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WHO Supports Circumcision Despite What They Know About Injection Safety in Africa?


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.

Mass Male Circumcision: Western Sponsored Institutionalized Racism


Malawi News Agency has put out a fatuous ‘article’ about a journalist who has been duped into being circumcised in an effort to persuade others to follow his ‘example’. This reminds me that about 6 months ago I blogged about a misinformation service called Internews, connected with the rather smug Gates Foundation and the BBC. Internews boasts about being able to ensure that only ‘positive’ coverage of the US Government’s mass male circumcision program in African countries with medium to high HIV prevalence appears on African news sources.

This Malawian journalist was, apparently, persuaded also by the fact that circumcision is said to protect against human papilloma virus (HPV), although the evidence for this is even slimmer than that relating to HIV. More importantly, many African countries are already receiving assistance to vaccinate millions of Africans against HPV (currently being piloted), so why promote mass male circumcision as well? Are they afraid the HPV vaccination will not give as much protection as their promotional literature claims?

However this journalist was either too innocent, or too well paid off, to check available figures for HIV prevalence among circumcised and uncircumcised men in Malawi. In 2010 HIV prevalence was 14% among circumcised men and only 10% among uncircumcised men. This makes it look as if not being circumcised is protective. But things get a lot worse if you look at the three regions of Malawi, where HIV prevalence and circumcision are very clearly correlated:

Malawi (2)

How much clearer could this be? It is even possible to view these figures for Malawi another way. A 2013 article entitled ‘Mapping HIV clustering: a strategy for identifying populations at high risk of HIV infection in sub-Saharan Africa‘, using the same data (from the 2010 Demographic and Health Survey) identified three major HIV ‘clusters’ in Malawi. The cluster in the North and the one in the center of the country were of relatively low HIV prevalence, where circumcision rates are low. The cluster in the South of the country was of high HIV prevalence, where circumcision rates are high.

Internews and their collaborators would not wish anyone to mention this in a national newspaper, as their express aim is to ensure that only positive coverage about mass male circumcision and HIV transmission sees the light of day; or at least that those who are being told these lies and deceptions don’t know that there are things about circumcision they would be well advised to research. Reading a newspaper that has been bought off by some misinformation service is not research.

The article is full of the usual anecdotal rubbish about mass male circumcision, including some deluded victim of Internews and Co. (also a journalist) who had a problem with penetrative intercourse before being circumcised, the old chestnut about circumcision making people “clean and free of bad odours” (despite making it clear that some of these people suffering from bad odors ‘wear the same underwear for several days), sex being better, etc.

Several times the official claim about mass male circumcision is repeated, that it only ‘gives 60% protection, that people still need to use condoms’ and the usual claptrap. The article even points out that circumcision rates are high in the South and low in the other two regions. But, and this is the clever Internews bit, they don’t bother mentioning that HIV prevalence in the country is highest where circumcision is more widely practiced and lowest where circumcision is less widely practiced.

One of the biggest worries about mass male circumcision is that being circumcised only sometimes appears to be correlated with lower HIV prevalence; just as frequently it appears to be correlated with higher HIV prevalence. Given that there is no known mechanism by which circumcision could protect against HIV infection (only a handful of vague protohypotheses), these differences make it clear that there is a lot more to HIV transmission than circumcision status.

The clear message about mass male circumcision and HIV being payrolled by Internews, Gates Foundation, UNAIDS, PEPFAR and the likes is that Africans are promiscuous, reckless, ignorant and unhygienic; this kind of neo-imperialist institutionalized racism is par for the course in the HIV industry (yes, it is an industry, just like development) and would be condemned as such in most western countries (aside from the US, and perhaps the UK, apparently). So why do we find it acceptable to allow people in high HIV prevalence countries to be systematically deceived?