AIDS, abstinence and circumcision

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