Saturday, April 19, 2014

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Circumcision is no Cure for HIV

Jonathan Friedman argues that the focus on sexual behaviour modification in African HIV policies has led to inefficient and unethical male circumcision campaigns.
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In 2008, Ban Ki-moon, Secretary General of the UN, stated of the Millennium Development Goals: "Halting the spread of AIDS is not only a goal within itself; it is a prerequisite for reaching almost all the others."

This view is beginning to be challenged. Dr Michael Grimm and Deena Class, authors of a policy brief criticising the reliance of global HIV/AIDS policy on poorly interpreted data, object. "Today more and more experts accuse [leading world health organisations] of a biased presentation of the facts to distort priorities in favour of the treatment and prevention of AIDS compared to other disease and global health issues... Experts estimate that [HIV aid] receives 25% of international healthcare aid... In some countries HIV aid clearly exceeds total domestic health budgets.”

Distortion of economic impact

The authors emphasise the distortion of the economic impact of HIV/AIDS on sub-Saharan countries. Effects such as the decrease in economic growth rates and an increase in unemployment probability have little meaning without comparison to the effects of other chronic diseases: “Infant mortality due to acute respiratory infections, diarrhoea, measles, malaria and malnutrition in general causes more than twice as many deaths as AIDS... Despite these facts, UNAIDS is still calling for a drastic budget increase."

Grimm and Class also note that many "sloppily written reports" on the effects of HIV/AIDS on household income rely on "anecdotal evidence". The assumption that the deceased are always primary income earners further exaggerates the economic impact of the HIV/AIDS crisis.

Ignorance of transmission modes

Another argument in the report is that medical transmission of HIV has been underestimated at below 2% of all infections. The prevailing belief that sexual transmission and being born to HIV-infected mothers are the primary modes of transmission do not hold up in the light of real-world data. An HIV outbreak investigation "linking" infections has never been performed. Without a comparison of HIV strains between sexual partners, beliefs of the predominance of sexual transmission modes of HIV can have little basis in reality.

UNAIDS estimates that 90% of HIV infections in children are due to mother-to-child transmissions. This estimate contradicts real-world data. Only 25-35% of children born to HIV positive mothers are born with HIV in the absence of antiretroviral drugs. Furthermore, a significant number of children born to non-infected mothers have HIV.

Some have tried to explain away this unacceptably high number of HIV infections in children by “casually” suggesting that these HIV infections are due to sexual transmissions, implying, without any supporting evidence, that children experience rape and other forms of sexual violence in an astonishingly high number of unreported cases.

The reality is that the significant number of HIV infections in children is due to blood exposure in poor health settings. The authors cite a study by the Health Ministry of Mozambique, which found a “positive and significant” correlation between medical injections and HIV positivity in children.

Furthermore, “blood exposures in high prevalence settings occur for adults as well, but due to the overwhelming focus on sexual transmission, these exposures in adults are systematically ignored in health policy”. A 2009 study in Mozambique found that only 69.5% of donated blood units were screened for HIV in a “quality assured manner”.

Mass circumcision campaigns

The over-emphasis on sexual transmission modes of HIV infection has fostered the implementation of unsafe and unethical mass circumcision programmes in Africa in order to "prevent" HIV. Tens of thousands of men have already lined up to get circumcised, after three studies purportedly showed a 60% protection benefit.

These mass circumcision campaigns continue to receive millions in funding from leading organisations, including WHO and UNICEF. These health aid organisations have received strong criticism from human rights organisations and experts who question the ethics and the purported health benefits of male circumcision.

Organisations such as Attorneys for the Rights of the ChildDoctors Opposing Circumcision, and Jews for the Rights of the Child have worked tirelessly to stop the practice of child circumcision in the US and around the world. These organisations have repeatedly called upon the UN to recognise the practice of male circumcision as a form of genital mutilation.

Opposition to “Voluntary Male Medical Circumcision” programmes

While these organisations are not opposed to adult circumcision, there are at least three grounds for opposition to the current mass circumcision campaigns in Africa. First, mass circumcision campaigns are based on misinformation, as men are not being informed of the functions of the foreskin.

Second, many countries are being pressured to draft plans for routine infant circumcision. Earlier this year, the South African Medical Association called these plans to circumcise infants for HIV prevention “unethical” and “illegal”. In addition to the dangers of circumcision, cells from "donated" foreskins are used to manufacture a wide range of biomedical products, ranging from skin grafts to facial beauty creams. (Oprah featured SkinMedica's TNS Recovery Complex on her show, a product which contains foreskin fibroblasts.)

Third, the three studies which purportedly show that male circumcision protects against HIV by up to 60% have several flaws. According to a UNAIDS demographic survey, 10 out 18 countries have higher HIV prevalence amongst circumcised males. Furthermore, the reported 60% protection benefit is for male acquisition only: studies show that male circumcision increases female acquisition of HIV by up to 50%.

Explanations for HIV exceptionalism

The exaggeration of the effects of HIV, along with the preference for using anecdotal evidence over empirical evidence, might simply be a case of wide-spread cognitive dissonance, i.e. people “seeing what they want to see”. While there are clear financial incentives for over-exaggerating data, the relationship between a distortion of the facts and the motives needs further examination.

In a private communication, the authors stated that there are at least four reasons for HIV Exceptionalism:

"First, due to a lack of data and problematic methods... prevalence rates of HIV/AIDS were systematically overestimated in the late 80s and in the 90s. Second, the belief – without... empirical evidence – that a disease that affects so many people in the age of activity must have tremendous economic consequences. Third, a very strong lobby of popular rock stars and alike that backed the fight against AIDS and put strong pressure on donor countries to do something. This was reinforced by the set-up of a special UN agency to fight AIDS (UNAIDS). Fourth, at least in the beginning... the fear that the epidemic could spread from Africa to Europe and the US and lead to similar prevalence rates there. As always, once such dynamics have started it is very difficult to stop and reverse them. Who from UNAIDS would admit today that many things went wrong?"

UNAIDS is slowly beginning to listen to an increasing number of outspoken experts, such as Grimm and Class, who are re-examining the evidence. Recent studies have shown that the UN numbers over-estimate by 25-40%. In response, the UN has scaled down its estimate of 37 million worldwide HIV infections to 33 million.

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Thanks, Jonathan, for your courage to speak the truth.  We've buried more than half a million circumcised men, who died of AIDS.  There are significant studies which show that circumcision status has little or nothing to do with disease transmission.

Those RCTs about which we have heard so much improperly assumed that all HIV transmission was sexual. That is simply not the case, so those RCTs are worthless. Circumcision will not prevent HIV transmission

Not having examined all the evidence or arguments, I can't comment on this in general, but wanted to point out that these two statistics as presented do not contradict each other:
"UNAIDS  estimates that 90% of HIV infections in children are due to mother-to-child transmissions. This estimate contradicts real-world data. Only 25-35% of children born to HIV positive mothers are born with HIV in the absence of antiretroviral drugs."
I would understand this to mean that 90% of children who are infected with HIV are infected through mother-to-child transmission, and that this 90% of HIV-positive children account for 25-35% of all children born to HIV-positive mothers - the remaining 65-75% are uninfected and therefore not included in the first statistic.

E, you bring up a good point. Apologies for the delayed response, I hadn't checked for comments.If you use conditional probabilities, you can show that the 90% figure is too high.Let A be the event that a child is HIV-positive and let B be the event that its mother is HIV-positive. The UNAIDS figure is related to P(B|A), the probability that the mother is infected given that the child is infected. P(B|A) > 0.9, since B|A expresses association, not causality (i.e. association includes more cases).Let's take a look at the next figure:"Only 25-35% of children born to HIV positive mothers are born with HIV in the absence of antiretroviral drugs."This relates directly to P(A|B), the probability that the child is infected given that the mother is infected. I'll use the midpoint of this estimate, P(A|B) = 0.3.Now use the identitiy:P(B|A) = P(A|B)P(B)/P(A),and expand the denominator using the law of total probability:P(B|A) = P(A|B)P(B)/(P(A|B^) + P(A|B)),where B^ is the event that the mother is not infected, so that P(A|B^) is the probability that a child is infected given that its mother is not infected. I mentioned that this number was "significant," some studies estimate it to be around 15-20%:"17.5% of HIV-positive children had HIV-negative mothers," P(A|B^) = 0.15, the low end of this estimate, and substituting values gives:P(B|A) = 0.3*P(B)/0.45The only variable left is P(B), the probability that a mother is infected. There doesn't appear to be any direct statistic available for this. I'm going to use P(B) = P(W), where W is the event that a woman is infected. I'll pick P(B) = 0.3, a high number. This gives us P(B|A) = 0.2, meaning that 20% of infections in children are associated with HIV-positive mothers. The percentage of infections due to mother-to-child transmission is less than this as associations include more cases than direct-cause cases.This is a crude estimate (tweak the numbers if you like), nevertheless I demonstrate a few important concepts. The problem is the high number of infections in children who do not have HIV positive mothers, this cannot be ignored. You also can't assume that a child contracted HIV from its mother if they are both HIV-positive.And finally, my reply is that yes E, you are correct, the UNAIDS figure and the 25-35% figure for newborn infections do not contradict. However, you left out the third statement which, together with the second, is shown to make all the difference.