So it looks like the Big Apple is going to take the BIG SNIP. Pull out those foreskins gentlemen, the circumcision express is coming to a chopping block near you... With ZERO data on the highest risk group in the United States - GAY MEN and Men who have SEX with Men - and what can be assumed LITTLE TO ZERO efficacy for those having unprotected receptive anal intercourse - the most effective means of transmitting HIV - I have one question - WHERE ARE THE BREAKS ON THIS CRAZY TRAIN?
Jim
Read the New York Times article, beginning below, "New York City Plans to Promote Circumcision."
New York City’s Department of Health and Mental Hygiene is planning a campaign to encourage men at high risk of AIDS to get circumcised in light of the World Health Organization’s endorsement of the procedure as an effective way to prevent the disease.
While the Centers for Disease Control and Prevention in Atlanta is just beginning to convene meetings and design studies to help it formulate a national policy, New York City is moving ahead on its own.
In the United States, “New York City remains the epicenter of the AIDS epidemic,” Dr. Thomas R. Frieden, the city’s health commissioner, said in an interview. Referring to H.I.V., he said, “In some subpopulations, you have 10 to 20 percent prevalence rates, just as they do in parts of Africa.”
His department has started asking some community groups and gay rights organizations to discuss circumcision with their members, and has asked the Health and Hospitals Corporation, which runs city hospitals and clinics, to perform the procedure at no charge for men without health insurance.
A spokeswoman for the corporation said it was “having conversations” with the health department but had not reached a decision.
Read the rest
Several African studies have demonstrated that circumcision reduces female-to-male HIV transmission in those epidemiologic conditions. But
ReplyDeleteAfrican conditions are quite different than in the US.
African HIV prevalence is at far higher levels, particularly among females who comprise roughly half or more of the cases in many African communities.
African heterosexual infection rates comprise a far higher portion of cases than in the US. And STD treatment accessibility in many African communities is very low, resulting in enormous prevalence of STDs which
raise male succeptability to infection.
In the US, female-to-male HIV
transmissions remain a low percentage of new infections. Male-to-female transmissions comprise a far higher portion of new US infections, but the African circumcision studies found no protective benefit to female partners. And those studies did not even examine MSM infections, many associated the largest risk contributor to new US infections.
MSM infections associated with receptive anal intercourse are unlikely to be impacted at all.
So the NYC Health Department's promotion of circumcision has been intiatiated in advance of an assessment of its community acceptability. It is occuring without a pilot study or even an epidemiological computer simulation to assess its likely efficacy in NYC conditions. And its launch is unaccompanied by any mention of an evaluation plan to assess its actual impact relative to its costs.
At best, this seems a bold gamble that might pay off with a small but compounding benefit in infections prevented. At worst,
it could be an impetuous diversion of resources from proven strategies
that jeopardizes public health credibility in communities already painfully sensitized by its historic lapses in ethical judgment.
-Curt Hicks
Not sure I agree that it's worth waiting for more data -- particularly in terms of making circumcision available. The data on MSW transmission from Africa are substantial and significant. While there are very few data on MSM transmission, the analogy for insertive intercourse is at least highly plausible, and the few data that exist support the idea. Also, NYC has a substantial portion of MSW transmission (much of it probably secondary from MSMW); even if circumcision weren't effective for MSM, it could have some benefit in protecting women. And it's not like the NYC DOH is knocking on the doors of uncircumcised men with a warrant and a mohel. They're just making the option available without charge. Finally, I suspect that, unlike some places in Africa, there won't be men lining up around the block to get snipped, and the cost won't be terribly high. Essentially the city is eliminating a potential barrier for men who want to be circumcised rather than taking major steps to make circumcision widespread...
ReplyDeletelet me just add, that if we had a microbicide with this efficacy rate, or a vaccine with an this efficacy rate, we wouldn't even be having this discussion.
ReplyDeleteWhere in the US do we have heterosexual prevalence rates that mirror those in Africa?
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteHey Jim,
ReplyDeleteI didn't say the criteria was whether or not we have the same prevalence rates of heterosexuals as Africa- but rather whether or not there is a significant percentage of new infections attributed to opposite sex sexual behavior.
Our Data is flawed in DC - but if you look at AIDS Cases reported between 2000 and 2004 in DC, about 25% of those cases were attributed to heterosexual sexual transmission, and about 27% were men who have sex with men (non-idu). The rest are IDU, not reported, perinatal, etc ...
If you further break it down to just the men - that's 11 percent - plus another 15 percent of men who did not report their risk.
Again, these numbers are flawed, but they are the best we have. And we have no circumcision data for DC, although one might expect it to be low due to the high percentage of people of color and immigrant populations.
so to speak very broadly, there are several thousand men who might benefit from this and a few thousand who might decide to do it.
Again, if we have those kind of numbers, I say let the men decide for themselves. God knows we've funded many, many HIV prevention programs that haven't been able to reduce HIV transmission by 50%. This can.
And of course if DC implemented such a program where grown men could make this decision for themselves, I would also suggest that at the same time they launch their own study to answer the question about Men who have sex with men.
If we don't have the data, I don't respond by saying "this is crazy!", I respond by saying let's get the data so we know for sure.
It is not crazy to consider this intervention, it is crazy to move forward without data. That is my point. My concerns for gay men and MSM remain around this intervention. How is DC planning to message this to the community you are targeting?
ReplyDeleteAlthough I think the research has been astounding (never before have we seen an intervention reduce transmission rate by 50%!), I have to agree that until this intervention is further studied in MSM, it's irresponsible to offer it with public health dollars. As others pointed out, in the U.S. female to male transmission remains a very low rung on the "transmission ladder."
ReplyDeleteI worry about using cookie cutter interventions. What works with one population does not necessarily work with another. For example, part of the reason I believe we have seen the increase in new HIV infections in African American women is that all the first interventions were targeted towards gay white men. Once HIV started affecting other groups, we tried to use those same prevention models. We quickly learned that interventions had to be adapted to fit the population we targeted.
With this being said, if they are going to target men who are having unprotected sex with HIV positive women and are uncircumsized, then this will be a wonderful intervention. However, I think that they are trying to target "high risk" men, which continue to be MSM, and I'm afraid it won't have the same effect on this population that it had in Africa and may offer a false sense of security to many....
I think it's ironic that Freiden espouses a data/numbers driven, epidemogiocal focused ideology, yet he is once again forging ahead with an HIV prevention program that lacks data (his previous recent proposal to change HIV consent procedures being another recent major example). The manner in which he goes about his proposals also follows his autocratic pattern of pushing through controversial measures without collecting community input first.
ReplyDeleteAll that said, I like any proposal that increases men's access to sexual and reproductive health options (whatever their sexual identity and behavior). While circumcision is a rather extreme measure, NYC is an extremely diverse place with many high-risk communities who could benefit from an option like this (an option which is clearly already available to those who can afford a private doctor to do it).
Lastly, I question the assumption that some seem to be making that data from African studies can't be extrapolated and generalized to those in the United States. Is the problem that the studies did not include MSM, or that they didn't focus on anal intercourse, or is the problem that they happened in a developing country? We should be more specific about what our concern is there. Having not read the studies directly myself, I can't say for sure that the participants weren't having anal sex (opposite sex or same-sex). There seem to be variation in the populations, locations and conditions of the participants in studies in various African countries. I think before we outright reject generalization, it's more helpful to look at the details and really explore what the specifics are to see where there are similarities, and where there truly are differences.
The data from Africa only represents heterosexual vaginal sex. Anal sex among ANYONE was NOT considered and this is where I have a concern. Of course, there is HUGE denial about the prevalence of anal intercourse among heterosexuals ---- a bigger issue that affects things like rectal microbicide research and our overall understanding of the epidemic. There is this idea that in Africa, it is all about vaginal intercourse. Of course, we KNOW there is anal intercourse happening among gay men, MSM, and heterosexuals, and we have a little data to back that up, but not enough...
ReplyDeleteInteresting discussion, guys. I'm not sure how easy it is to translate the African data to the US, EVEN for heterosexual transmission. There are many factors that could be different where these trials occurred such as presence of other microbes or STDs (I believe these were controlled for within the African studies, but that doesn't mean the same effect or lack of effect could be assumed in the US), availability of clean water for hygiene (again, not making assumptions, just raising possibilities), length and vigor of intercourse (I won't speculate here either, but who knows).
ReplyDeleteThe circumcision studies also attempted to compare the number of infections prevented through circumcision against a potential increase in transmission caused by disinhibition (i.e. increased sexual behavior) associated with men believing that circumcision provided protection for them and their partners against HIV. These studies found that the risk of disinhibition was real but likely not enough to offset the benefit. BUT, the studies measuring the effect of disinhibition is not as easy nor did they have the same level of resource as the main circumcision study(ies). And of course level of disinhibition is likely to be very culturally specific.
Here is my opinion on the matter: We are all eager for effective strategies to reduce HIV transmission. The large percentage reduction in transmission touted by the circumcision studies makes it tempting to adopt, or even irresponsible-seeming to ignore, the findings. However, it is amazing how many studies are dismissed or not implemented because of the difficulty of replication or the limits of translating practices from one setting to another. It does seem to be somewhat naive to think that a practice that has been associated with specific cultures and religions can be recommended to and adopted by other cultural groups based on 2 or 3 studies (albeit pretty good ones) taking place 10,000 miles away.
And by the way, there is some (small) risk of infection and sexual dysfunction associated with adult male circumcision which is reported in these studies. It is small, but it is there.
By the way, how about Thomas Frieden requiring HPV vaccine for every 11-year old in the New York City school system (male and female) to wipe out cervical and anal cancer in women and gay men in the Big Apple?
Education not mutilation. How about more funds and better distribution of condoms and material that teach about foreskin hygiene? Every time a magic-bullet-one-strategy-fixes-all headline, we seem to repeat our longstanding and ignorant love affair with the 'magic pill' theory. (A pill I might add a lot of us have been expecting for far too long.) The 50% success rate needs to be seen in the over all numbers from the world wide set of infection rates.
ReplyDeleteIt seems like this kind of 'hoo ra ra' over a small prevention technique can too easily take away from the multiple prevention techniques we will need to truly defeat this pandemic. No magic cure. No magic pill. No magic procedure. Instead, a dynamic approach suitable for each local community that has multiple prevention methods.
Regarding the comment from Amy - it's not fully correct to say that we haven't seen an intervention reduce transmission rates by 50% or more. In the US- where prenatal counseling, access to short course ART and followup is available, perinatal transmission has been virtually eliminated. Sadly, this well known, inexpensive and effective intervention continues to be denied to other countries even 10 years after its availibility and serves as a lesson to everyone about implementation delays. I know Amy was probably referring to interventions affecting adult sexual transmissions not all transmissions but it's important to keep in mind when supposedly startling news comes out how many effective measures are already availible- PMTCT, needle exchange, female condoms, etc. Very soon there is likely to be important good news about preventing transmission with low cost treatment of herpes infection. The question again will be how to deploy these proven relatively easy interventions fairly quickly and not get tied up in headline news.
ReplyDeleteToday's Kaiser Daily HIV/AIDS report has the following item:
ReplyDeleteNYC Mayor Bloomberg Raises Questions About Plans To Promote Male Circumcision as HIV Prevention Method
New York City Mayor Michael Bloomberg on Thursday raised questions about plans recently announced by the New York City Department of Health and Mental Hygiene to launch a campaign promoting male circumcision after the World Health Organization and UNAIDS last month recommended the procedure as a way to help reduce the spread of HIV, the New York Times reports. Following the health department's announcement, Bloomberg officials said the administration has not decided if it will pursue the campaign (Cardwell, New York Times, 4/6). UNAIDS and WHO released the recommendations in response to growing evidence that routine male circumcision could reduce a man's risk of contracting HIV through heterosexual sex. According to final data from two NIH-funded studies conducted in Uganda and Kenya published in the Feb. 23 issue of the journal Lancet, routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65%. New York's health department has begun asking community organizations and gay advocacy groups to discuss male circumcision with members and has requested that the Health and Hospitals Corporation, which runs hospitals and clinics in the city, provide circumcisions at no cost for men who lack health insurance. City Health Commissioner Thomas Frieden said he believes health insurers might agree to cover preventive circumcisions because they already cover them as treatments for infections and urinary blockage. According to Frieden, even 1,000 circumcisions performed in certain populations could curb the spread of HIV in the city (Kaiser Daily HIV/AIDS Report, 4/5). Bloomberg at a news conference said that he has not discussed the campaign with Frieden or HHC Chair Alan Aviles. Bloomberg also expressed support for seeking new methods to combat the spread of HIV but said he is not convinced that government should be involved in promoting or providing male circumcisions. According to Bloomberg, the number of HIV/AIDS cases in the city is very high, despite education campaigns. "We have to do something about it, and we should be looking at everything," Bloomberg said, adding that when "reputable health organizations talk about ways to do it, you certainly are going to give it some serious consideration." He also said that "whether it's something that the government should be involved in, or just giving advice and making sure that people get educated, education in the end is the real tool to stop the spread of AIDS in our society" (New York Times, 4/6).
Health Department Distributes Five Million Condoms in One Month
The New York City health department on Wednesday announced that from mid-February to mid-March it distributed five million no-cost condoms, or about two condoms per every man living in the city, as part of its efforts to curb the spread of HIV, the New York Times reports (Perez-Pena, New York Times, 4/5). The health department in January approved a $1.57 million contract to deliver Ansell Healthcare's Lifestyle condoms and packets of lubricants to organizations and venues in the city to help curb the spread of HIV. The health department will pay Ansell four cents per condom, putting the cost of the program at about $720,000 annually, according to health officials. City health officials in February unveiled the official condom, which features a subway theme with different colors for various train lines. Officials plan to track the progress of the program through an annual community health survey, which polls 10,000 city residents by telephone. New York City currently distributes about 1.5 million condoms monthly, or about 18 million annually, at no cost to organizations, health clinics, advocacy groups, bars, restaurants, nail salons, nightclubs and prisons. Organizations or venues can request an unlimited supply of condoms at no cost through an online ordering system set up by the city health department (Kaiser Daily HIV/AIDS Report, 2/20). According to the Times, the health department last year worked with 877 businesses, health clinics, advocacy groups and other organizations to distribute 18 million condoms. Since the department unveiled the subway-themed condom, an additional 500 groups have joined the effort, according to Adam Karpati, assistant city health commissioner in charge of HIV/AIDS programs (New York Times, 4/5). Some of the groups asked by the health department to participate distributed about one million of the five million condoms, the AP/Long Island Newsday reports. Frieden in a statement called the program a "sensation," adding, "Hundreds of community organizations are signing up to give out free condoms, many for the first time." According to the AP/Newsday, the condom distribution campaign also aims to prevent unplanned pregnancies and curb the spread of other sexually transmitted infections (Kugler, AP/Long Island Newsday, 4/4).
#WHO says this... WHO says that ....:: and WHO is WHO? a set of high HUMANS, N O T G O D S .
ReplyDeleteCircum???They go by a small study in 3 countries in mid Africa.There are 1 billion of circumcised men in the world, and has WHO cared to get the stats for them reg their resists to HIV? N O .
Male circumcision is impractical imposs on ANY mass scale, is not easy, and risky for the surgeon-nurse helper. There IS a bit of ring mucous surface left.
DO YOU KNOW THAT WASH_WELL THE INVOLVED SKIN AND MOUTHwash ,VAGINAdouche ,AND RECTUM [retention],SOON AFTER SEX ,WITH 35% SPIRIT ALCOHOL in water 250mils ,will kill the Virus on contact???
# Devote all all all your energies to care support help protect the HIV Positives and Negatives, their spouses, offspring,and close contacts.# not the silly foreskin biz.