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Circumcision: Digital Manipulation May Lead to Reduced Vision

Following my previous post, I’ve put together some of the data available on HIV and circumcision on this site, along with some additional data, in order to emphasize a few points.

Convincing arguments have been made to show that there is no overall benefit found when comparing HIV prevalence among circumcised and intact men in a number of countries for which figures are available; prevalence is higher among circumcised people in some instances and higher among intact people in others.

This raises the question of whether circumcision, or perhaps circumcision on its own, might be irrelevant to heterogeneity among HIV epidemics. After all, there are other differences, aside from circumcision status, between the populations of various countries for which figures are available.

Here’s an example: there’s a group of seven countries which were formerly colonized by Belgians, French and Portuguese (or remained uncolonized) for which circumcision/HIV related information is available. With the exception of Mozambique, the former Portuguese colony, HIV prevalence in the others is low to medium. The total number of HIV positive people in these countries is estimated at just under four million.

Country, year HIV+ Circ HIV+ Intact Ratio Colonial Power HIV prev PLHA
Burundi, 2010 1.6 1.3 1.3 Be 1.3 89,000
Rwanda, 2005, 2010 3.8, 3.4 2.7, 3.1 1.4, 1.1 Be 2.9 210,000
Burkina Faso, 2003, 2010 2.1, 0.9 4.2, 1.9 0.50, 0.47 Fr 1 110,000
Cameroon, 2004 5.1 1.5 3.5 Fr 4.5 600,000
Cote d’Ivoire, 2005 3.4 5.2 0.64 Fr 3.2 450,000
Ethiopia, 2005, 2011 1.2, 1.2 1.3, 1.1 0.93, 1.1 n/a 1.2 790,000
Mozambique, 2009 7.8 15 0.52 Po 11.1 1,600,000
TOTAL           3,849,000

But there’s another group of nine countries which were formerly colonized by the British. Although prevalence is low in one of them, located in lower prevalence West Africa, the others are all high to very high prevalence countries, coming to a total of just over nine million HIV positive people. Indeed, about 80% of all HIV positive Africans reside in former British colonies, which comprise more than half the population of Africa.

Country, year HIV+ Circ HIV+ Intact Ratio HIV prev PLHA
Ghana, 2003 2.0 1.8 1.1 1.4 240,000
Kenya, 2003, 2008-09 3.6, 3.9 22, 21 0.16, 0.17 6.1 1,600,000
Lesotho, 2004, 2009 26, 23 24, 25 1.0, 0.94 23.1 360,000
Malawi, 2010 14 10 1.4 10.8 1,100,000
Swaziland, 2006-07 26 29 0.91 26.5 210,000
Tanzania, 2003-04, 2007-08 7.5, 4.6 7.4, 9.0 1.0, 0.51 5.1 1,500,000
Uganda, 2004-05, 2011 4.7, 5.3 7.3, 8.0 0.64, 0.67 7.2 1,500,000
Zambia, 2007 13 15 0.87 12.7 1,100,000
Zimbabwe, 2005-06, 2010-11 20, 16.1 19, 15.5 1.1, 1.0 14.7 1,400,000
TOTAL         9,010,000

Undeniably, HIV prevalence and circumcision do show a very strong North/South divide. Most men (and many women) in northern African countries practice some form of genital alteration, known as circumcision when applied to men, and HIV prevalence is very low in these countries. In contrast, circumcision is not predominant in most of the highest prevalence countries in southern Africa.

There are fewer than 150,000 HIV positive people in Egypt, Libya, Algeria, Niger, Mauritania, Tunisia, and Morocco combined, these countries comprising almost 20% of the population of Africa. But I would argue that the northern countries did not ‘successfully fight off’ HIV, as is sometimes suggested. In fact, the virus didn’t arrive in the region until the mid-80s, more than three decades after it established itself in eastern Africa.

There are sex workers, men who have sex with men, intravenous drug users, clients and partners of these groups in northern African countries, just as there are in all other countries in Africa (and the rest of the world). The enormous Sahara Desert may have shielded northern African countries to some extent from the spreading virus, but prevalence is not low there because ‘unsafe’ sex is less common than in southern countries.

Southern and eastern African countries are almost all former British colonies, whereas only a handful of former British colonies can be found in Equatorial, western or northern Africa. Of course, the British colonials didn’t spread a virus they still hadn’t heard of, nor did the non-British colonials avoid spreading it.

Rather, the colonials developed the structures that allowed the virus to spread, with varying levels of efficiency; the roads, railways and ports, the overcrowded cities, the oversubscribed health facilities, the industrial outlets, especially extractive industries, the huge pools of labor, living in squalor away from their families, etc.

So, the influence of certain types of administration on determinants of health (and disease) may be behind much of the heterogeneity found HIV epidemics in African countries. But there is nothing to lead one to the conclusion that circumcision status, or even sexual behaviour, are clearly linked to HIV prevalence.

If you start out believing that HIV is almost entirely transmitted through ‘unsafe’ sexual behavior, and that circumcision gives some level of ‘protection’ against HIV transmission, some of the figures bandied about might persuade you that it’s a good idea to spend billions aggressively recruiting as many men as possible to be circumcised; but that’s all down to your preconceived views.

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