Health-e (Cape Town)
9 May 2008
Top researchers have called for male circumcision and the reduction of multiple sexual partnerships to become the cornerstone of HIV prevention in Africa if a significant impact is to be made on the HIV epidemic.
Policy analysis led by researchers at the Harvard School of Public Health (HSPH) and the University of California, Berkeley, found that the most common HIV prevention strategies - condom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinence are having a limited impact on the predominantly heterosexual epidemics found in Africa.
The researchers also said some of the assumptions underlying such strategies such as poverty or war being major causes of AIDS in Africa are unsupported by rigorous scientific evidence.
"Two interventions currently getting less attention and resources- male circumcision and reducing multiple sexual partnerships - would have a greater impact on the AIDS pandemic and should become the cornerstone of HIV prevention efforts in the high-HIV-prevalence parts of Africa," the researchers argued.
The research paper appears in the journal Science this week.
"Despite relatively large investments in AIDS prevention efforts for some years now, including sizeable spending in some of the most heavily affected countries (such as South Africa and Botswana), its clear that we need to do a better job of reducing the rate of new HIV infections. We need a fairly dramatic shift in priorities, not just a minor tweaking," said Daniel Halperin, lecturer on international health in the HSPH Department of Population and International Health and one of the paper's lead authors.
The AIDS pandemic continues to devastate some populations worldwide.
In most countries, HIV transmission remains concentrated among sex workers, men who have sex with men and/or injecting drug users and their sexual partners.
In many parts of Africa, especially sub-Saharan Africa, HIV has jumped outside these high-risk groups, creating generalised epidemics spread mainly among people who are having multiple and typically concurrent (overlapping, longer-term) sexual relationships.
In nine countries in southern Africa, more than 12% of adults are infected with HIV.
The authors said that the current widely used prevention strategies, while having value in some instances, are not as effective at preventing HIV transmission as male circumcision and reducing multiple sexual partners and thus should not continue to receive the bulk of donor investments for prevention, especially in Africa.
They cited the example of Thailand where condom use is widely promoted as an HIV prevention measure and is effective as the epidemic is spread primarily through sex work.
"However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa," the authors said.
They said this was mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.
"The evidence is similarly lacking for other popular prevention approaches as well," Halperin and his nine co-authors said.
Studies have shown no consistent reduction in risk for those testing HIV-negative and testing programs have produced no evidence of HIV reduction in populations, they said.
"The treatment of other STIs has had discouraging results; vaccine development trials and microbicide testing have been disappointing; and abstinence is not likely to have a major impact since most HIV infections occur among people in their 20s or older, when most are already sexually active," they said.
The authors pointed out that in contrast, many studies in the last two decades have shown that male circumcision significantly reduced the risk of heterosexual HIV infection.
In west Africa, where male circumcision is widespread, the prevalence of HIV remains relatively low.
When initial findings from three recent randomized controlled trials of male circumcision in Africa showed at least a 60% reduction in HIV risk, the trials were stopped early because it was not ethical to withhold the clearly proven benefits of this simple surgical procedure.
"It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling. Large numbers of people will die as a result of this error," said Malcolm Potts, co-lead author and Bixby Professor of Population and Family Planning at UC Berkeley School of Public Health.
Similarly, partner reduction appears to have played a primary role in reducing HIV rates in Uganda, Kenya, Zimbabwe, Cote dIvoire, and in urban Malawi and Ethiopia.
Ugandas Zero Grazing campaign, initiated in 1987, indicated that reducing partners can be achieved on a large scale as later surveys revealed that the number of people reporting multiple and casual partners declined by over half.
"The political fight in the United States between supporters of condoms and supporters of abstinence has obscured the importance of what is arguably the most powerful of what are known as the three ABC strategies (Abstinence, Be Faithful, Condoms), which is the B, or partner reduction and fidelity aspect," according to the papers authors.
The authors also argued that HIV prevention priorities needed to shift significantly to reflect the best available scientific evidence. They noted that only 1% of total prevention funding requested by the United Nations AIDS Program is earmarked for male circumcision, and that reducing multiple sexual partnerships would probably garner only a small fraction of community mobilization and mass media, workplace or other HIV prevention investments.
The vast majority of donor investments in HIV prevention in the generalized epidemics of Africa continue to go to approaches for which the evidence of actual impact is increasingly unclear, said Halperin.
"Many of these approaches, such as HIV testing and treating other STIs, do have important public health benefits, and should be continued, but not because we believe they will definitely have a major impact on reducing HIV infections," he said. - Health-e News Service
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Circumcision can only possibly help men who have unsafe sex with HIV+ partners, so why this bizarre obsession with genital surgery when we know that ABC works better than circumcision ever could? (ABC=Abstinence, Being Faithful, Condoms). The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than in intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, and Tanzania. Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives. It's worth noting that Daniel Halperin is the grandson of a mohel, so can't be considered objective about circumcision.
Latest news is that HIV+ men are more likely to transmit the virus to women if they are circumcised.
Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that. In fact we're trying to stamp out female circumcision, something which won't be made easier by promoting male circumcision.
It is the same few "top researchers" - Daniel Halperin among them - who did the human experiments in order to claim that circumcision protects against HIV, who multiplied the small numbers of men involved by hundreds of thousands to claim that millions would be protected, and who now push for funding to be diverted from condoms - which work - toward circumcision.
In the Kenyan experiment, a greater proportion of the circumcised men got HIV than the non-circumcised men in Uganda, where there was a "Zero grazing" campaign.
These experiments were not (and maybe could not have been) double-blinded or placebo-controlled, and both experimenters and experimentees very much wanted circumcision to be effective, so bias is likely. Many more men dropped out, their HIV status unknown to the researchers, than were known to be infected, so circumcision could easily have had no effect at all. Evidence of non-sexual transmission was ignored.
For thousands of years people have believed that cutting men's and boy's foreskins off will have magical benefits. This is just one more.
What these authors are suggesting here is insane. There is a very real risk that many people will miss the part that CONDOMS are STILL required. There are already stories leaking out about people overestimating the protective effects.
In this recent article in the trinidad express[1], we have this gem: "Aah," one subject said during trials, "I have a natural condom." Or from Rwanda, in a recent article[2] by David Gusongoirye, Nothing can fight HIV/AIDS better than discipline, speaking of the new campaign a man was quoted as saying: "Mister, these Aids people have spoken for long about fighting the disease, but they had never come up with a practical solution as good as this one. Don’t have sex, don’t do this, don’t do that. Eh, man, how can a young man such as I forfeit sex, eh? And the condoms – where is the sense in putting on a condom when you are having sex? Sex is about feeling, and so no young person likes them!" There are some circumcised men who will get HIV in part because now they believes they has a "natural condom".
In a study published on the effectiveness of condoms in preventing HIV acquisition, heterosexual couples that included an HIV-infected partner used condoms consistently in a total of about 15,000 instances of intercourse. None of the uninfected partners became infected.[3] So if we just get down to the proverbial brass tacks the whole issue boils down to the following question: If you are circumcised can you have unprotected sex with a partner whose HIV status is positive or unknown and NOT worry about getting infected? Clearly the answer is no. The critical point is you have only two options:
A. You don't need a circumcision, but you need to always wear a condom and be choosy about your sex partners.
B. You can get a circumcision but you need to always wear a condom and be choosy about your sex partners.
The primary advice just doesn't change. A recent article[4], The No-Brainer Syndrome, discusses this point particularly well; as does a recent editorial in Future Medicine[5]. The Australian Federation of AIDS Organization's had two excellent publications on this issue: Their July 2007 statement[6] and one that was distributed at at last year's International AIDS Society Conference[7]. The second said in part: "How a man factors the known risk reduction alongside the unknown variables into his sexual decision-making is the important thing. Unless he opts to use condoms with all sexual partners whose HIV status is positive or unknown, he remains at risk of acquiring HIV (and if he does this, there is no need to be circumcised for added protection)." That's good advice.
There has been a lot of progress made in Africa over the last decade with regard to HIV. In Rwanda, for example, the HIV/AIDS rate has fallen from 11% of the adult population in 2000 to 3% in 2007 using conventional HIV reduction strategies. There are no short cuts, no silver bullets. The only way to deal with HIV in Africa is through safe sex, education, and pulling people out of poverty. We won't cut our way out of it and if we want to do them a favor we would buckle down and do the actual hard work that needs to be done. If condoms are not available everywhere we need to solve the distribution problem. If they are for some reason not willing to use them this too must be fixed. It is a message that we shouldn't muddy lest we undo all the hard work that has been done to ameliorate the epidemic over the last 20 years.
[1] http://www.trinidadexpress.com/index.pl/article_features?id=161191863
[2] http://www.newtimes.co.rw/index.php?issue=13438&article=4113
[3] De Vincenzi, I. “A Longitudinal Study of Human Immunodeficiency Virus Transmission by Heterosexual Partners,” New England Journal of Medicine 331 (1994): 341-6.
[4] http://www.rhrealitycheck.org/blog/2008/03/04/the-no-brainer-syndrome
[5] http://www.futuremedicine.com/doi/pdf/10.2217/17469600.2.3.193
[6] http://www.afao.org.au/library_docs/policy/Circumcision07.pdf
[7] http://www.circumcisionandhiv.com/files/CircumcisionIAS07.pdf
I think "top researchers" is big spin. At least Mr. Halprin is a big pusher of circumcison. The people that did the African studies were pushing it too. They don't talk much about the companion study where circumcised men passed HIV at a higher rate than intact men. How can it be more effective to cut off a genital part and dull sexual pleasure instead of pusing condoms?
I agree with the report that gets little notice:
Promoting male circumcision in Africa is risky and dangerous and could lead to more HIV infections, warns a new paper published in the May issue of Future HIV Therapy.
Lead author Dr. Lawrence Green says, "Having served on both the US Preventive Services Task Force and the Community Preventive Services Task Force, which do systematic reviews of research to arrive at government-supported evidence-based guidelines for practice, I believe the African studies on the basis of which some are promoting circumcision as HIV prevention would be classified at best as 'insufficient evidence%u2019 by both panels."
"Promoting circumcision will drain millions, possibly billions, of dollars away from more effective prevention strategies," cautions co-author John Travis, MD, "and cause tens of thousands of infections and other surgical complications, further straining an already overwhelmed healthcare system and undermining the current ABC (abstinence, be faithful, and use condoms) campaigns by creating a false sense of immunity and increasing risk-taking behaviors. African males are already lining up to be circumcised, believing that they will no longer need to wear condoms, and this is a serious concern."
Travis says, "The African studies were conducted in atypically sanitary clinics with highly skilled operators and cannot be extrapolated to the general population. The studies have been criticized for their poor science including: the men were paid to be circumcised, received free condoms and extensive education, and the studies were halted after only 21 to 24 month periods."
During the course of these studies, 77 fewer circumcised than uncircumcised males contracted HIV, however, the circumcised group needed to refrain from sex to recoup from surgery, and they were receiving extensive monitoring and counseling about sexual behavior. Also, hundreds of study participants were lost to follow-up. "There is not enough evidence to conclude circumcision would offer any real long-term benefit in the HIV battle. Even if circumcision did reduce the risk of HIV infections, condoms and safe-sex practices are still far more effective. If an individual is engaging in high-risk behavior, he and his partner are at risk, regardless of whether he is circumcised or not."
The paper also cautions against neonatal circumcision for HIV prevention, stating it is unethical to circumcise an infant for a possible benefit 15%u201320 years later, if at all, to reduce the risk of contracting an adult-acquired disease for which there are far more effective prevention strategies available.
Circumcision proponents, hailing from English-speaking countries, have been intensely lobbying world health agencies to adopt male circumcision as an additional HIV-prevention tool based on the release of three African randomized clinical trials reporting reduced HIV infections during their study periods.
Many sources of data contradict the claim that circumcision protects against HIV. The United States has one of the highest rates of circumcision and HIV infection in the developed world. European nations, which rarely practice circumcision, have very low rates of HIV. Numerous regions in Africa show higher rates of HIV in circumcised populations compared to uncircumcised populations. For example, 2004 data from Lesotho show HIV infection of 15 percent for uncircumcised males and 23 percent for circumcised males. A 2007 study showed that, once commercial sex worker patterns were taken into consideration, circumcision status was irrelevant in HIV infection rates.