The ABC of HIV prevention means “Always Be Cutting”?

I don’t know which is more frustrating, stupid “science” articles or the reporting on those articles. Last week, my news world was filled with various regurgitations of this nonsense:

According to a new policy analysis led by researchers at the Harvard School of Public Health (HSPH) and the University of California, Berkeley, the most common HIV prevention strategies-condom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinence-are having a limited impact on the predominantly heterosexual epidemics found in Africa. Furthermore, some of the assumptions underlying such strategies-such as poverty or war being major causes of AIDS in Africa-are unsupported by rigorous scientific evidence. The researchers argue that two interventions currently getting less attention and resources-male circumcision and reducing multiple sexual partnerships-would have a greater impact on the AIDS pandemic and should become the cornerstone of HIV prevention efforts in the high-HIV-prevalence parts of Africa.

Hold off on assessing the validity of such claims. Wouldn’t it be appropriate if they put the two key words – voluntary, adult – in front of male circumcision? That’s all that the studies being cited as gospel looked at. The press release does later invoke voluntary, so I wonder if the omission of adult implies that children consent. Perhaps a look back at past writings from one of the studies authors, Daniel Halperin, might reveal anything:

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 men would want the service if it were affordable and safe, and even more women prefer it for their partners and children.

Excerpted from Halperin’s essay referenced in my original entry.

How convenient. Even more women prefer it for their partners and children. Regarding the former, I don’t care what influences or reasons adult males use if the decision to undergo circumcision is voluntary. But with the latter, that simply isn’t the case. And how is it sexually relevant to (male) children what their mothers prefer regarding their genitals? (Also notice how nearly all of the studies revealed that most intact males would want circumcision. Contradictory evidence is still evidence.) Obviously I don’t come to this report with any pre-established respect for circumcision promoter Daniel Halperin. But continuing from the new article.

The AIDS pandemic continues to devastate some populations worldwide. In most countries, HIV transmission remains concentrated among sex workers, men who have sex with men and/or injecting drug users and their sexual partners. In some parts of Africa, HIV has jumped outside these high-risk groups, creating “generalized” epidemics spread mainly among people who are having multiple and typically “concurrent” (overlapping, longer-term) sexual relationships. In nine countries in southern Africa, more than 12% of adults are infected with HIV.
…

For example, condom use is widely promoted as an HIV prevention measure and is effective in countries such as Thailand, where the epidemic is spread primarily through sex work. However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa, the authors note. This is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.

I want to pound my head on my desk until I can’t think any more. Where HIV transmission occurs, it occurs because the couple is engaging in unprotected sex where one partner is HIV-positive. If a condom is not used, that is not an indictment on condoms as a prevention technique. It’s not even about condom use in a relationship. It’s obviously about unsafe promiscuity. It does not take a genius to figure out that, if behavior remains consistently immune to logic, circumcision will not matter. HIV will spread. The only potential difference under discussion is the rate at which the disease spreads. Have unsafe sex with HIV-positive partners and you will become infected. It may take an extra encounter, but it will occur.

Circumcision also has the potential to encourage “just this once” disregard for safe sex practices. “I’m circumcised, so just this once, I’ll ignore the condom.” How many times will be “just this once”?

Under this focus on the rate, though, the true implication becomes clear. This is best shown in the poor reporting regurgitation of articles like this. For example:

In western Africa, were male circumcision is high for cultural and religious reasons, the prevalence of HIV is low and controlled trials have shown that the operation can stem the rate of infection, said Professor Malcolm Potts, of the University of California, Berkeley. “It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling,” he said. “Large numbers of people will die as a result of this error.”

Because we didn’t implement mass circumcision of males in Africa, large numbers of people will die. As opposed to saying that, because many individuals¹ aren’t engaging in safe sex practices, large numbers of people will die? Which is more accurate at portraying a direct cause? Which advocates speculation that can’t be verified? Which is scientific?

Individual actions matter. If We&#153 are going to intervene, we must provide nothing more than the tools for individuals to choose for themselves. Where individuals ignore known risks and engage in dangerous behavior, there will be consequences. Suggesting that we shift from truly voluntary prevention techniques such as ABC (Abstinence, Be Faithful, Condoms) and voluntary, adult male circumcision to involuntary male child circumcision is little more than an indication that We will save Them. Because They do not partake of the known methods to protect themselves as individuals, we must do it for them.

Of course, there’s the giant elephant in the room. “Reducing multiple sexual partnerships” sounds a lot like Be Faithful. So we’re left with only one different approach the authors believe should receive more funding. New articles and studies like this always have the goal² of pushing mass male circumcision, voluntary and involuntary, adult and child. Always.³

¹ I know that the issues of consent in sexual relations are more complicated than assuming every sexual encounter is voluntary and free from any pressure. Conceded. But that does not change the point that involuntary circumcision is not an answer to this problem. Correcting a wrong with a wrong is not valid. Individuals have rights, not collective groups.

² If you look at what the article is saying, you’ll also note that the validity of ABC instead of a collectivist, utilitarian perspective on male circumcision applies to the United States. Our HIV problem is not caused by what circumcision is supposed to protect against. That hasn’t stopped circumcision advocates from promoting (infant) male circumcision in
the United States as a way to reduce the risk of female-to-male HIV transmission.

³ It would require its own blog entry, but I don’t think any of this is some mass conspiracy by any group or profession. A mindset closed to a full set of facts, maybe, but not groups. Still, the point remains: it’s always about circumcision first, even if the stated justification is “public” health or some other goal perceived to be noble.