Effective HIV prevention does not involve distorting facts.

I saw this Richard Holbrooke essay on HIV when it appeared a few weeks ago. Nothing in it warranted¹ specific comment from a circumcision perspective that hasn’t been said repeatedly. This is all he offered:

A viable prevention strategy would encompass education and counseling, free condoms, female empowerment, more male circumcision, and abstinence.

Implement four of those five suggestions and number four becomes irrelevant. Or, if you’re in an intelligent mood, replace more male circumcision with more personal responsibility. Life has consequences, even with circumcision. (At the very least, insert voluntary adult between more and male.)

Today, thanks to Daniel Halperin and his essay in today’s Washington Post, I must reference Mr. Holbrooke. Halperin opens with praise for Holbrooke’s stance that we need to reduce the number of new infections before we can suggest any progress. Fair enough, with quibbles, but it’s stunning how quickly Halperin will abandon the logic he demonstrates here:

The most rigorous study yet conducted, a randomized trial from Zimbabwe published last month in the journal AIDS, found an increased rate of HIV after people underwent testing and counseling compared with those who did not, though the increase was not quite statistically significant. The London-based researchers noted that some other studies similarly have found “disinhibition,” or a worsening of behavior, among people who learned they were not infected. While it might seem intuitive that knowing one’s HIV status and, ideally, receiving good counseling would lead to behavior change and reduced risk, the real-world evidence for this conventional wisdom is still unclear, especially for the large majority who test negative.

With what other strategy might disinhibition be a problem?

As Holbrooke noted, circumcision has indisputably been proven to prevent HIV. It reduces the risk of male infection during intercourse by at least 60 percent and, unlike a condom, cannot be forgotten during a moment of passion. Nearly all of 15 studies conducted throughout Africa found that most uncircumcised [sic] men would want the service if it were affordable and safe, and even more women prefer it for their partners and children.

Holbrooke did not state in his essay that circumcision prevents HIV. If he had he’d be spreading untruths, but he chose not to, speaking of ways to reduce the transmission. To be fair, I suspect prevent is a fill-in as a less awkward way for Halperin to say reduced risk. This distinction is important, though, because prevent has stronger implications. Only abstinence prevents sexually-transmitted HIV. Because there are lives involved, this topic deserves more care with words.

It appears – not indisputably, when looking at all data – that (voluntary adult) male circumcision reduces the risk of female-to-male² transmission by up to 60 percent³, not at least. Why the distortion, if not to promote a preferred solution?

Returning to the potential problem of disinhibition in HIV, the real-world consequences of our actions should never be dismissed as a factor the way they are in the circumcision debate. But circumcision advocates already dismiss that in their rush to portray adult males as too irresponsible, so better to address Halperin’s statement in his own context. A condom can be forgotten. True. But it can also be intentionally abandoned because (voluntary adult) male circumcision “prevents” HIV. (See how important words can be in this topic?) Could that possibly lead to disinhibition? Does Halperin believe that circumcised men can engage in unprotected sex and not become HIV infected if they skip a condom only once?

Time to revisit Halperin’s next sentence and put the emphasis where it should be:

Nearly all of 15 studies conducted throughout Africa found that most uncircumcised [sic] men would want the service…

Which studies contradict the belief that men want circumcision? Of those men who do not want it, is it reasonable to assume that some of the infants now being circumcised would not want it?

Remind me again how only people who believe that males (and females) should be protected from medically unnecessary surgery are passionate – in the frothy, derogatory sense – about circumcision. Lying and selective omission of data are the actions of a passionate circumcision advocate.

¹ Also from the Holbrooke essay:

… Anthony Fauci, the famed director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has stated the case in dramatic terms. Speaking in July at an international conference, Fauci said: “For every one person that you put in therapy, six new people get infected. So we’re losing that game.” He went on to say, “Clearly, prevention must be addressed in a very forceful way.”

Draw from that what you will, but the evidence suggests what kind of force too many people prefer to “prevent” HIV.

² Notice how Halperin wrote “male infection”, not “female-to-male infection”. The latter is correct, as no study has shown that (voluntary adult) male circumcision reduces male-to-male infection. He’s speaking of Africa, where heterosexual transmission appears to be the primary route of infection, but public health advocates like Halperin are rather quick to justify routine infant circumcision for potential benefits it has not been demonstrated to potentially offer. Unfortunately, male-to-male is the primary transmission method in the United States, not female-to-male. But promoting circumcision conforms to our cultural obsession, so it allegedly passes such semantic omissions.

³ The reduction in risk appears to be up to 60 percent when studies on long-term transmission risk are ended early. There is a lag between infection and testing positive. This period is also the most infectious for HIV transmission. Halperin acknowledges this. Might this matter, especially in light of disinhibition?