Rwanda, which has a shockingly low number of doctors and other health personnel per patient, is claiming that they can circumcise two million men in the next one and a half years. Even Kenya, which makes exalted claims, has only managed 250,000 or so in a longer period of time. Apparently, the trick is to be unchoosy about who carries out the operation. However, if large sums of money are available, why not train more personnel? The effect would be far more significant and sustainable and would benefit health in general, not just HIV alone.
Well, there are plenty of unemployed people in Rwanda, but this doesn't sound like the best way to spend the 100 million dollars or so, which is about the lowest amount such a program could cost.And that's just if everything goes well. If Rwanda can barely cope with the most minor, non-invasive medical procedures, why rush into circumcising most of the adult male population when there's no guarantee it will be of benefit? In fact, it may even do a lot of harm.
Not many Rwandan men are circumcised, but in the latest figures available for HIV prevalence among circumcised men (2005, later figures are yet to be released), the operation would appear to increase transmission. This is nothing unusual; in many countries HIV prevalence is higher among circumcised men; prevalence for circumcised Rwandan men is 3.8%, compared to 2.1% for uncircumcised men. So what evidence is the country using to persuade men to undergo this operation when they will still have to use condoms, which could protect them from HIV, unplanned pregnancy and a whole host of sexually transmitted infections in one go?
Indeed, national HIV prevalence in Rwanda is relatively low, at 3%. But female prevalence is 3.6%, whereas male prevalence is only 2.3%. As in all medium and high prevalence countries, rates are far higher among women, especially urban dwelling women, wealthy women and women with the highest levels of education. And it is not even clear if transmission from men to women is reduced by male circumcision. There is evidence that transmission from men to women may increase as a result of a mass circumcision program.
It is often claimed that HIV prevalence among Muslim populations is lower and it is even stated or implied that this is because Muslim men tend to be circumcised. In Rwanda, HIV prevalence is indeed lower among Muslim men than any other religious group. But Muslims as a whole have by far the highest HIV prevalence because female rates stand at 11.4%, compared to less than 4% for every other religious group. (It could be argued that polygamy, said to be common among Muslims, results in higher HIV rates; but rates are often lower where polygamy is common; besides, many non-Muslim groups practice polygamy, even if they identify themselves as Christian.)
Apparently the PrePex device will be used to carry out the circumcisions, a simple piece of plastic with an elastic band. This device has been widely advertised, especially through infomercials, and is backed by the Gates Foundation amongst others. One of the infomercials was run by the BBC; there's a link to the clip in a blog post I wrote some months ago. But with HIV prevalence so low, 97% of the adult population are uninfected, how valuable could this operation really be (aside from the clear value to the manufacturers of PrePex and other commercial interests)?
Even the headline to this piece is a lie; HIV prevalence is not HIV transmission. Two studies have now shown higher HIV prevalence among gay men who use post-exposure prophylaxis most often - would you argue that means that PEP increases HIV transmission and cannot protect against HIV infection?
Your post on Malawi is based on the same fallacy.
You're so right, prevalence is not transmission. But if HIV is prevalent, transmission must have occurred at some time. The fact that HIV prevalence is sometimes higher and sometimes lower among circumcised men may well be irrelevant to the circumcision; however, it is the fact that prevalence is sometimes lower that is being used to sell circumcision, at the same time ignoring the fact that prevalence is only sometimes lower. As for your PEP straw man argument, it sounds like you know all about fallacies.
To make a straw man argument is to misrepresent what someone is saying in order to shoot it down. An example is your misrepresentation that the PEP example I cited was a straw man argument. It wasn't.
I didn't suggest you were arguing that PEP increases HIV transmission in order to shoot that argument down; I asked if you would make that argument because it's a particularly clear example of the fallacy you're promoting in this post and the one on condom use in Malawi. You're suggesting there's an association between two variables when you cannot make that assertion based on the data you're citing; you cannot know what other factors not captured in the data might influence that association. Your attempted justification: "but if HIV is prevalent, transmission must have occurred at some time" strongly suggests that you have no grasp of this whatsoever. The same issue complicates interpretation of associations documented in cohort studies, although in that case there is typically more data collected on potentially relevant variables than in the surveys you are citing here.
This is of course the reason why prospective randomized controlled trials are so important. And what is driving consideration of circumcision as an HIV prevention intervention is the consistency of the results from three large randomized controlled trials, not ecological associations.
Mr. Jefferys: Here is the bottom line. Go read those three "randomized" studies. They are available on the Internet, but I am too lazy to look them up again.
Read the studies (not just the conclusions) and you will find the most amateurish and sloppy research possible. These trials are bogus. In fact, their conclusions are not justified by their research. Their conclusions are repeatedly shown to be counter to the real world as shown by careful observational research and massive numbers.
Also, are you suggesting that if HIV is prevalent, it means that transmission did not occur? This kind of statement calls all of your argument into serious question.