The World Health Organization’s (WHO) mass male circumcision page states that the operation reduces risk of HIV transmission from females to males (etc), and that they and UNAIDS recommend circumcision as a strategy for HIV prevention, “particularly in settings with high HIV prevalence and low levels of male circumcision”. The claimed maximization of “public health benefit” raises many questions, about compatibility with their current victim blaming and individual responsibility strategy, and also about what can be done in areas with high rates of circumcision and high rates of HIV prevalence (or do they have a policy on foreskin reconstruction?).
But the question I’d like to concentrate on is what WHO means by ‘settings’. If it refers to high HIV prevalence countries, then they must be aware that most HIV epidemics do not follow national or other geographical or political boundaries. Malawi, as mentioned in a previous blog, can be divided into three clusters, two clusters of low HIV prevalence and one of high prevalence. Only the high prevalence cluster has high rates of circumcision. Rwanda, similarly, has three clusters, two of low prevalence and one of high prevalence. Burundi has only one cluster, and that’s the capital city, where most of the country’s HIV positive people reside.
Indeed, high HIV prevalence tends to cluster in cities in most African countries, yet the vast majority of people in most high prevalence countries live in rural areas, where prevalence is often low, sometimes very low. So WHO aims to target up to 80% of males, when most of them can not be said in any useful sense to live in ‘high HIV prevalence settings’. Although HIV epidemics are heterogenous, within as well as between countries, if high prevalence settings refer to anything at all they refer to areas where access to healthcare facilities is high and levels of safety in healthcare facilities are low (for example).
It gets worse because if you look at Burundi and Rwanda’s Demographic and Health surveys (just two examples out of many) you will see that HIV prevalence is higher among Muslim men (mostly circumcised) than men of some of the other (often non-circumcising) denominations; prevalence is lower even among uncircumcised Muslims than circumcised Muslims. Other Demographic and Health Surveys show that HIV prevalence is far higher among Muslim women than among women of other denominations, not just higher than among Muslim men. So, not only does circumcision not always protect men from HIV, it may well have something to do with higher rates of transmission from men to women; this at least merits a bit of investigation, doesn’t it?
What does this have to do with WHO’s (somewhat vague) data on injection safety and healthcare safety, more broadly? Well, in a document on injection safety success stories, the WHO notes that an estimated 25 billion injections are administered annually and that an estimated 70% of them are unnecessary. The report states that “Unsafe practices and the overuse of injections can cause an estimated 32% of Hepatitis B virus, 40% of Hepatitis C virus and 5% of all new HIV (human immunodeficiency virus) infections every single year.” “At least 50% of injections were unsafe in 14 of 19 countries…for which data were available” according to another WHO report.
We don’t know what levels of injection safety are like in WHO ‘priority’ countries for mass male circumcision programs (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). But we may assume, in the absence of data, that high HIV prevalence countries also tend to have higher rates of HIV transmission through unsafe injections. So what is the range of ates? 10%? 20%? The rate would be very low in many Western countries, so it must be fairly high in at least some high HIV prevalence countries to average at 5%. But if we are not told how high rates are, and for which countries, how can ‘priority’ countries even weigh the benefits against the risks? How can WHO, for that matter (yet they do claim benefits, up to “3.4 million new HIV infections” to be averted by 2025, not forgetting savings of US$16.5 billion)?
The 20 million figure that WHO recommends to be circumcised only refers to medical circumcisions (and it doesn’t include children or infants, not yet anyhow), not to all those non-medical circumcisions carried out in unsterile conditions. The number of non-medical circumcisions would be many tens of millions, perhaps even over one hundred million over the course of these mass male circumcision programs (another 11 years to go). What if even just 5% of them were to be infected with HIV through unsafe practices? They won’t be receiving injections, presumably, but one would like to think that WHO approved programs would have higher standards of safety than circumcisions performed in unsterile conditions by non-medically qualified people. Alas, it is difficult to estimate rates of HIV infections through unsafe medical and traditional practices because so little effort has ever been made to collect such data.
WHO and UNAIDS are obsessed with sexual behavior, but reluctant to assess non-sexually transmitted HIV, especially via unsafe injections and unsafe healthcare in general. Yet they are willing to promote mass male circumcision programs to reduce HIV transmission when their own figures suggest that the number of people who risk being infected with HIV through these programs is likely to be far higher than even the most outlandish estimates of infections ‘averted’. Far from being a ‘distraction’ from effective HIV prevention, as some have called it, mass male circumcision programs are likely to transmit several times more infections than they could ever hope to avert.
More salient than country-against-country or even region-against-region comparisons are man-against man comparisons. In 10 out of 18 countries where USAID has figures (including Malawi), more of the individual circumcised men have HIV than the non-circumcised. Circumcision advocates will say (if they address the issue at all) that traditional circumcision (by a pull-forward and chop method) takes less skin than surgical methods. They’ve forgotten, it seems, that the original claim that circumcision protects against HIV at all was made on the basis of comparison between traditionally-circumcising regions and intact regions. So once they’ve climbed that ladder and used it to justify the trials, they kicked it away behind them.
Thanks Hugh, quite so. They are sneaking in infant circumcision in Kenya at the moment, telling people it’s ‘easier’, ‘safer’, even cheaper (which it is, but that’s hardly a reason to choose it for your baby). They’ve found that it’s much easier to recruit very young people, especially those who need their parents’ consent. Infants are even easier still, strangely. But they haven’t had much success with their target groups, who are said to be those most at risk from sexual transmission. So instead they’ve moved to target groups who are at no risk, but are not as difficult to persuade.
Please see the following link for a brief summary, with linked references, of the ethical, legal and methodological flaws with past research informing the present campaign of circumcision-as-HIV-preventative in Africa (which also forms the basis for much of the ‘renewed interest’ in circumcision in recent years among some in the English-speaking world), some of the adverse consequences of funding circumcision-as-HIV-preventative in Africa (coercion of men and boys to be circumcised; misdirection of limited medical resources from higher priority areas) and the absence of oversight of organisations promoting and facilitating male circumcision in Africa:
Thanks Jay Doug, there’s so much wrong with these programs that it’s hard to know where to start. But most of the money is coming from the US and their love for democracy certainly doesn’t extend to ‘foreign’ countries, being essentially neo-imperialist and paternalistic. Some would say it doesn’t extend to a lot of American people as well, but that’s beyond the scope of this blog. Anyhow, keep protesting, tell anyone you can, especially if they are not interested.