Sunday, 31 May 2009

Circumcision and HIV/AIDS: 2

Ritual circumcision is a different area but its practice in South Africa, for example, has important ramifications for the promotion of circumcision as an HIV/AIDS prophylactic.

 This story was in the news this week:

 Eight boys have died and three are in hospital after botched circumcisions in the South African province of Mpumalanga, officials say. The teenagers were at an initiation school in the town of Kwamhlanga. One of the initiates died in hospital and the seven others were found by health officials dead at the school.

These circumcisions were done as part of a widespread traditional rite of passage for boys before they can be considered men and play a full adult role in their community.

 There are two separate issues here, the ethical/moral and the medical.

Commenting on another culture’s traditions has become taboo in some circles thanks to Post Modernism and cultural relativity where one culture may not be judgmental of another, especially if it’s a Western culture commenting on a Third World one. This is seen as a kind of cultural imperialist invasion or at best patronizing and ignorant. Just because something is considered wrong in one culture doesn’t mean it’s wrong for another. Everyone’s traditions and beliefs should be respected because there are no absolutes.

 The question of whether it is a cultural crime to raise ethical and Human Rights objections to children being mutilated without their consent, putting their health and sometimes their lives at risk is not the subject of this current post. But the serious implications for HIV/AIDS prevention is germane.

 The South African Government recognizes the health risk of ritual cutting; in 2001 it passed an act (The Application of Health Standards in Traditional Circumcision Act) requiring a license from a medical officer for each (male) circumcision. But the act seems to be having little effect. In July last year, 15 boys died and 90 were taken to hospital after botched circumcisions. The main causes of death and hospitalisation are blood loss and dehydration.

 Despite the Government’s attempts, community leaders are resisting medical supervision and licensing because, as they said, this ‘infringed community rights’.  Protecting children’s lives is apparently less important than protecting beliefs.

Researchers found that ‘in general, communities considered morbidity and mortality as par for the course. Interviewers were told that "deaths and injury were seen as a way of separating out those boys who were not fit to play the role of men in society." Compounding this 'natural selection' technique, another popular belief is that if an initiate suffers medical complications, he has brought it upon himself through some form of wrong doing, and is therefore being punished.

 There may be cultural resistance to condom use – albeit a different kind of resistance, based on male preference rather than ancient tradition – but overcoming entrenched beliefs about who has the right to cut boys and in what context (ritual rather than clinical) makes it difficult to see how an initiative to encourage it as a preventive will work in areas where it is seen as belonging to cultural practice, a ritual based on a belief that may not be invaded by science – even in the minimal form of sterile conditions and instruments.

 Moreover, some research has found that ritual cutting can increase infection rates:

Traditionally an assegaai is used. Implements may be blunt or reused. This practice has been implicated in the spread of blood-borne infections, such as Tetanus, Hepatitis B and STDs, including HIV/AIDS (source as above).

 In addition, one researcher has revealed a further problem:

 Of late, the practice has degenerated into a money-making operation. People pay as much as R400 per boy for the attendance of (circumcision) schools. The schools are launched annually at some localities (as opposed to the old tradition of every five years) (as above).

 Illegal procedures will prove even harder to monitor and medicalise.

 Even if it were possible to tap into an existing culture of circumcision to use it as a preventive, research done in South Africa and published in the South African Medical Journal states that:

 It is, however, questionable how circumcision, and particularly neonatal circumcision, could achieve such a goal. A rational and critical analysis of the scientific evidence ought to conclude that non-therapeutic infant circumcision is merely the medicalisation of an old ritual that should not, in the 21st century, be advocated as prevention strategy for HIV/AIDS. (my underlining)

 This whole article is worth reading.

 The evidence against circumcision is stacking up. The statistics do not show that it is an effective protection. Ritual circumcision is likely to prove an obstacle to (the alleged benefits of) medical prophylaxis and may also worsen the problem.

Finally, some further information from this article to add to last week’s post about the situation in America, the country behind PEPFAR, a major partnership initiative to promote preventive circumcision in America.

 Teens 15 years and older in the USA have the highest rate of STDs in any industrialised country and half will contract a sexually transmitted disease by age 25, despite two-thirds of young males having been circumcised. Such reports suggest that the social experiment of circumcision to prevent STDs, including HIV, has already failed in the USA, which has the highest rate of non-therapeutic infant circumcision in industrialised countries and the highest rate of HIV in the developed world.

 The call for neonatal non-therapeutic circumcision for prevention of HIV by some members of the Catholic Church suggests misunderstanding of the local context, and supporting genital surgery on newborn boys but discouraging the more effective preventive measure of condom use lacks logic.

 Of course, it is not just the Catholic Church and Catholic organisations that are anti-condom (and often pro-abstinence), there are other religiously-inspired organizations promoting circumcision as the list of PEPFAR partners discussed in the previous post shows.



Monday, 25 May 2009

Circumcision and HIV/AIDS

An article in the Independent on May 19 2009 reports that:

'Three landmark randomised controlled trials conducted in South Africa, Kenya and Uganda between 2005 and 2007 demonstrated that adult male circumcision reduced the risk of contracting HIV by 50 to 60 per cent'.

 It opens with the assertion that:

'New evidence suggests removal of the foreskin can protect not just against HIV, but other diseases that kill millions. Now some doctors are reconsidering their views on an ancient and controversial procedure'.

 What exactly are (or should be) doctors considering? Is circumcision the best option worldwide for HIV/AIDS prevention and why is it being promoted above condom use? Currently, around 30 per cent of males worldwide are circumcised, but this is done mostly for religious and cultural reasons rather than medical ones.

 I discussed this with Dr. Antony Lempert of the Secular Medical Forum who pointed out that interpretation of this latest research has to be tempered by the fact that the Cochrane collaboration who reported on these trials stated that the risk of bias is very high.

 Moreover, the mechanism by which circumcision may work is not even known yet. The New England Journal of Medicine (NEMJ) report, from which the Independent article is drawn, reports: ‘How circumcision prevents HIV transmission is not completely understood, but scientists believe that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells lining the foreskin's inner mucosa’.

Even if the research can be shown to be good and that circumcision does reduce the transmission of HIV/AIDS, it still only brings the risk down to around 50:50 and it does not tackle the whole problem of sexually transmitted infections (STIs). According to the article, there is some emerging evidence that circumcision also reduces infection with Human Papilloma Virus (HPV) by 35% and Herpes Simplex (HSV) by 25% but again, these are not persuasive percentages when compared with condom use.

In fact, it may worsen the problem as men who have been circumcised see the operation as a licence to ride bareback, thus spreading other STIs and, of course, causing unwanted pregnancies. In fact, they may ask what is the point of being circumcised if you still have to wear a condom. Many men are not keen to use condoms as they reduce sensitivity so it is hard to see why they would opt for an operation that reduces it permanently.

 Although HIV/AIDS is the most serious of STIs, chlamidia and gonorrhoea are not without long-term risks if undiagnosed or untreated, which could be the case in remote, rural or some highly religious communities in the developing world (the jury is still out on the effectiveness of circumcision against syphilis).

 Who will benefit even from the 50:50? The NEMJ report also says: ‘Reaching women through other prevention methods is important because there is no direct evidence to date that circumcision reduces the risk of transmission from men to women.’

 In addition, the new research looks only at adult men having sex with women, not at the long-term effect on boys or men having sex with men.

In fact, the Independent article quotes Professor Terence Stephenson (President of the Royal College of Paediatrics and Child Health), who says that there is ‘no evidence that circumcision is protective in men who have sex with men’.

The risks of adult circumcision are small but not negligible, especially if they are not carried out in sterile circumstances. One recent report indicated that severe complications developed in 18% of men, and 6% had permanent adverse sequelae including mutilation of the glans, excessive scarring, and erectile dysfunction. (NEMJ).

So adult male circumcision doesn’t appear to protect women or men having sex with men. With such scanty evidence in favour, who is promoting adult male circumcision, particularly in Africa?

One of the largest bodies is PEPFAR, the US President's Emergency Plan for AIDS Relief who are ‘working with local governments and public health partners to create an acceptable and sustainable model for implementing circumcision programs’ in Africa and other countries (including Haiti and Vietnam). 

Who are these partners? They include the Catholic Relief Services, Family Health International and the Elisabeth Glaser Paediatric AIDS Foundation. The PEPFAR website lists them and their areas of concern. For many of them, ‘Abstinence and Be Faithful’ are on that list. Taking a random sample of countries, in Rwanda 11 out of the 23 partners promote abstinence and in South Africa, 28 out of 93 partners – for a few of them,  this is their only agenda.

Given the Catholic Church’s opposition to condoms to the point of lying about their effectiveness, and that of many American Evangelical organisations, could it be possible that circumcision is being promoted over condom use for less-than scientific reasons? Abstinence has been shown to be an ineffective programme in the US and under the Bush regime, many lies were spread about condom use, so are they promoting circumcision rather than condoms? Pro-abstinence campaigners, especially religious ones, are often anti-condom.

In America, circumcision has been declining in some states but the overall prevalence is still 65% (compared with 16% in the UK). As Dr Lempert points out:  ‘the majority of the American male population has been circumcised whilst they have a rather high rate of HIV infection’.

There is also the issue of consent. Adult men may be able to weigh the facts and make their own decision, but boys and new borns cannot.

To go back to the Independent article, it implies that all parents should seriously weigh up circumcising their male children. But the issue is far more complex than is being presented. There is undeniably resistance to condom use in many cultures for a variety of reasons that need to be overcome and logistical questions of distribution, but the promotion of both circumcision and condom use is tainted with many unknowns and mixed motives; should anyone – doctors, funding bodies, sexually active men or parents - be contemplating or recommending an irreversible surgical procedure just yet?







The Blame Game

In the endless argument about whether religion or atheism has caused the most bloodshed, believers wheel out Hitler (who was a Catholic), Stalin, Pol Pot etc while atheists bring out the Crusades, the 16th century wars of religion in France, Northern Ireland – to name just three. Stalin's the tricky one for atheists - although he trained as a priest, communism was an atheist movement. Mainly because he didn't want any rivals to his mind control.

However, the argument over whether religion or atheism has caused the most deaths is spurious. There will always be wars and dictators. Rulers and warmongers will use whatever tools suit them best to justify their actions. That's human nature. In fact, arguing over atheism/religion is just another in group/out group war.

Where do those leaders and conquerors fit who had a faith but did not use it to justify their actions? Alexander the Great slaughtered his way across half the known world without needing religious justification and the Mongols didn’t much care what faith you were as long as you submitted. The Romans conquered Europe in the name of Rome, not in the name of any particular god – and then used religion as a post hoc tool to unite and subdue - choosing the one they thought would best serve. Mithraism was a contender but didn’t quite fit the bill although if it had included women and been more peaceful, we’d all be Mithraists now and Christianity would be at best a footnote in history.

 The way to prevent wars and dictators is not to get rid of religion or atheism as we will just find some other justification. Animals fight over territory, resources and mates. The only thing that will work is to change human nature. Good luck with that.