroys viruses (including HIV) on the spot before they can infect their real targets further in the body.

Anyway, point is, condom use >>> circumcision. If you're going to have sex with an STD-infected partner, you're probably going to catch whatever they have - cut or uncut. The media gives preferential attention to the studies that praises circumcision and the studies that oppose that get little/no press attention.

I hope this answers your questions. If you'd like further clarification or know more, email/IM me. :)

Randy: My sentiments exactly.

James: Yeah, well, ugh.

Jason Carwin said...

I liked what you said in your second to last paragraph about how homophobia is fueling the AIDS crisis. I know this is a major issue, but many people ignore it. I recall reading a newspaper article in the Hindustan Times (or maybe it was Times of India) where the Indian Health Minister was leading a drive to legalize gay sex because the sodomy laws where making the AIDS crisis worse.

Of course, this was 1 year ago, which was well before the court ruling in Delhi legalizing sodomy.

j said...

wow somebody is extremely defensive about their foreskin

Aek said...

Jason: Yes, when I read that I realized just how marginalized the role of homosexuality is in the spread of HIV/AIDS in Africa. I'm ashamed to say that it didn't even register on my mind before now. The focus has always been on male-female sex in Africa, not male-male or female-female sex.

J: Hmmm? Perhaps that might've been the undertone (if so, it wasn't entirely my intention). However, you cannot claim that my rationale is false or falsely stated.