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AIDS, abstinence and circumcision

21 May 2010
by Guest author

On March 4th, we reported on the UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV. In the following post, Dr Sander Gilman, Distinguished Professor of the Liberal Arts and Sciences and Professor of Psychiatry at Emory University, takes a critical look at policies promoted as an answer to the spread of the epidemic.    

The AIDS epidemic hit Uganda hard in the early 1980s, with prevalence rates up to almost 30% in some urban areas. Following the end of the civil war in 1986, a vigorous government-led campaign saw prevalence declining dramatically until around 2000, and Uganda was hailed as one the few success stories in the continent’s fight against the disease. Then, the situation stabilized, and in some areas has started to get worse again. What happened?

The successful campaign was known as ABC, summarized as: “Sexual Abstinence until marriage; secondly, advising those who are sexually active to Be faithful to a single partner or to reduce their number of partners; and finally, especially if you have more than one sexual partner, always use a Condom.”

American support for HIV/AIDS intervention increased, but the corollary was the expansion of the “abstinence only” program, and the virtual elimination of the “C” from the ABC model. But “abstinence only” clearly did not work any better in Sub-Saharan Africa than it did among those who had taken abstinence pledges like this one in America. Centers for Disease Control (CDC) studies of “abstinent” teenagers showed that they had equal rates of gonorrhea as sexually active ones (albeit in the form of oral and anal infections).

While this approach is now being reversed, and a broader and more comprehensive sex education model has been advocated recently, the legacy in Africa remains.  

And it remains in ways that are rather frightening because they evoke a historical moment that led to quite devastating results. For as money increased and American foreign policy demanded abstinence only in combating HIV/AIDS in sub-Saharan Africa, the 19th century “solution” of circumcision as a major prophylactic against STIs (which proved to be universally ineffective) was reinvented to combat AIDS, even though the studies that argued for this were seriously flawed.

They assumed a causality between adult circumcision and reduced rates of infection in all populations and they looked at populations of circumcising religions including indigenous ones without asking whether belonging to a self-policing religious or social group might be a cause for less risky sexual behavior because of a decreased rate of exposure.  Equally unnerving was the refusal to report the “serious adverse event data” resulting from circumcision itself.

Even during the 19th century, claims for circumcision as a prophylaxis against syphilis (and other STIs) were always countered with the claim that the very act of ritual circumcision actually transmitted syphilis and often caused death or impairment through the surgery itself.  In the 1930s, a proposal in the UK to require infant male circumcision sparked a debate in the British Medical Journal.  

Needless to say, infant male circumcision never became state policy in Great Britain because the science of the time did not support it.  The clearest result of the some one hundred and fifty years of debates about the efficacy of circumcision as a prophylaxis against infectious disease is the determination both anecdotally and epidemiologically that such a procedure has little or no effect on STI transmission. Thus tracing the rates of STIs among those ritually or medically circumcised in the United States showed no difference in rates of infection that could be attributed to circumcision.

The spike in HIV/AIDs in Uganda today is because “… old-fashioned prevention has flopped. Too few people, particularly in Africa, are using the “ABC” approach pioneered here in Uganda” as the New York Times reported on May 11, 2010. The article continued “Science has produced no magic bullet — no cure, no vaccine, no widely accepted female condom. Every proposal for controlling the epidemic with current tools — like circumcising every man in the third world… is impractical.”  And one can add, not proven in terms of any one’s science.  

What is needed in Uganda and elsewhere is what was and is successful in the global West:  public education tied to specific groups that has reduced in many cases risky behaviors, and the funding of HAART (highly active antiretroviral therapy), now the standard of care in the United States, that has dramatically changed the experience of being infected with HIV by offering a means to “live” with a once terminal disease.  This works. Circumcision simply does not.

Useful links

Data on Official Development Assistance to HIV/AIDS control by recipient

Meta-analysis of Development Co-operation on HIV/AIDS commissioned by Finnish Ministry of Foreign Affairs 

7 Responses leave one →
  1. Tally permalink
    May 21, 2010

    Too many are pushing their agenda using HIV as a vehicle. Some religions don’t like condoms. Other religions actively promote circumcision. Others (some hypocritcally) promote the impossible, like abstinence. Science and proven methods are taking a back seat to the cure-of-the-day that promotes certain groups beliefs.

  2. Harvey Jackson permalink
    May 24, 2010

    I think it would be better to simply withdrawing funding and aid in regards to these issues rather than wasting money advocating abstinence-only. I’ve always felt – and the science obviously confirms me – that the results of these abstinence-only education are as bad or worse than advocating child abuse. With that kind of track record, we may as well be paying for a trip back subsidizing the empowerment of pedophiles. We are simply funding the destruction civilization by even going down that route.

  3. Harvey Jackson permalink
    May 24, 2010

    Unlike FB, your blog doesn’t let me delete/edit/repost. Sorry for the grammar errors, but I think you get the drift – I’ll just try to slow down and proof read better next time.

  4. Caroline permalink
    May 24, 2010

    Thank you! Excellent post. One day the world will look back the circumcision and hiv claims as preposterous. The same way we do the Victorian ideal masturbation caused disease.

  5. Jeff W permalink
    May 25, 2010

    abstinence is not the answer. the fact that we continue to waste money on these sorts of things is just silly. at the same time, there is more to the solution than simply getting people to use more condoms. cheap, easily accessible, testing or even home testing kits would help keep people aware of theirs and even their partners conditions. more open social acceptance of a variety of sexual identities would allow a more open discussion amongst individuals. even a more honest discussion about the difficulty of attempting to limit partners might lead to a more realistic discussion of such possibilities. detailed, honest truths about the diseases we face, are the best offense we can hope to have.

  6. Harvey Jackson permalink
    May 27, 2010

    I’d just like to reiterate that funding abstinence only education is not just a waste a money, its an absolute harm akin to organized child abuse. I think that was obvious from my previous comment, but somehow I just don’t think it can be said enough. If someone wants to do this to their own children, perhaps we can’t stop them, but anyone supporting or imposing this on any greater population should be prosecuted for crimes against humanity. I hope that’s clear enough. And not just in my opinion assuming these barbarians understand what science is.

  7. July 20, 2010

    Usually, medical studies tend to study how to preserve the human body, not vilify it and justify its destruction. For example, hernias used to require large incisions that left the patient with a scar. Now, with laproscopic technology, doctors can operate using just a few incisions in the body. The study of cancer is a tedious one, and usually researchers are trying to find ways to avoid the loss of organs, such as the testicles, the prostate, and/or the mammary glands. Circumcision “studies” are unique. They’re the only ones of their kind that seek to preserve a procedure, and not the human body.

    I’m sure that researchers have considered the scenario that not everyone will want to get circumcised. Have they considered or studied alternatives for HIV/STD prevention WITHOUT having to circumcise? Is the WHO or NIH doing anything to eventually move past circumcision? Is there research looking for ways in which men don’t have to consider circumcision anymore?

    According to the WHO Bulletin, African ritual circumcisions have a 35% complication rate, while clinical circumcisions have an 18% complication rate. A neonatal circumcision complication rate of 20.2% was found in Nigeria. Won’t dealing with these complications divert resources away from other more needed programs, such as mother-to-child transmission reduction? The treatment of people who are already infected? Antiretroviral therapy?

    These are hard economic times. I hear lots of talk of “efficacious spending” and “evidence-based decision making.” Studies show one thing, but reality shows another.

    In America, for example, 80% of men are already circumcised from birth. The rates of infant circumcision are dropping, but at large, the population remains circumcised. These rates are at their highest in the East Coast, where cities such as Philadelphia and Washington DC rival HIV hotspots in South Africa. In the 1980s, when the AIDS epidemic first hit, the rate of circumcised men in America was at 90%. One needs to question how something that never worked here in our own country is suddenly going to work wonders in Africa.

    In other countries, the “protection” remains to be seen as well. AIDS is a rising problem in Israel, where the majority of the male population is already circumcised. On Wednesday, July 7th, two weeks ago, Malaysian AIDS Council vice-president Datuk Zaman Khan announced that than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims (in other words CIRCUMCISED). The Muslim, circumcised population accounts for 70% of the incidence of HIV, but only 60% of the population, which would mean that the circumcised population is getting HIV at a much higher rate than the non-circumcised population.

    It is a waste to be spending money on a procedure with dubious benefits, when that money could be better spent on more effective modes of prevention. WHO, UNAIDS etc. need to start looking beyond circumcision for HIV prevention.

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