/ 29 July 2011

Going off half-cocked — again

Millions of South African men — myself included — tremble in fear of pronouncements from the ANC Youth League and its leaders, Julius Malema and Floyd Shivambu.

No, not because of those songs, not in fear for our daughters because Malema seems not to respect women, not for their lack of grasp of basic economics, but because the league has now entered the arena of medicine and proposes that all males be forced to undergo circumcision.

On June 19 at the league’s congress, Shivambu is reported to have said: “It is scientifically proven that circumcision can reduce the chances of HIV infection.”

No one will separate me from my foreskin by force. What’s more, I will fight for the right of little boys, be they Jews, Muslims, gentiles, Hindus, Jains, Mormons, atheists and even Xhosa and Basotho males, to retain this much-maligned little piece of tissue which, if treated properly, not only causes no problems but also ensures great pleasure.

Contrary to Shivambu’s utterance, the evidence for embarking on wholesale male genital mutilation is not conclusive. The 2006 study by V Mishra in Burkino Faso, Cameroon, Ghana, Lesotho, Malawi, Tanzania and Uganda states in its results summary that HIV prevalence ranged from 2% in Ghana and Burkino Faso to 24% in Lesotho: “The proportion of uncircumcised men was highest in Lesotho (52%) and lowest in Ghana (5%).”

“That proves it!” youth league medics might trumpet.

Hang on, comrades. The report goes on to detail that “circumcised men had a lower HIV prevalence in only two of the eight countries”. Furthermore, when age, education, wealth and various sexual and behavioural risk factors were considered, in only one of the eight countries were circumcised men at an advantage. In the other seven countries, the opposite might be the case.

The leap to false conclusions started with the “Auvert study”, presented in 2005, which tracked 3 273 men of Orange Farm, aged 18 to 24, wishing to be circumcised. The men were divided into “control” and “intervention” groups; the former were offered circumcision (by medical doctors) at once, while the latter were offered it after 21 months. The conclusions were charged with unscientific excitement. The authors gushed: “Male circumcision provides a high degree of protection — equivalent to a vaccine with a 63% efficacy.

The promotion of male circumcision in uncircumcised men will reduce HIV incidence among men and, indirectly, will protect females and children from HIV infection.”

Far from it. The study drew widespread criticism, as did other studies, in Kenya and Uganda. Critics point out that in the Orange Farm study, the 1 600 or so men who were circumcised were warned about the dangers of sexual activity following the operation. If they must have sex, they were told, use a condom.

Nothing concentrates the mind like having one’s genitals pruned, so many of those circumcised early were likely to have abstained or used condoms. The uncut men just went on their merry way, unwarned.

About 14% of the subjects were lost to the study or disqualified. How many found that in spite of being circumcised they had Aids? These numbers could refute the published results. A researcher trying to achieve a positive result ignores dropouts.

In addition, the Kenya and Uganda trials were stopped early, ostensibly because the benefits of circumcision had been established: another research ploy — stop when you’re ahead. Had the trials run their full gamut, the results might have been less impressive.

The statistical trick of “relative risk ratio” gave a “63% reduction”. The percentages in these ratios are extrapolated from very small numbers. In all the trials, one might hope for about 12 circumcised men of each 1 000 staying HIV-negative, as opposed to six (yes, six) uncircumcised men per thousand. Using the Kenyan and Ugandan figures, it would take 56 circumcisions to prevent one case of HIV in one year and in societies where HIV is less common, many more. No treatment with such scant effect should become standard practice.

What about a follow-up on all the circumcised men who for several years imagined themselves protected by the operation. How many have since become HIV positive?

The biggest danger is that the mantra “circumcision prevents Aids” will be accepted as truth, instead of abstinence, being faithful and using condoms — the “ABC” of prevention. This is as fallacious and dangerous as the myth that sex with a virgin cures Aids.

The human rights, law and ethics committee of the South African Medical Association declared last month that it was unethical and illegal to circumcise infant boys. The committee expressed “serious concern” that there was not enough scientific evidence to confirm that circumcision prevented HIV. The committee “did not support circumcision to prevent HIV transmission”.

William Barker is a freelance journalist