Bloodborne HIV: Don't Get Stuck!

[This introductory page links to other pages: Intact men have less HIV in many African countries! — Circ’ing and HIV outside Africa — Critique of 3 trials of circ to protect men — do vaginal fluids stop HIV? — options for intact men to avoid HIV from sex — Men and boys harmed by circ’ing — Impact of male circumcision on women’s HIV risk — Plans to circ millions, achievements falling short — Some anti-circ resources. But if you still want to get circ’d, here’s how to ensure you don’t get HIV from the procedure.]

Blood-borne transmission drives Africa’s HIV epidemics

For more than 30 years, from the first use of tests for HIV antibodies in Africa in 1984, researchers who have asked about injections and other skin-piercing procedures, and not just asked about sex, have repeatedly found that healthcare likely infects as many or more Africans as does sex.[1,2] Public health agencies from WHO to Africa’s ministries of health have ignored the evidence, have not cleaned up health care, and have instead accused HIV-positive Africans of sexual misbehavior. Sexual transmission, is there, of course, but it is derivative; people who get HIV from unsafe healthcare can pass it to sexual partners.

Africa’s continuing HIV epidemics presented an opportunity for proposed solutions, even ones that made no sense. Circumcising men is one such nonsense response.

The US wants to circumcise millions of men in Africa

In 2007, WHO and UNAIDS recommended circumcising men in Africa to prevent HIV.[3] The US leads the charge. WHO’s and UNAIDS’ 2012 “joint strategic” plan to circumcise more than 20 million men in 14 countries lists 11 “stakeholders”: four US government agencies (Department of Defense, USAID, CDC, and the State Department’s global AIDS czar), the Gates Foundation, and three international organizations in which the US is the major funder (World Bank, UNAIDS, and WHO).  No other government or organization in Europe or elsewhere signed the plan.[4]

Why are so many US politicians and health experts so eager to circumcise men in Africa? At least part of the answer may be the unusual popularity of circumcision in the US. Across 35 rich countries (ie, OECD member countries), the median percentage of men circumcised 6%. Aside from Israel and Turkey, where religion promotes circumcision,  no other rich country has more than 33% of men circumcised – except the US (71%) and South Korea (77%).[5]

Why circumcise? Relying on selected evidence from unethical trials

Outside Africa, less than one man in 1,000 gets HIV through their penis, and most men are intact (uncircumcised). Within Africa, intact men are less likely to be HIV-positive compared to circ’d men in more than half of the countries with available data, including 4 of 14 countries where the US targets men for foreskin removal.

The main excuse to circumcise men in Africa – the excuse the US uses — comes from three partially reported and unethical trials in Africa that are widely believed to show circumcision reduces men’s risk to get HIV from sex by >50%. Even the reported evidence from these trials undermines that claim. And why did study teams withhold so much collected and relevant evidence?

Dangerous procedures

As a response to a nosocomial epidemic, circumcising millions of men is dangerous. It has been promoted with insufficient care — putting men at risk for discomfort and much worse, including bloodborne infections, such as HIV, hepatitis B, hepatitis C, and other infections. These dangers are coming to the fore with recent reports of adverse events, including deaths from tetanus. Thankfully, the numbers circumcised have fallen far short of targets; but ambitious targets remain.

References

1. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003; 14: 148-161. Available at: http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf (accessed 18 April 2018).

2. Gisselquist D. Randomized controlled trials for HIV/AIDS prevention among men and women in Africa: untraced infections, unasked questions, and unreported data. Social Science Research Network 2011. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999 (accessed 21 May 2017).

3. WHO, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. Geneva, WHO: 2007. Available at: http://apps.who.int/iris/bitstream/handle/10665/43751/9789241595988_eng.pdf;jsessionid=FBAEAFE7FB9E7D69C17004CF4BE9801E?sequence=1 (accessed 17 April 2018).

4. WHO, UNAIDS. Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa. Geneva: WHO, 2012. Available at: http://www.who.int/hiv/pub/strategic_action2012_2016/en/ (accessed 17 April 2018).’

5. Morris BJ, et al. Estimation of country-specific and global prevalence of male circumcision. Pop Health Metrics 2016; 14: DOI 10.1186/s12963-016-0073-5. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4772313/pdf/12963_2016_Article_73.pdf (accessed 17 April 2018).