Saturday, February 24, 2007

HIV, male circumcision and India

This blog has dealt with ethical questions about male circumcision and HIV before, but somehow the assumption crept in that this is a distinctively African controversy. Maybe it was because of the high HIV prevalence in that part of the world. Maybe its was because of the longstanding interest -- especially among anthropologists -- with circumcision rituals in Africa. Let us make a confession here: the author of this post has co-authored an article in the Journal of Medical Ethics called Male Circumcision and HIV Infection: Ethical, Medical and Public Health Tradeoffs in Low-Income Countries. And it too is guilty of identifying the issue a bit too much with sub-Saharan Africa.

Whatever way this came about, the ethical questions concerning the promotion of male circumcision to lower risk of HIV transmission have to embrace India. For one thing, the number of new HIV infections has rising in India dramatically over the last years. For another thing, male circumcision is a highly charged matter, both politically and religiously, when Hindus do not traditionally circumcise and Muslims do.

An article in the Times of India today gives an indication of just how sensitive the question is. The National AIDS Control program in India will not even think of conducting randomized controlled trial to test whether being circumcised lowers a man's risk of getting HIV infected: not because three such studies have been done before, but the whole idea seems too hot to handle. When Richard Feachem, Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said that he expected that Hindus would increasingly have more HIV infections because their men do not get circumcised, his inbox was inundated by hate mail. An interesting post on the Olive Ridley Crawl shows some of the passion the debate raises, and the issue is inseparable from the larger relationship between mainly Hindu India and its Muslim neighbor and rival, Pakistan. The foreskin has geopolitical significance.

The question is: when circumcision acts as a religious/cultural marker from neighboring groups, will men still agree to do it, to reduce their chances of getting HIV? A World Health Organization/UNAIDS meeting in Switzerland on March 6 is set to tackle these tradeoffs between cultural identity and public health, among others. When HIV infections globally are increasing, vaccines are probably at least 10 years away, and the once-promising microbicides are crashing and burning, the ancient practice of male circumcision is strangely enough carrying the torch in the fight against HIV/AIDS.

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10 Comments:

Blogger TLC Tugger said...

Sorry, the question really is not "will men still agree to do it," but rather, how on earth did these studies get funded? Other studies have shown the opposite. If that had been the case this time, the study team would be guilty of a permanent mutilation which left the volunteers definitively worse for the experience.

That's a pretty strong incentive to MAKE SURE the outcome turned out as hoped for by the long-time circ justifers who ran these trials.

In non-cutting Japan, AIDS is more rare than in 95%-cut Israel. In the African nations of Malawi, Lesotho, Ghana, Rwanda, Tanzania, and Cameroon, AIDS is MORE prevalent among the circumcised than among the intact. In the mostly-cut US, we have 3 times the AIDS problem Europe has, even though circumcision is rare in Europe. 450,000 American men who were cut at birth have died of AIDS.

Circumcision does not prevent AIDS.

10:48 PM  
Blogger Stuart Rennie said...

Thanks for your comments. Let me reply point-by-point.

You are right that a few studies have not indicated any reduction in HIV transmission among circumcised males, but the majority did. That is precisely why these studies were funded: in order to test, in a randomized controlled trial setting, the association between circumcision and HIV transmission suggested by 25 years of observational and other studies.

As for higher prevalences among the circumcised in selected countries, that phenomenon has to be subjected to the same scientific scrutiny as the (majority of) settings where the circumcised have a lower prevalence. Again, the trials in South Africa, Uganda and Kenya were done to try to isolate the association from possible confounding factors. The old 'ecological' studies that brutely linked lower HIV prevalence with circumcision practices in a given region were considered unsound, because there were could be other factors responsible for the lower HIV prevalence. The same goes for your own ecological counterargument.

In USA, HIV transmission has historically been driven by homosexual sex and injection drug use, not heterosexual activity. The studies in question obviously do not claim to say anything about links between circumcision, male-to-male sex or injection drug use.

I agree that circumcision does not 'prevent' HIV. That is a misleading statement, especially if it suggests total protection. But there is a substantial scientific argument for circumcision reducing risk of HIV transmission from women to men.

Let me be frank: if a research team had run three randomized trials on an HIV vaccine that showed 65% efficacy, they would be preparing their Nobel speech. But because it is circumcision rather than a vaccine, they find themselves wading into an ideological quagmire instead.

12:34 PM  
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5:30 AM  
Blogger Unknown said...

I am sure that male circumcision does not prevent or reduce the risk of contracting HIV or tumor cells .. This is a crazy idea, and international health agencies should be involved in such practices

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