Saturday, August 1, 2009

Zambia Goal: 80% Circumcised

You have to admire some of the health ministers and governments in Africa that understand the health value of circumcision -- and, more importantly, are not afraid to set goals aimed at universal male circumcision.

The latest word from Zambia, reported in The Post, is that the country's health minister has embraced circumcision as an important HIV prevention strategy. Moreover, the World Health Organization's representative in Zambia, Dr. Olusegun Babaniyi, has said the country must achieve an 80% circumcision rate in 10 years to maximize the effectiveness of circumcision. The current rate is about 13% circumcised. This would require about 2.5 million males to be circumcised.

Of course, the most effective way to achieve universal circumcision is neonatal circumcision. Circumcising at birth is easier, less complicated, and much less costly. University Teaching Hospital urologist Dr. Kasonde Bowa says his hospital has begun a neonatal circumcision pilot program, but admits they have a long ways to go.

Taking a country that is only 13% circumcised up to 80% circumcised and, preferably, 100% circumcised takes a time and dedication. Countries like Zambia deserve world acclaim -- and our help -- to achieve their goal of a clean foreskin-free environment.

Here in the United States, where perhaps 75% to 85% of males are clean-cut, we need stronger government advocates for circumcision. The anti-circ fanatics are reportedly putting intense political pressure on the Centers for Disease Control and the American Academy of Pediatrics to ignore all the medical studies of recent years. Whether America's doctors cave in to political pressure when the medical evidence is so abundant remains to be seen. But there's no question that those who recognize the health benefits to both men and women of a clean-cut foreskin-free society need to speak up -- now!

8 comments:

  1. Who would have thought that Africa could lead the world in this aspect of 'best-practice' medicine?

    Neonatal is the way to go, as you point out. But in countries which have had lower circumcision rates in recent years, children and adult circumcision programs also need to be offered to have a chance of getting a foreskin-free society.

    Here in Australia, we have a lot of catching up to do given the failure of circumcision policies in the 1980s, 90s and 00s. If offered freely to all ages (particularly in school), we could go close to getting it universal again.

    As the old saying goes, it's never too late to circumcise!

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  2. You're absolutely right, Anon. It's never too late to circumcise! I have been saying on this blog for months now that the African nations are putting western nations (especially USA, UK, Canada, NZ, and Australia) to shame. If circumcision reduces HIV by 60% in Africa, then it surely does the same in our countries!

    I understand that Australia let its guard down and left too many kids uncirc'd. Now the country is paying a price, but hopefully you and others like Dr. Morris are getting things back on track. Here in the USA, we are hoping that the Centers for Disease Control and the American Academy of Pediatrics will resist the political pressure of the anti-circs -- and just follow the medical evidence in favor of universal neonatal circumcision.

    A foreskin-free world will take time, but America & Australia -- not Zambia -- should lead the way!

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  3. "It's never too late to circumcise!" Glad to hear you admit that, PD. That's why there's no panic to do it before the person most concerned can give his informed consent.

    "If circumcision reduces HIV by 60% in Africa, then it surely does the same in our countries!" Quite fallacious, because in theory, HIV is mainly tranmitted by heterosex in Africa, by sex between men and IV drug use in the developed world, and circumcision has no effect in either case. But recent studies are finding what everyone ignored, that male-male sex is prevalent in Africa, just much more hidden - which throws the claim that circumcision will be effective there into doubt, to say the least.

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  4. To respond to Hugh7:

    "If circumcision reduces HIV by 60% in Africa, then it surely does the same in our countries!" Quite fallacious, because in theory, HIV is mainly tranmitted by heterosex in Africa, by sex between men and IV drug use in the developed world, and circumcision has no effect in either case. But recent studies are finding what everyone ignored, that male-male sex is prevalent in Africa, just much more hidden - which throws the claim that circumcision will be effective there into doubt, to say the least.

    Oh dear. Where do I begin? Well, let's start with what you got right: circumcision has no effect on HIV transmission through IV drug use.

    It's not exactly correct to say that "HIV is mainly tranmitted by heterosex in Africa, by sex between men and IV drug use in the developed world". For example, "infections acquired through heterosexual sex account for the largest number of HIV diagnoses in the UK" (though "In terms of HIV infections actually occurring within the UK, gay men (and other men who have sex with men) accounted for two thirds of new cases", see http://www.avert.org/aids-uk.htm). Certainly, heterosexual HIV transmission cannot be ignored in developed nations.

    Whether circumcision is protective against HIV transmission among men who have sex with men (MSM) is still uncertain. Unfortunately, most HIV infections among MSM occur when a man takes a "receptive role" (as it is often put); in such situations his circumcision status obviously has no effect. This makes it difficult to establish the true effect of circumcision. Some studies of MSM who exclusively or primarily take an "insertive role" indicate that there may be a protective effect, but not enough research has been done to make a definitive conclusion.

    What is apparent, from decades of research, is that circumcision is protective against female-to-male transmission and, that it is associated, quite consistently, with lower HIV incidence at the population level.

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  5. Then how does Jake, or anyone in the field, explain the at least six African countries where more of the circumcised men have HIV than the non-circumcised?

    Jake, unsurprisinglyly, ignores the substance of my objection, that the much lower prevalence of HIV in the US and Australia, and the different predominant means of transmission, mean circumcision surely will NOT "do the same in our countires."

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  6. To address Hugh7's points:

    Then how does Jake, or anyone in the field, explain the at least six African countries where more of the circumcised men have HIV than the non-circumcised?

    First of all, I'd point out that it would be prohibitively expensive - and a logistic nightmare - to try to perform HIV tests on the entire male population of any country. What is possible is studies that use a sampling methodology of some kind.

    Second, these sources of data are observational studies by design (this would be true even with a 100% sample). They aren't experimental. And that means that they're inherently limited by confounding factors. For example, circumcision status may be associated with urban vs rural location, which may in turn be linked to different exposure to risk. Or circumcision status may be associated with religion or cultural status that is, in turn, associated with high-risk sexual behaviour. Or circumcision status might be associated with age, which in turn is associated with length of exposure to risk.

    There must be more than 50 (perhaps twice that) observational studies by now, and the majority of these are consistent with the experimental evidence. Given the relatively poor quality of observational studies, though, some exceptions can and should be expected.

    Jake, unsurprisinglyly, ignores the substance of my objection, that the much lower prevalence of HIV in the US and Australia, and the different predominant means of transmission, mean circumcision surely will NOT "do the same in our countires."

    Well, the lower prevalence of HIV won't make a difference to a relative reduction in risk. 60% is still 60% whether it's 60% of 0.5 or 60% of 20. It affects the risk:benefit balance, certainly, and consequently it can affect public policy. But it doesn't affect the truth of the statement. As to the modes of transmission, it depends how you understand "If circumcision reduces HIV by 60% in Africa". If you take it to mean "reduces [female-to-male transmission of] HIV..." then it's fine. If you take it to mean "reduces [the incidence of] HIV..." then it isn't.

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  7. "If circumcision reduces HIV by 60% in Africa, then it surely does the same in our countries!"

    That's probably why HIV rate in USA is 3 time higher than in Europe?

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  8. "Circumcising at birth is easier, less complicated, and much less costly."

    And, which beats everything, the owner of the penis can't refuse.

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