Posted by: davidjolson | 07/23/2010

A proven HIV strategy is overshadowed by an unproven one

Bill Gates talking about male circumcision in Vienna.

VIENNA, Austria – Much of the excitement at the just-concluded AIDS conference here centered around the news of microbicidal trials that have shown to be almost 40% effective. While this is exciting and encouraging news, we are still years away from having this product on the market. Meanwhile, there is a proven and effective HIV strategy that reduces transmission by nearly 60% and doesn’t depend on remembering to use it every time you have sex. But it got much less attention at the conference than the microbicidal gel.

I’m talking about male circumcision (MC). But at least at this year’s AIDS conference, MC, for the first time, got some attention.

Two years ago in Mexico City, nary a word was said about male circumcision — and certainly not in a plenary meeting — despite the fact that its effectiveness had already been proven. PSI, one of our member organizations, did organize a press conference on MC, which was successful in generating some media buzz and attention. However, donors and governments, for the most part, continued to sleep and do little to scale up an intervention that could have saved millions of lives.

In December 2008, the Gates Foundation became the first donor to scale up MC, quietly providing funding for PSI to expand its male circumcision pilot project in Zambia to two other countries (a third country was added later). There was no fanfare, no announcement, as everyone was concerned about provoking a negative reaction for an intervention that addressed long-standing cultural practices.

However, that negative reaction never came, and now the environment seems to have changed, and MC seems to be going mainstream. Both Bill Clinton and Bill Gates mentioned MC prominently in their speeches in Vienna. In particular, Bill Gates could hardly stop talking about the wonders of MC, calling it and prevention of mother-to-child transmission two of the interventions that “are so effective that in endemic countries it is more expensive not to pursue them.” While more than 41 million men in sub-Saharan Africa could benefit from the procedure, he said, just 150,000 have been circumcised in the past few years.

“I have to admit: When it comes to circumcision, I used to be one of the skeptics,” he said in his speech. “I thought: ‘Sure, it reduces transmission by nearly 60%. But there’s no way that large numbers of men will sign up for it. I’m glad to say I was wrong. Wherever there are clinics available, men are volunteering to be circumcised in far greater numbers than I ever expected.”

It is an intervention whose time seems to have come. In a press conference in Vienna, PSI said that scaling up MC to reach 80% of adult and newborn males in Eastern and Southern Africa by 2015 “could avert more than 4 million new HIV infections between 2009 and 2025 and could yield a total net savings of US $20.2 billion during the same time period.  And without any promotion or advertising of any kind, the demand for MC exceeds the supply. For every man we reach with the male circumcision services that he already wants, the fewer new HIV infections will be produced.

Like Bill Gates said, it’s so effective that it’s more expensive NOT to do it.


Responses

  1. Male circumcision has not been proven to be effective for reducing the HIV epidemic. There are three trials that showed a correlation, but there has been no followup studies to corroborate or prove the trial results. If male circumcision is as effective as many claim, such evidence should be easy to collect. Many men have been circumcised. What is their rate of HIV infection compared to the rate in general population? The absence of any followup is telling.

  2. Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they’ve been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.

    The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

    ABC (Abstinence, Being faithful, Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

  3. “For every man we reach with the male circumcision services that he already wants, the fewer new HIV infections will be produced.”

    Well, for the 5,400 men the three trials reached with the male circumcision that they wanted (since they were paid volunteers for it), 73 men didn’t get HIV in two years who might have (assuming the trials really demonstrated what everybody involved was hoping they would, and their expectations had no effect on the non double-blinded, non placebo-controlled trials). That works out at about one fiftieth of a man fewer getting HIV for every man circumcised. Is that really bang for the buck?

  4. If you believe Bailey, Gray, Wawer etc. have shown that circumcision might help fight AIDS, then have you asked of them why they only studied amputation of the foreskin?

    Amputation in any other medical context is reserved as a last resort for diseased or damaged tissue.

    They claim the toughening of the mucosa once it is no longer protected by the foreskin is what might thwart HIV. Why not investigate other less destructive, less risky, less expensive ways to toughen the mucosa? Perhaps a means of wearing the foreskin rolled back off the glans 24/7 could be rolled out. It could be as cheap as 20cm of twine.

  5. […] A post at the Blog 4 Global Health from the Global Health Council discusses male circumcision as an HIV prevention strategy that is already tested and ready for use. Male circumcision reduces HIV transmission by as much as nearly 60%. […]


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