Bloodborne HIV: Don't Get Stuck!

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Kenya: Needle Exchange Programs Could Save Lives

Despite the success of needle exchange and other harm reduction programs around the world, there people and institutions who still reject them. Even though injection drug use is said to contribute a relatively small proportion of HIV infections in Kenya, apparently some community and religious groups don’t always wish to support them. Perhaps they do not understand harm reduction?

Canada has been particularly open to needle exchange and other programs, and the view that “Drug users shouldn’t be given clean needles…it only encourages them” is a minority view now, thankfully. If needle exchange reduces transmission of HIV and hepatitis, it must be encouraged. While it may not cut injection drug use directly, it provides a means of reaching out to users in a meaningful way.

Persecuting durg users and suspected drug users, searching and questioning them, using possession of syringes as a reason for arresting them and confiscating their injecting equipment, do not ultimately result in a reduction in injecting drug use. Worse still, these actions result in users facing potentially more dangerous conditions, as well as increasing syringes and needle reuse.

Community and religious groups may be influenced by a hangover from the Bush era. Bush had a sort of ‘victorian’ influence; if he believed something, no matter how stupid, his supporters (sort of hard to believe he had them, but he must have) would believe the same thing. This is especially true of his supporters who were in receipt of US funding for their activities.

The contribution of prison populations to the HIV epidemic in Kenya is also said to be high. Even Canada, the US and Australia don’t have a needle exchange program in prisons, but it would be wise for Kenya to establish where infections are coming from among prisoners.

Aside from the copious innuendo about what men do in prisons, male to male sex is likely to be an issue in a country where it can land you in prison. Prisoners must face other risks, too. Injection drug use is one possibility, but also perhaps tattoos, body percing, blood oaths, traditional practices occur in prisons? Even sharing razors and other sharp objects carries some risk.

Kenya’s Modes of Transmission Survey is not a reliable means of estimating the combined contribution of several groups, such as injection drug users and prison populations. People who fall into these groups may face a high risk of being infected, yet few intervention programs are currently aimed at them.

Needle exchange programs would be a good start and may help to launch other programs, such as opioid replacement therapy, in the long run. But other programs addressing prisoners, men who have sex with men, sex workers and others could address between 20 and 30% of HIV transmission, which is a very substantial figure.

Too many African countries have been swayed by Western prudishness about sexual behavior in their approach to HIV. They have adopted some of the homophobia, xenophobia and other prejudices on which various wars on ‘terror’, ‘drugs’ and the like have been based. This has not led to rapid reductions in HIV transmission; so it’s time for a change.

The Only Certainty About Unsafe Healthcare and HIV is Ignorance About It

An article by Ndebele, Ruzario and Gutsire-Zinyama, who work for the Medical Research Council of Zimbabwe, claims to dismiss the ‘wait and wipe’ finding, which came from circumcision studies carried out in Africa. This refers to the finding that men who waited at least 10 minutes after coitus and used a dry cloth to wipe their genitals were far less likely to be infected with HIV than both circumcised and uncircumcised men who did not follow this procedure.

What is most extraordinary about this finding is that it has been feebly denied by some, but ignored by far more; in contrast, the findings about a rather weak association between circumcision and HIV transmission was used to push an extremely aggressive, well funded and loudly publicized program to circumcise as many African males, both teenagers and children, as possible.

One should no longer be surprised when researchers embrace the results they expected, while at the same time distancing themselves from those they don’t expect, and certainly don’t want. The ‘wait and wipe’ finding was presented at a conference some time back and was covered by US media. But it never received the attention, or subsequent funding, that mass male circumcision programs received.

So, seven years after those hyped mass male circumcision programs started, and a claimed several million men and boys circumcised under the programs, no further research appears to have been done into this interesting finding. Ndebele et al, who don’t seem aware that HIV prevalence in Zimbabwe is higher among circumcised men, rebuke several commentators, including myself, for suggesting that ‘wait and wipe’ could become an alternative strategy to circumcision.

What I said was that appropriate penile hygiene is a lot simpler, cheaper, safer and less invasive than mass male circumcision. The circumcision enthusiasts have encouraged people to associate circumcision with hygiene, but they have never shown that HIV transmission has anything to do with penile (or vaginal) hygiene. It simply suits their purposes that people seem ready to believe in such a connection.

So how can Ndebele et al question the findings about penile hygiene without also questioning those about mass male circumcision? And how can they not call for further research to be carried out? They accuse myself and other commentators of engaging in ‘pure speculation’, which we do engage in. But we are not the ones who collected the original data, some of which we now wish to selectively dismiss, and the rest of which we wish to use to aggressively promote circumcision programs.

So they proceed to engage in pure speculation of their own, and they seem to believe they are ‘dismissing’ arguments about the possible role of unsafe healthcare with a rhetorical question: they ask “With all the campaigns on safe needles that have been going on, where on earth can one still find health professionals using unsafe needles?” The answer is that syringe reuse is likely to occur in every high HIV prevalence African country.

Merely running a campaign about unsafe healthcare and syringe reuse does not reveal the extent of HIV transmission through these routes. Nor does running a campaign ensure that unsafe healthcare simply ceases to be an issue after a few years. No number of strategies, position papers, frameworks, roadmaps, multi-page reports, toolboxes or other pen-pushing exercises so beloved by the HIV industry will tell us the extent of non-sexual transmission of HIV through unsafe healthcare.

Nor will ‘putting unsafe healthcare on the agenda’ (no matter for how long) ensure that any meaningful changes will come about. Most people know little about non-sexually transmitted HIV and are constantly told that 80% of transmission or higher in Africa is a result of unsafe sex. Researchers rarely even mention HIV transmitted through unsafe healthcare, except to dismiss it, without evidence.

The authors argue that the results they wish to embrace are correct and that the results they wish to deny are merely a “coincidental finding”, and conclude that “there is no need to conduct further research” into the ‘wait and wipe’ finding.

This just about sums up the HIV industry’s approach to mass male circumcision. This has been a process of scrabbling about for data, any data which appears to support the program, and denying or ignoring any data which shows the program to be a hoax; all cobbled together by greedy (and probably somewhat pathological) ‘experts’, who will do anything to promote circumcision, ably supported by an institutionally racist HIV industry.

Hepatitis B Virus and Kenya’s Mass Male Circumcision Programs – Why the Secrecy?

With all the posturing in the recently released Kenya Aids Indicator Survey (2012) about mass male circumcision, whether performed in completely unsterile conditions found in traditional settings or the (hopefully) more sterile settings of health facilities, nothing was mentioned about hepatitis B or C. But an article in the East African describes a piece of research carried out by the Kenya Medical Research Institute into hepatitis B (HBV) which finds that prevalence is increasing.

Amazingly, the article admits that the “modes of transmission [for HBV] are similar to HIV — sexual transmission, contaminated blood products and mother to child transmission”; it is “passed from person to person through bodily fluids such as blood, semen or vaginal fluids”. Following a recent paper on HIV transmission through medical injections, it is very important to stress that HIV, like HBV, can be transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

The article is equally frank about the lack of research into HBV in Kenya: “scientists say the reason for the rise in HBV in Kenya is still unknown since no scientific study has been done to explain the phenomenon”. In contrast, the HIV industry is a lot less frank about non-sexual HIV transmission, even though the country’s Infection Control Policy admits that “Epidemiological data on HAIs [Healthcare Associated Infection] in Kenya is currently lacking, but the risk for HAIs is high”. Slowly, some of these glaring gaps in research are being filled in, though the HIV industry displays a confidence that seems entirely unjustified.

Importantly, HBV among blood donors in Kenya is rising. Are those donating their blood being exposed to contaminated medical instruments through the blood transfusion services? The Kenyan Blood Transfusion Service is not able to supply enough blood to keep up with current demand, so they would need to make sure that people who donate are not being put at risk of infection with HBV or other blood borne viruses. While no one would want to scare people away from health facilities or from blood donation, keeping risks a secret would surely be a lot worse, wouldn’t it?

The article suggests that the counties finding high rates of HBV are in the Northern parts of Kenya (which often have the lowest HIV rates). It is suggested that “The likely causes of HBV in the region are cultural practices like tattooing, circumcising without using sterilised implements and because the regions are dry and people may not be able to get proper nutrition that ensures strong immunity.” As usual, there is a reluctance to ask if health facilities might also be somewhat responsible; does that mean these facilities will not be investigated, and that conditions, if unsafe, will not be improved?

There are various hepatitis related campaigns, but are WHO and other international health institutions going to ensure that all the people involved in the country’s mass male circumcision programs, will be protected from infection with HBV and hepatitis C virus (HCV) as well? WHO makes vague claims about huge proportions of HBV and HCV being transmitted as a result of unsafe healthcare. But what exactly are the figures for ‘priority’ mass male circumcision countries? Again, it’s likely that healthcare safety is more of a risk in these ‘priority’ countries, some of the poorest countries, with amongst the lowest levels of healthcare spending in the world, than it is in Western countries; why are we only given one, generalized figure, when the viruses must be much more prevalent in some countries than others?

Egypt, as (just one) example of a country with a serious hepatitis problem, has seen the figure for years of life lost (YLL) through HBV increase by 3,930% in the 20 years from 1990 to 2010. Liver cancer has increased by 361% in the same period. Cirrhosis has increased by 40% to become the number three cause of YLL, accounting for 1,127,000 YLLs, or 7.1% of all YLLs. Whether the almost 100% prevalence of circumcision in the country contributes to these figures is another question, but it shows what can happen in a country where there is a very high level of access to healthcare, yet where healthcare safety is not adequately addressed. One of the main reasons HCV prevalence is higher in Egypt than anywhere else in the world is because of schistosomiasis vaccination programs, which were carried out using inadequately sterilized glass syringes.

Reusable syringes and needles are no longer commonly used, but the WHO data shows that there is still a problem with unsafe injection practices. So the last thing high HIV prevalence African countries need is a vastly increased risk of bloodborne virus transmission through unsafe healthcare, whether this involves reuse of injecting equipment or other items that are used to pierce the skin during healthcare procedures. Mass male circumcision programs will likely increase the incidence of unsafe healthcare practices, including injections, and the WHO’s claimed benefits in terms of averted infections may not be enough to outweigh the risks involved.

Even if levels of protection against sexually transmitted HIV outweigh the risks, and this is highly debatable (and debated, outside of the HIV industry), what about the risks of infection with HBV, HCV or other bloodborne pathogens, including HIV, during the circumcision procedure itself? Some recent research has questioned the safety of Kenya’s health facilities. There are clearly more risks than those pushing the circumcision programs would like to admit; so will those who succumb to HIV industry pressure be advised of those risks? I suspect they will not.

Mass Male Circumcision: Cultural Imperialism and ‘Public Health’

Three-quarters of women interviewed in Kenya’s highest prevalence province say they prefer circumcised partners” screams the headline. Except that only 30 women were interviewed.

There’s a whole rash of articles in praise of circumcision on the PLOS ONE site (Public Library of Science) that I simply don’t have the time or energy to read. Articles about how wonderful the operation is in reducing HIV transmission from females to males (not the other way, though) don’t appear to have found anything new in all the years they have been coming out. That is, aside from different ways of exaggerating the very small level of protection circumcision may afford men, other things being equal.

Women interviewed also believed, incorrectly, that circumcised men are ‘more hygienic and cleaner’. I wonder what would lead to them believing such a thing? Many people believe that a woman must wash herself after (and sometimes before) sex to be ‘more hygienic’, yet it has been known for some time that this is not only untrue, but that ‘vaginal douching’ increases the risk of infection with HIV. The same is true of male genital douching, but it was circumcision enthusiasts who established this, so they are not in a hurry to disabuse people of this dangerous myth.

It is hard not to see the push for circumcision, which comes almost entirely from the US, as highly stigmatizing and culturally imperialistic. It sounds as if men (and women), who in this instance belong to a non-circumcising tribe, are being told that Luo men are dirty because they are uncircumcised and that, since HIV is almost always transmitted through unsafe sexual behavior in Africa (a popular HIV industry myth), this ‘lack of hygiene’ is caused by not being circumcised. All they have to do is submit to circumcision and everything will be fine.

The branding of Luos as unclean and unhygienic by Western health practitioners is no less despicable than the views of other Kenyan tribes, who do practice circumcision, about Luos being ‘mere children’ and their leaders being ‘unfit to govern’ the country because they are uncircumcised. It is beliefs like this that have contributed to a lot of the ‘tribal’ violence Kenya has experienced, especially around election time. It seems the Western funded efforts to circumcise hundreds of thousands of Luos, perhaps millions, are not above using ‘tribalism’ to achieve their own ends.

Despite the small numbers, it is alarming that most of the women are said to express a ‘preference’ for circumcised men on the basis of beliefs that even the author accept are unproven: that circumcised men are ‘cleaner’ or ‘more hygienic’, that it takes them longer for them to ejaculate and that they ‘perform better’. Especially as the number who have ‘true’ beliefs, ones propagated by those promoting circumcision, is a lot smaller.

Is this kind of ‘demand creation’, based on complete lies, acceptable just because those doing the highly aggressive promotion claim that circumcision is effective at reducing HIV transmission from women to men (the absolute reduction being about 1.3%)? Or is it completely unacceptable, not because the reduction is very small, or because the randomized trials constantly referred to are highly suspect, but because this is a crude piece of cultural imperialism dressed up as a public health program?

GlaxoSmithKline: “How Modern Clinical Trials are Carried Out”

We would need further details to investigate what actually took place, but the practices outlined certainly don’t reflect how modern clinical trials are carried out. We conduct our trials to the same high scientific and ethical standards, no matter where in the world they are run.

That’s a comment from a GlaxoSmithKline spokesperson following the discovery of mass graves of an estimated 800 children in Ireland, who are thought to have died while taking part in ‘secret’ clinical trials, for which there is no evidence informed consent was ever given. That’s a huge number of deaths, by any standards. It is to be wondered how many deaths (and injuries) it took before the trials were stopped.

It would be nice to think that the GSK spokesperson is right, that such things could never happen today. But there’s a whole list of unethical practices in Wikipedia that GSK have been involved in, and those are just the more recent cases. And what about their current collaboration with the Gates Foundation to develop a malaria vaccine? Such a vaccine would be a godsend, but who is keeping an eye on them, given their record?

I don’t doubt that such things no longer happen in Ireland, nor in other Western countries. But unethical practices in African countries are certainly not a thing of the past.

The Don’t Get Stuck With HIV site has a section on DepoProvera (DMPA) hormonal contraceptive, which evidence suggests may increase infection with HIV among those using, and onward transmission by those using the method. Also on this site David Gisselquist has written about the unethical behavior of health professionals who have failed to investigate or act in any way on evidence that infants and adults may have been infected with HIV through unsafe healthcare.

WHO have been dragging their feet over unsafe healthcare, especially unsafe injections through reuse of injecting equipment, use of DepoProvera in HIV endemic countries and various non-sexual modes of HIV transmission. There are also the mass male circumcision campaigns, which are based on lies about research that was carried out in Kenya, South Africa and Uganda. It has never been explained how people who seroconverted during these trials were infected with HIV, it was just claimed that they must have had unsafe sex. Though many of the men did not have any obvious sexual risks, non-sexual risks were not considered, including the circumcision operation itself.

The list of serious ethical breeches goes on. Some participants taking part in the circumcision trials were not told they were infected with HIV, and were followed to see how long it would take for them to infect their partners, who also weren’t told they were at risk. This resembles the Tuskegee and Guatemala Syphilis ‘Experiments‘, which also ended in the 1960s. Yet mass male circumcision campaigns are ongoing and extremely well funded, despite not having anything like the rate of takeup anticipated by those making a lot of money from carrying out the operations.

There has been some secrecy surrounding DepoProvera, and a lot of data about mass male circumcision may have been collected but never released, but much of the data about these issues is readily available to anyone with an internet connection. Like the results of the Irish trials, much of the research was published in “prestigious medical journals”. But I assume this is not what GSK is referring to when they talk about ‘modern clinical trials’?

Uganda: Mystery About Effectiveness of Circumcision Against HIV

The HIV industry’s circumcision division has put a lot of effort into denying that circumcised men may feel that they can safely engage in ‘risky’ sexual behaviors. But some peer reviewed articles have found that circumcised men feel that, being circumcised, they are not at risk of sexually transmitted HIV, or that their risk really is lower as a result of being circumcised.

The problem is, how do they know how circumcised and uncircumcised men become infected? They may believe the HIV industry’s mantra about almost all HIV transmission being a result of unsafe sex in African countries, but nowhere else. But what if the HIV industry is wrong? They have never checked. They have never traced people’s partners systematically or assessed their non-sexual risks, from unsafe healthcare, traditional and cosmetic practices, they have never investigated infections that were clearly not sexually transmitted.

The industry seems to feel that the end justifies the means because HIV prevalence has turned out to be lower among circumcised men in some circumstances. But if they don’t know how some men, circumcised and uncircumcised, became infected, how do they know that circumcision protects them? If circumcision is associated with higher HIV prevalence in some countries and lower prevalence in other countries, perhaps circumcision status is irrelevant. Perhaps sexual behavior is irrelevant, the HIV industry just doesn’t know.

So millions of men are said to be lining up to be circumcised and they don’t know whether it will really protect them, whether it will increase their risk or whether it will have no effect at all. They also don’t know how safe conditions are in the clinic where the circumcision is carried out.

[For more about the ineffectiveness of Male Circumcision against HIV visit our circumcision related pages.]

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?

What Happens when an ‘Activist’ Site is Bought off by the Multinationals?

The website ‘’, which is about HIV, but from a US point of view, has a recent article on circumcision by Ben Ryan, who is apparently a journalist. The strapline reads “Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?” The question is odd, because the article is not primarily about whether the operation can or can not lower transmission in the US (Ryan seems to suggest the answer is ‘yes’, but in a country where HIV transmission is predominantly among men who have sex with men and intravenous drug users, ‘no’ seems much more likely to be correct). The article is not really about the science either, but rather how that ‘science’ is used. (Even the title, ‘Cut to Fit’, sounds like an ironic reference to the author’s journalistic style.)

Ryan gives a selective review of the ‘science’ as he sees it, listing the major players in circumcision promotion, major in terms of the funding they receive, anyway. But all this is contrasted to an ‘ideological war’, by what Ryan brands as a small group of ‘dissidents’. The fact that many of those who oppose the imposition of mass male circumcision on tens of millions of African men who are not already circumcised, and male infants born to people who would not normally choose circumcision in infancy, are also scientists doesn’t seem relevant. The facts that skepticism is not inherently unscientific and that not all those who oppose mass male circumcision can correctly be referred to as ‘dissidents’ also seem unimportant to Ryan.

Although Ryan enjoys the term ‘intactivist’ to refer to people who oppose mass male circumcision on the grounds that the ‘science’ is highly flawed, this is not a widely used term by opponents. Some, like myself, oppose mass male circumcision on human rights grounds, and on the grounds that insisting on every man conforming to what is an American preference is an outrageous instance of cultural imperialism; but I certainly wouldn’t call myself an intactivist. According to Ryan, those who oppose mass male circumcision are mainly Americans and Europeans, without pointing out that those who promote it are almost all American, and all their funding is from America.

Part of the pretence of ‘giving both sides of the story’ involves interviews with people whom Ryan subtly belittles. One of those interviewed is John Potterat, who has carefully outlined the reasons for skepticism about the ‘scientific’ literature, which is freely available on the Social Science Research Network. According to Ryan and his favored informants, ‘dissidents’ are ‘hampering progress’, ‘spreading misinformation’ and ‘creating skeptics among those who stand to benefit’, the last referring to African people, whose future is being put in jeopardy because of a handful of unscientific people who are not epidemiologists or health scientists, and therefore should not hold an opinion on human rights or cultural imperialism, or so Ryan wants us to believe.

Ryan also interviews Rachel Baggaley, MD, who reassures us that the three million figure the WHO claims have been circumcised under the program sounds very low beside the 20 million originally hoped to ‘benefit’ from the operation because 20 million was an ‘aspirational’ figure; that the WHO had “underestimated the complexities and social sensitivities required to successfully promote the program in certain populations”. Could some of these ‘social sensitivities’ be similar to the views of the people Ryan considers to be a mere fringe of ‘dissent’? What Baggaley is delicately referring to is a dearth of safe health facilities, experienced health personnel and supplies needed to provide mass male circumcision that doesn’t result in a lot of botched operations and a huge increase in hospital transmitted HIV; also, that infuriating barrier to US cultural imperialism: foreigners, non-Americans.

Another ‘dissident’ cited is David Gisselquist, who has spent years publishing articles showing that unsafe healthcare and cosmetic practices may be making a significant contribution to the most serious HIV epidemics in the world, which are all in sub-Saharan Africa. The evidence for various types of non-sexually transmitted HIV is spread over hundreds of papers, written by people from various backgrounds, including public health, medicine, epidemiology and others. Indeed, one of the most important factors in transmitting HIV in African countries is circumcision itself, not just medical circumcisions carried out in unsafe health facilities, but also circumcisions that are carried out for cultural reasons, generally carried out in unhygienic conditions.

While presenting arguments against mass male circumcision in a context that makes them sound futile, Ryan lists the arguments for the program as if they were some kind of holy grail of truth, true for all time, in all places, as true for non-Americans as for Americans. Those pushing for the program keep going on about how similar the results of all the randomized controlled trials were, without this being held up to any kind of questioning; were these crusaders really so lucky, that all three trials came up with almost the same results? Why were the trials carried out in those areas, among those people, with those specific (poorly described) methodologies? Were any other trials carried out that may show the opposite effect? And why are the mass male circumcision programs going ahead in areas where HIV prevalence is already higher among circumcised men than uncircumcised men? What about current programs that are currently suggesting that mass male circumcision programs seem to be increasing HIV transmission, for example in Botswana and Kenya?

Oddly enough, Ryan gives the last word to Baggaley, who now refers to those who oppose the US funded mass circumcision of African men as ‘denialists’. She says they are generally not from high HIV prevalence countries, as if those promoting the program are. Seeing herself as having the perspective of a ‘young man in South Africa’, she finds objections to the operation to be ‘paternalistic’. Evidently she doesn’t see the paternalism in spending billions of US dollars on persuading people to be circumcised by telling them that there are numerous advantages to be enjoyed. How is that different from the various (also US funded) efforts to persuade poor people to be sterilized? How is that different from various syphilis ‘experiments’ carried out on African Americans, or similar ones carried out in Guatemala?

In stark contrast to Ryan’s stance of appearing to be ‘giving both sides of the argument’ while achieving no such thing, Brian D Earp has written a very cogent rebuttal of all the bits and bobs that Ryan thinks of as science. Earp does put his cards on the table: he is not undecided about whether mass male circumcision is a good or bad thing. But neither is Ryan, he just pretends to be. If you are interested in reading solid rebuttals of the arguments of those claiming to be ‘scientists’, and others, it’s worth reading Earp’s article in full. I can not do it any justice by paraphrasing it.

To conclude, branding people as ‘denialists’ or as being ‘unscientific’, even when the point is not a scientific one, or not entirely a matter of science, has a long history. Journalists pretending to be (or thinking that they are?) even handed is also an old trick. So people have to think for themselves: would you do it to someone you love, or would you wait till they were old enough to decide for themselves? And even if your answer is ‘yes’, and you would circumcise your son when he’s still an infant, does that mean tens of millions of African men should be persuaded by the US (and by US funded ‘Kofi Annan’ type figures) to do the same, using a hotch-potch of scare stories, half baked theories and outright lies, all dressed up as some kind of scientific canon, and that tens of millions of African infants should also be circumcised, their parents having been primed using the same body of ‘evidence’?