Promoting Male Circumcision for Hindus

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. 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.
-Stuart Rennie

Male Circumcision and HIV: a Hard Sell

A hard sell: that is how Bill Clinton, at the last International AIDS conference in August, soberly described the use of male circumcision as way of reducing the risk of HIV transmission from women to men. He was not doubting the science. After a string of randomized controlled trials, the science looks about as promising as HIV prevention science can look. Clinton was suggesting there may be pitfalls in the actual implementation of the science into policy and practice in the countries where HIV is most prevalent. This last month seems to have proved him right, and also showed how different perspectives on male circumcision and HIV can be.

As an early Christmas present perhaps, UNAIDS executive director Peter Piot is reported to have declared on December 19th that African countries should prepare to perform male circumcisions on a large scale, starting with baby boys first, then adolescents, then adults. Strangely, Piot stated that UNAIDS had no plans to promote male circumcision in high-HIV prevalent India 'where the issue is sensitive for the Hindu and Muslim communities.' Hopefully UNAIDS will catch wind of the idea that male circumcision is a sensitive issue everywhere that circumcision is not traditionally performed, or everywhere it is performed but not on the schedule (with baby boys) that UNAIDS might prefer.

The New York Times also ran a piece on male circumcision and HIV by Tina Rosenberg that profiled male circumcision as the only sort of HIV vaccine we've got, and even if it does not provide perfect protection, we should be darn happy with it. Since there is no vaccine of the immunological sort around, according to Tina, we should promote mass circumcisions right away.

The cold shower on circumcision came from the Ugandan President, Yoweri Museveni. At a discussion with medical students in Kampala, he claimed that the recent science on circumcision and HIV gives a 'mixed message' to men: if you are circumcised, you stand less of a chance of getting HIV if you practice unsafe sex. As is well-known, Museveni (and his backers among religious conservatives in the USA) prefer the unmixed message of abstaining from sexual activity until married, and then being unfailingly faithful to your wife or husband. From that perspective on HIV prevention, it does not matter if you are circumcised or not.

International agencies and domestic journalists should draw a lesson from Museveni's statements: just because a study shows that an intervention would have a big public health impact, it does not mean that everyone will be sold on it. The persuasive power of science only goes so far. The rest will be messy, and involve politics, morality, economics and culture. A hard sell, as Bill said.
- Stuart Rennie

An AIDS Vaccine that Works??

Nature Medicine reports that a French research trial fuels hope for prevention and mollification of the effects of HIV infection. Even as preliminary data, this is promises to be the biggest news in the history of HIV & AIDS research and will be cause for much discussion about next steps. The sample size is very very small and it is very important that the results not be blown out of proportion, which no doubt they will - although at the time of this posting lots of American papers are clueless about this finding. But let's just say that the research pans out ... what happens then? Let your mind wander back to the early science and policy wars over the way in which AIDS research is prioritized, and then consider a political world in which gay marriage might have been the defining issue in an election that brought to power a president who "owes" fundamentalist protestants and despises the UN...

Women and Infants in HIV Trials

A WHO and UNAIDS meeting discussed the issues of gender and age, as well as race, in HIV trials. Macklin is quoted: "We have identified measures aimed at rectifying the injustice stemming from the frequent exclusion or low participation of women and adolescents in HIV vaccine clinical trials. Clinical trial enrolment needs to be more inclusive, so the benefits of research are more fairly distributed."

On MCW Today ... Suing a Prostitute with HIV

Jennifer Bard sends us to Amarillo on today's MCW chatline, where the city has brought suit against a prostitute to compel her to seek treatment and to "stop spreading the disease."