Bloodborne HIV: Don't Get Stuck!

[go to or return to first circumcision page]

Last week, while looking for something else, I ran across a report that has big implications for HIV/AIDS prevention in Africa: Almost five years ago, a trial of circumcision to protect men in Rakai, Uganda, reported that intact (uncircumcised) men who waited at least 10 minutes after sex before cleaning their penis were at less risk to get HIV than men who had been circumcised: intact men who waited to clean got HIV at the rate of 0.39% per year compared to 0.66% per year for circumcised men. Although the study team reported these results to an international AIDS conference in 2007, and several newspapers wrote about it at the time, the report has dropped out of view. That is a big mistake.

Why is this report important? Here are three reasons.

First, if you are intact, this report says you don’t need to get circumcised to reduce your risk to get HIV. Use a condom, of course, if your partner has or might have HIV. But if that fails, this report says you are as safe with a foreskin as you would be without one. Just don’t clean your penis for at least 10 minutes after sex, and then wipe it with a dry cloth, without water. A later report from the Uganda study team suggests waiting to clean is good for all men, both circumcised and intact: men who didn’t “wash genitals after sexual intercourse” got HIV less than 1/3^rd as fast as men who did.

Second, if you are a politician or public health official who is considering whether to go along with the largely US-promoted program to circumcise 20 million African men by 2015, you can take another close look at the evidence and options. The evidence that advocates use to promote circumcision comes from three studies (in South Africa, Kenya, and Uganda during 2002-06) that recruited thousands of intact, HIV-negative men, circumcised some and not others, and then followed and retested them to see who got HIV. All three studies reported that circumcised men got less HIV. But the study team for at least one of those trials – the trial in Uganda – has data showing that intact men who waited to clean after sex got less HIV than circumcised men.

Circumcision is expensive and dangerous and takes doctors and nurses away from other tasks. Why put scarce public resources into campaigns to circumcise millions of men if you can get the same results by advising men to use condoms, and if that fails to wait least 10 minutes after sex before wiping their penis with a dry cloth?

Third, this is another example of people reporting important evidence that contradicts well-funded misinformation about HIV risks. WHO, USAID, and other organizations pay for a lot of messages – some are true and helpful, but some are at best only partial truths. It’s important for people to speak up when they have good information about how to avoid HIV risks, even though what they say disagrees with the official “line” at the time.

Here are some examples of truth meeting official misinformation.

WHO warns UN employees they might get HIV from health care in Africa, but doesn’t warn the African public. But not everyone goes along with such misinformation. For example, Demographic and Health Surveys finds and reports HIV-positive children with HIV-negative mothers (in Mozambique, Swaziland, and Uganda) and virgin men and women with HIV. As more people speak up, Africans hear that a lot of infections come from minor blood exposures, and learn how to protect themselves.

Another example of official misinformation is WHO’s continuing promotion of Depo-provera injections for birth control without warning Africans that good evidence shows – and many experts believe – using Depo-provera increases a woman’s risk for HIV. One expert who has spoken out – eloquently and repeatedly – on this issue is Paula Donovan, a former high-ranking UNICEF official, who has had the heart and courage to challenge official misinformation.

Circumcision is another issue with a lot of well-funded misinformation, but also with many people speaking out to set the record straight (eg, see the article by Daniel Ncayiyana, editor of the South African Medical Journal, in this link). Unfortunately, crucial evidence is still unreported from the three key trials of circumcision to protect men: A lot of men in the trials got HIV despite no reported sex partners – what were their risks? None of the three study teams has reported the HIV status of any of the men’s sex partners, and only two have reported minimal information about blood exposures.

As for waiting and wiping to reduce HIV risk, here’s the record of partial and incomplete information from the 2003-06 trial of circumcision to protect men in Rakai, Uganda:

13 December 2006: The US National Institutes of Health reported that men circumcised in the trial had 48% lower HIV incidence compared to intact men, WITH NO MENTION OF POST-COITAL CLEANING.

24 Feb 2007: The Uganda study team reports selected trial data in Lancet, concluding: “Male circumcision reduced HIV incidence in men… Circumcision can be recommended for HIV prevention in men.” THE ARTICLE MAKES NO MENTION OF WAITING TO CLEAN, WHICH THE TEAM’S UNDISCLOSED DATA SHOWED TO BE MORE EFFECTIVE THAN CIRCUMCISION.

28 March 2007: WHO announces recommendations from an experts’ meeting: “Based on the evidence presented…experts attending the consultation recommended that male circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men.” SEVERAL MEMBERS FROM THE UGANDA STUDY TEAM TOOK PART IN THE MEETING. THERE IS NO INDICATION THEY TOLD ANYONE ABOUT THEIR UNDISCLOSED EVIDENCE THAT WAITING TO CLEAN WAS MORE EFFECTIVE THAN CIRCUMCISION IN PROTECTING INTACT MEN FROM HIV.

25 July 2007: Frederick Makumbi and several other members of the Uganda study team tell an international AIDS conference: Among intact men reporting post-coital cleaning with all partners, “HIV incidence was significantly higher among those reporting cleansing within 3 minutes (2.32/100 py [person-years]), compared to those reporting a delay of more than 10 minutes (0.39/100py [person-years…).” (The best source i have found for these data is the last several slides in this link.)

So there you have it: In December 2006, the Uganda study team reported that circumcised men got less HIV than intact men. Not until 8 months later, in July 2007, did they disclose evidence that intact men who waited to clean their penises got less HIV than circumcised men. Despite their 2007 report, the Uganda study team has continued to say that circumcision is the way to go, and has said nothing more about waiting to clean as an effective option to reduce HIV risk for intact men.

Africans facing HIV risks from both blood exposures and sex need good information. Well-funded official fountains of stigmatizing misinformation blame Africa’s HIV epidemics on too much sex and too many foreskins. But there are also a lot of people offering good information and evidence. As more people speak up – telling what they know about HIV risks, even if it does not coincide with the party line – the African public will get a better idea about HIV risks and how to protect themselves.