Rolling on and rolling out – circumcision and sexual health: 2010 and beyond Opening Address

1. Rolling on and rolling out – circumcision and sexual health: 2010 and beyondOpening Address Professor Gary Dowsett, PhD, FASSA Australian Research Centre in Sex, Health & Society Melbourne, Australia www.latrobe.edu.au/arcshs

2. Abstract Does the framing of circumcision as another 'prevention technology' mask a number of scientific and ethical questions about the widespread deployment of circumcision? Most crucially, it seems to represent a return to large-scale, coercive, public health programmes and a refusal to engage with modern ideas about the social determinants of health so important to this epidemic. Will circumcision increase the challenges of achieving a social consensus on the virtues of prevention?

3. Background The three sub-Saharan clinical trials Is this the only evidence we need? No sophisticated social science research took place at the time of the trials A need for wider discussion of the social, political and cultural issues in consideration of male circumcision

4. What is evidence? The three trials did produce evidence of efficacy, but: Bias leading to overestimation of treatment effect (van Howe, 2009) in: Selection Lead time Expectation Attrition Intervention Length

5. What is evidence? Randomised Controlled Trials (RCTs) The gold standard? The dominant paradigm in late-modern positivist, scientific theory RCTs are debated in medical science Useful in clinical intervention studies and drug treatment trials Not always regarded as appropriate for research on surgical techniques Behavioural studies often cannot reproduce same levels of efficacy in practice

6. What is evidence? Evidence from the three RCTs is insufficient to design evidence-based practice: Other considerations, e.g. Feasibility Funding Sustainability Confounding variables

7. What is evidence cont? Evidence-based practice is: ‘a multifaceted rationalisation [that] constructs a regime of truth’ (Walker, 2003: 151) i.e. it is a social and historical product, not simply objective ‘fact’ or ‘truth’ ‘an ideologically driven practice that ignores the contexts of experience’ (Murray et al. 2007: 154) i.e. there are dangers of ‘decontextualisation’ in truth claims that can accompany evidence

8. More recent evidence Garenne (2008) reviewed 14 countries in Sub-Saharan Africa: In South Africa ‘mean yearly HIV incidence and net reproduction rate of the epidemic were not lower in provinces with higher levels of male circumcision’ (2008: 1) Of 13 other countries, only two showed lower prevalence among circumcised men (Uganda & Kenya, i.e. where the trials are) No difference in eight countries Higher HIV prevalence among circumcised men in Cameroon, Lesotho and Malawi Associations are complex and need to be treated with caution – other factors are involved

9. Contradictory evidence In Australia The epidemic mostly focused on gay and other homosexually active men, mostly older generations of men, more likely to be circumcised In Western Europe Mainly among gay men too, but mostly uncircumcised In the USA High circumcision, high income, expanding epidemic Something other than circumcision is central to driving different epidemics, their onset, speed and scale

10. New evidence Philippines High circumcising culture with a small epidemic so far Reported cases leaped from 342 in 2007 to 835 in 2009, and 232% rise in incident infections in 2009 Most new infections among young men aged 25-35 Factors other than almost universal circumcision at work here The drivers of epidemics are many and they interact to produce different effects, in different places, at different times

11. Efficacy and Effectiveness Cochrane review (Siegfried, et al. 2009) Efficacy in the three Sub-Saharan trials was between 38% and 66% over 24 months What might this range mean in real-world settings? Why are avid proponents of male circumcision so resistant to acknowledging the common drop in real-world effectiveness? The results pertain to experimental studies in settings of high prevalence, in generalised epidemics in Sub-Saharan Africa, among ‘heterosexual’ men only

12. The claims of efficacy have been inflating since release of the trials findings At WHO/UNAIDS policy meeting (Montreux, March 2007), it was agreed that circumcision was ‘partially protective’ The phrase ‘proven effective’ is now increasingly standard i.e. ‘there is overwhelming evidence of the efficacy of circumcision for HIV prevention’ (Wamai, et al., 2008: 399)

13. Remember: Being circumcised will not protect a man from being infected if he engages in unsafe sexual behaviour Circumcision is not really an individual-level protection strategy The hope is that MC will have a population-level effect over time Other factors in play at the trial sites where prevalence may be dropping: Nature of the research intervention itself High levels of resources, funding Global attention

14. Caution: Cost-effectiveness of circumcision less encouraging compared with: Highly effective prevention initiatives utilising enhanced condom provision Encouraged sexual culture change Accelerated anti-retroviral treatment roll-out In those observational sites where circumcision appears to have little or negative effects on prevalence or incidence patterns, roll-out of male circumcision could have other, even detrimental effects

15. Protecting women Circumcision lowers HIV risk for men in vaginal sex with HIV+ partners – what about women’s risk in sex with HIV+ men? Uganda trial-related study of female partners (Wawer et al., 2009): Circumcision of HIV-infected men did not reduce transmission to female partners over 24 months More efficacious and effective prevention methods should be prioritised More social and contextual studies required to provide a clearer idea of whether any benefit to women will accrue in assessing circumcision as part of overall epidemic drivers

16. Risk compensation ‘Dis-inhibition’ Trials indicate that circumcised men are not more likely to engage in riskier sex practices after circumcision, on some but not all indicators This is not a direct biological outcome of circumcision itself: A psychological effect? An artefact of the trial methodology? Some men rushed to have sexual intercourse before wound healing, raising their risk of infection – why too soon, and why without a condom? Condom provision remains important Need to understand the trials’ methodology better

17. Trials’ inputs? We have no idea if the trials’ education and care programs and condom provision levels can be achieved in real-world settings beyond the trials, and sustained over 10-20 years Significant levels of monitoring and support are required to achieve adherence to risk reduction To presume that risk compensation will not take place is foolish

18. Other infections Circumcision has no effect for: Penile or prostate cancer No consistent association for Herpes Human papilloma virus (HPV) Gonorrhoea Chlamydia Urinary tract infection Some effect for syphillis and genital ulcerative disease but these are context-specific and treatable in other ways

19. Treating STIs No consistent relationship between male circumcision and cervical cancer It might be more useful to fund HPV vaccination in girls in low income countries than to circumcise young men in the name of HPV prevention Discussions of STIs and their prevalence do not strengthen the argument for circumcision in relation to HIV infection

20. Constituting the ‘regime of truth’ Rationalisations without ethical or scientific basis that constitute a ‘regime of truth’ regarding the efficacy of circumcision: STIs and HIV Religious and cultural acceptability Historical practice Father/son similarity Appearance Hygiene Acceptability Female partner preferences These tend to support circumcision as inevitable and necessary and close down debate and discussion

21. Gay men and MSM No evidence of efficacy for gay men or other MSM Gust et al. (2010) concluded that circumcision status was not associated with incident infection Circumcision played no significant role in the epidemics among gay men across the world

22. Recent rises among gay men Recent changes in HIV incidence rates among Western gay communities Different rates of circumcision in these different communities MSM epidemics on the rise in Asia, with different circumcision patterns culture by culture Rises (and falls) over 10-year period Changes too rapid to be related to circumcision

23. Neonatal circumcision The trials offered no evidence on the efficacy of neonatal circumcision on HIV transmission The pro-circumcision and anti-circumcision lobbies cloud the issue Evidence on other STIs is contested; no Pediatric Societies’ support Circumcising a healthy infant male to provide protection against an infection that he might encounter a decade or more into the future, and for which he will also need a condom to be protected against is a spurious rationale for circumcision

24. Parental consent Parental consent as surrogate consent Is not absolute We don’t advise or allow parents to subject their children to non-indicated medical procedures The protection of children frequently ranks above parental prerogatives and cultural traditions in many jurisdictions Children’s rights and sexual rights now enshrined in international health agendas Surrogate consent to circumcision is a profound ethical and moral issue that requires more discussion and debate

25. Coercion and public health ‘An act of enforcing, of ensuring observance of, or obedience to’ Acts of force or moral persuasion or incentives Financial incentives Regulations Claims to ‘best practice’ Managed scarcity Cost recovery Targeted training resources Enhanced access, etc. Aims to create the ‘default option’

26. Creating the ‘default option’ Circumcision has been positioned as the ‘default option’ through establishing a ‘regime of truth’ Enormous weight of resources from donors Avalanche of pro-circumcision information coming from UNAIDS and WHO Historical and cultural authenticity assertions Mobilisation of evidence on HIV Influence of medical and scientific institutions, particularly from the USA Moral high ground claimed by pro-circumcision lobbyists Discursive downgrading of alternative prevention options – condom use, structural interventions, community education, sexual culture change, etc.

27. Coercion & the default option King of Swaziland’s decision – top-down approach ‘Over 80% of men in a large national survey in Botswana wished to be circumcised’ (Klausner, et al. 2008: 31) Will we ever know how informed these men’s choice is? South African pilots going ahead before full debate

28. Many other unresolved issues Including: Evaluation and monitoring of any scaled-up roll out, including culture shifts, condom use, etc. Vulnerability and strategies for women Outcomes for MSM who are usually neglected Quality control and health provider training Infrastructure provision and maintenance Sustaining STI control Adverse events reporting and injury compensation Social consequences (stigma, sexual violence, shifts in sexual behaviour) Legal issues concerning children’s rights Sustaining funding over the long term

29. What about HIV prevention? Now called ‘prevention science’ Focused on individual behaviour change Downgraded the experiential and elevated the experimental Shifted authority to prevention scientists away from health promotion practitioners From prevention education to technological fixes

30. Moving forward We must redress the balance between an overly scientistic approach and the social determinants of health Power and inequality Gender and sexuality Social, cultural and political change Access and provision Health literacy Social capital, etc.

31. References • Garenne, M. (2008) Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. African Journal of AIDS Research, 7(1), 1-8 • Green, L.W. et, al., (2008) Male circumcision is not the HIV ‘vaccine’ we had been waiting for! Future HIV Therapy, 2(3), 193-199 • Gust, et al., D.A. (2010) Circumcision status and HIV infection among MSM: reanalysis of a Phase III HIV vaccine clinical trial. AIDS • Klausner, J.D., et al., (2008) Is male circumcision as good as the HIV vaccine we’ve been waiting for? Future HIV Therapy, 2(1), 1-7 • Murray, S.J., et al., (2007) No exit? Intellectual integrity under the regime of ‘evidence’ and ‘best-practices’. Journal of Evaluation in Clinical Practice, 13, 512-516 • Siegfried, N., et al., (2009) Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic Reviews, 2 • Van Howe, R.S. (2009) Is neonatal circumcision clinically beneficial? Argument against. Nature Clinical Practice Urology, 6(2), 74-75 • Walker, K. (2003) Why evidence-based practice now?: a polemic. Nursing Inquiry, 10, 145-155 • Wamai, R., et al. (2008) Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence AIDS epidemics. Future HIV Therapy, 2(5), 399-405 • Wawer, M. et al., (2009) Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial. The Lancet, 374(9685), 229-237

32. Acknowledgments • Thanks to Dr Duane Duncan (La Trobe University), Professor Peter Aggleton (University of Sussex), Ms Mary Crewe (University of Pretoria) • Oxfam Australia • Centre for the Study of AIDS, University of Pretoria • Australian Research Centre in Sex, Health and Society, La Trobe University