Condoms: The real front-line or magic bullet against HIV-AIDS

For all the poorly thought out chit-chat and media hoo-hah about circumcision, the real magic bullet against HIV-AIDS is the same as it has always been: restraint, fidelity, safe-sex and condom use. Or as the old saying goes, If you can't be good be careful.

AIDS control breakthrough: Vatican approves condom use

For many years the struggle against HIV-AIDS, particularly in poor countries, has been weakened by the stance of the Catholic Church against the use of condoms. The basis for the ban is that they are a form of birth control, prohibited since the 13th Century on the word of the theologian Thomas Aquinas. Since condoms are about 95 per cent effective as a preventive of HIV and many other sexually transmitted infections, the prohibition has had much the same effect as would a ban on, say, smallpox vaccination or the use of penicillin as an antibiotic. The obstinacy with which the Vatican maintained this dogma has dismayed many compassionate people, including Catholics, who have reasonably pointed out that even if using a condom was a sin, it could not be a worse sin than infecting another person with a fatal and incurable disease.

It now appears that the current Pope, Benedict XVI, has at last seen the cogency of this argument, and agreed that Catholics are entitled to use condoms if their purpose is not to prevent conception, but to prevent the spread of HIV. The following report is form Yahoo News.

VATICAN CITY – In a seismic shift on one of the most profound – and profoundly contentious – Roman Catholic teachings, the Vatican said Tuesday that condoms are the lesser of two evils when used to curb the spread of AIDS, even if their use prevents a pregnancy.

The position was an acknowledgment that the church’s long-held anti-birth control stance against condoms doesn’t justify putting lives at risk. “This is a game-changer,” declared the Rev. James Martin, a prominent Jesuit writer and editor. The new stance was staked out as the Vatican explained Pope Benedict XVI’s comments on condoms and HIV in a book that came out Tuesday based on his interview with a German journalist.

The Vatican still holds that condom use is immoral and that church doctrine forbidding artificial birth control remains unchanged. Still, the reassessment on condom use to help prevent disease carries profound significance, particularly in Africa where AIDS is rampant. “By acknowledging that condoms help prevent the spread of HIV between people in sexual relationships, the pope has completely changed the Catholic discussion on condoms,” said Martin, a liberal-leaning author of several books about spirituality and Catholic teaching.

The development came on a day when U.N. AIDS officials announced that the number of new HIV cases has fallen significantly – thanks to condom use – and a U.S. medical journal published a study showing that a daily pill could help prevent spread of the virus among gay men. “This is a great day in the fight against AIDS ... a major milestone,” said Mitchell Warren, head of the AIDS Vaccine Advocacy Coalition.

Theologians have debated for years whether it could be morally acceptable for HIV-infected people to use condoms to avoid infecting their partners. The Vatican years ago was reportedly preparing a document on the subject, but it never came out. The groundbreaking shift, coming as it does from the deeply conservative pontiff, would appear likely to restrain any public criticism from Catholic conservatives, who insisted Tuesday that the pope was merely reaffirming the church’s moral teaching. …



In the book, “Light of the World: The Pope, the Church and the Signs of the Times,” Benedict was quoted as saying that condom use by people such as male prostitutes indicated they were moving toward a more moral and responsible sexuality by aiming to protect their partner from a deadly infection. His comments implied that he was referring primarily to homosexual sex, when condoms aren’t being used as a form of contraception. However, questions arose immediately about the pope’s intent because the Italian translation of the book used the feminine for prostitute, whereas the original German used the masculine.

The Vatican spokesman, the Rev. Federico Lombardi, told reporters Tuesday that he asked the pope whether he intended his comments to apply only to men. Benedict replied that it really didn’t matter, the important thing was that the person took into consideration the life of another. “I personally asked the pope if there was a serious, important problem in the choice of the masculine over the feminine,” Lombardi said. “He told me no. The problem is this: ... It’s the first step of taking responsibility, of taking into consideration the risk of the life of another with whom you have a relationship. This is if you’re a man, a woman, or a transsexual. ... The point is it’s a first step of taking responsibility, of avoiding passing a grave risk onto another,” Lombardi said. …

UNAIDS estimates that 22.4 million people in Africa are infected with HIV, and that 54 percent – or 12.1 million – are women. Heterosexual transmission of HIV and multiple, heterosexual partners are believed to be the major cause of the high infection rates. Benedict drew harsh criticism when, en route to Africa in 2009, he told reporters that the AIDS problem couldn’t be resolved by distributing condoms. “On the contrary, it increases the problem,” he said then.

In Africa on Tuesday, AIDS activists, clerics and ordinary Africans applauded the pope’s revised comments. “I say, hurrah for Pope Benedict,” exclaimed Linda-Gail Bekker, chief executive of South Africa’s Desmond Tutu HIV Foundation. She said the pope’s statement may prompt many people to “adopt a simple lifestyle strategy to protect themselves.” In Sierra Leone, the director of the National AIDS Secretariat predicted condom use would now increase, lowering the number of new infections. “Once the pope has made a pronouncement, his priests will be in the forefront in advocating for their perceived use of condoms,” said the official, Dr. Brima Kargbo.

Read full story at Yahoo News.

More evidence that circumcision leads to lower condom use

There is further evidence from Africa that the circumcision programs intended to reduce the risk of HIV infection are leading to reduced condom use. This is exactly what the critics of circumcision as an AIDS prevention strategy warned would be likely to happen, and events are proving the sceptics correct.

In Zambia, a school headmistress complains that media campaigns are driving teenage boys into agreeing to circumcision without any explanation of the risks or likely effects, and that the boys believe being circumcised means that it is now safe for them to indulge in unprotected sex.

In Swaziland, there are increasing fears that the aggressive circumcision programs there are discouraging men from using condoms, leading to an epidemic of unsafe sex. Men have realised that while the presence of the foreskin makes forms of safe sex such as masturbation highly enjoyable and satisfying, circumcision takes away most of the pleasure. Once circumcised, they find the only way to get satisfaction is by engaging in “bareback” sex with a partner.

Zambia: Boys see circumcision as licence for unprotected sex

THE recent headlines that circumcision has made are too loud for anyone to ignore. The media adverts coupled with other forms of campaigns for circumcision have certainly had an impact on the general public. Critics say circumcision is brutal and robs males of sexual sensation, but many in the medical community point to research that suggests circumcision reduces the risk of sexually transmitted infections including HIV.

According to the National Male Circumcision Strategy and Implementation 2010 - 2020 Plan, 2.5 milllion males have been targeted before 2020. However, what is worrying is that information filtering about circumcision is one that has been received with misconception especially amongst the youths and school pupils in particular.

Recently, the Education Post visited Kafue Boys Secondary School where close to ten pupils registered to get circumcised at a local health centre without the consent of school authorities. Confirming the development, school headmistress Catherine Mutale expressed disappointment at the decision by personnel at the health centre to enlist the pupils for circumcision without the school authorities’ approval.

Mutale learnt about the circumcision campaign at her school through the posters that had been stuck on trees within the school premises and that a parent to one of the pupils had also called the school earlier inquiring on how their child had been circumcised without their approval. “We found posters promoting circumcision stuck on trees and by the time the deputy head pulled them out ,the pupils had already read the message on the posters and were booked in for circumcision the next day,” Mutale said.

The headmistress said she then approached health personnel at Kafue Rural Health Centre over the matter who responded defensively, saying the boys were old enough to make their own decisions. “By the time we had gone there, five had already been circumcised, and five more were awaiting circumcision,” she said.

Mutale complained that the practice had disturbed some pupils because they were absconding classes due to the nature of the operation. “Some have been missing class because they are having problems in walking and sitting. Our other concern is on the cleaning of the wounds; we don’t know whether the boys are doing the right thing. They are targeting boys because they want to meet the target.

She also sadly noted that there was a misconception amongst pupils that once circumcised they could have unprotected sex without contracting STI’s and HIV. “These pupils think circumcision is a lee-way to indulge in unprotected sex and now my worry is they may decide to practice this whilst at home during holidays because then the school will have no control over them,” Mutale said.

Lenganji Sikapizye, Boys see circumcision as a licence for unprotected sex, The Post Online, 13 November 2010.

Swaziland: “Skoon sex” crisis looming after circumcision

EZULWINI – There is fear that male circumcision has led to people not using condoms and engage in “skoon sex”. As a result, there have been calls for a study to be conducted to determine whether the numbers between circumcision and condom distribution add up.

“I’m concerned about male circumcision. Last year there was a circumcision campaign. I would like to see if the numbers tally between circumcision and condom distribution. If the condom distribution is low then we have a problem which probably means that the circumcised are not using condoms. We need to carry out research. If the circumcised don’t use condoms then we are heading for disaster because of those that are HIV positive,” submitted Vusi Nxumalo. A participant of the indaba said it was obvious the circumcision concept had not been properly communicated to the public. “A sibling at home is now telling us he is circumcised and therefore has ‘skoon’ sex,” she submitted.

Another participant, identified as Magagula, made a statement that threw everyone into laughter when he said the penis foreskin was good for masturbation. “Now without the foreskin you can’t satisfy yourself but women can still do that through use of vibrators,” he said. However, Bertram Auvert [Western researcher behind the first circumcision clinical trial] said he had never heard of masturbation concerns from those that had circumcised.

16% of pupils have sex with four or more partners

Sixteen per cent of surveyed pupils in the country are reported to be having sex with four or more sexual partners. This was revealed by Mzwethu Nkambule, Campaigns Manager of Lusweti, when making a presentation on Multi-Concurrent Partners (MCPs) and the HIV incidence in Swaziland. He said this was seriously perpetuating the spread of HIV/ AIDS, to the extent that Swaziland had become the leading country in the level of HIV/AIDS prevalence in the Southern Africa region.

Nkambule also divulged that, “among the 15-19 year olds who had sex about a third had more than one partner.” He also disclosed that more women, according to statistics, are reported to have acquired HIV as compared to men. “Sixty-two per cent of the overall infections in 2008 were recorded among females while 38 per cent were recorded among men,” he said, while shedding light on the urgency of crafting initiatives that will lead to a Swazi HIV-free generation.

[On the evidence so far, that objective will not be achieved by circumcision.]

‘Skoon sex’ crisis looming after male circumcision, Times of Swaziland, 1 December 2010

HIV-AIDS control in Africa: Circumcised men more likely to have multiple partners and forget the condoms

From Africa there is ever-increasing evidence that men who have agreed to get circumcised because they have been told it will protect them from HIV infection believe they are immune. This is leading to an increase in high-risk behavior: increased promiscuity, multiple partners, more unsafe sex and failure to use condoms. As critics of the circumcision solution have warned from the beginning and emphasized on the rare occasions they have been allowed to get anything into print, such behavioural patterns are likely to increase the incidence of HIV infection, and at the very least must cancel out any benefits that might otherwise arise from the circumcision programs. As recent reports from Zambia, Kenya and Zimbabwe indicate, the much-vaunted circumcision programs are producing an epidemic of unsafe and high-risk sex, thereby defeating their own stated purpose.

Zambia: 25% of men resume sex before wounds from circumcision fully healed, HIV risk to women increased

Approximately a quarter of men undergoing circumcision resume sexual activity before their wounds have fully healed, Zambian research published in the online edition of the journal AIDS shows. Most of the men reporting the early resumption of sexual activity engaged in unprotected sex, often with multiple partners.

The investigators calculated that early resumption of sexual activity at this level could undermine the protective effect of circumcision against HIV at a population level. Indeed, if the proportion of men engaging in sex during wound healing increased to 30%, then circumcision would lead to more new HIV infections in women than it would avert. “The prevalence of sexual activity and, in particular, risky sex during the wound healing period in the Zambian context is not trivial,” comment the investigators. “Even relatively small increases in early sex can have a deleterious impact on women to a point where new infections exceed averted infections in that year.”

A number of randomised controlled trials have shown that circumcision can reduce a man’s risk of infection with HIV by approximately 66%. It has been calculated that universal male circumcision in sub-Saharan Africa could avert 2 million new HIV infections in the first ten years. Male circumcision programs are therefore being implemented in a number of countries in the region with generalised HIV epidemics. Zambia embarked on a national circumcision program in 2007. HIV-negative men aged between 13 and 39 years are targeted in this program and in 2010, some 61,000 men underwent circumcision.

However, the protective effects of circumcision suggested by randomised trials can be undermined by a number of factors. One of the most important is early resumption of sexual intercourse before the wounds from surgery have healed. Men undergoing circumcision are therefore counselled not to resume sexual activity until six weeks have passed. Investigators wished to establish how many men were having sex within this six-week period. They also wanted to see if any factors were associated with the early resumption of sexual activity, and if sex in the post-operative period would have wider implications for the impact of circumcision programs on the prevention of new HIV infections.

A total of 225 men were interviewed about their sexual behaviour before circumcision and again six weeks later. The men had a mean age of 21 years. At baseline they reported a mean of three lifetime sexual partners and 44% had a regular partner. Unprotected sex in the four weeks before circumcision was reported by 22% and 10% had been diagnosed with a sexually transmitted infection within the past twelve months. Just under a quarter (24%) of men reported resuming sex within the six-week healing period. Almost half (46%) of these men had sex within the first three weeks after surgery. Moreover, 81% of men resuming sex during the healing period reported unprotected sex, and 32% said they had had unprotected intercourse with two or more partners. Early resumption of sexual activity was associated with a higher number of lifetime sexual partners and unprotected sex in the period immediately before circumcision (p < 0.05).

The investigators calculated that a 24% prevalence of sex during the six-week healing period among the 61,000 men circumcised in Zambia in 2010 would result in 69 more HIV infections compared to sexual abstinence for the duration of healing. Some 32 of these extra infections would be in men and 37 in women. The investigators caution that resumption of sex during healing could put women at risk of HIV. If 30% of men undergoing circumcision had sex within the healing period, then more new HIV infections in women would be generated than averted. “The study findings suggest that the prevalence of risky sexual behaviour during the wound healing period is high,” write the investigators. “Programs need to continue to emphasise to clients the risks associated with early resumption of sex.”

Reference: Hewett PC et al. Sex with stitches: the resumption of sexual activity during the post-circumcision wound healing period in Zimbabwe. AIDS Official Journal of the International AIDS Society, 20 January 2012 26, online edition. DOI: 10.1097/QAD.0b013e32835097ff, 2012.

Michael Carter, “Quarter of men resume sex before wounds from circumcision fully healed in Zambian study”, AIDSMap, 31 January 2012





Kenya: Circumcised men more likely to have multiple partners, believe they are immune to HIV

THE Ministry of Public Health and Sanitation in conjunction with the National Male Circumcision taskforce have expressed concern over reports of multiple sex partners among those who recently underwent male circumcision. Nyanza provincial director of public health and sanitation, who is also the task force chairman Jackson Kioko, said there have been reports that those who have been circumcised are taking it as immunity against HIV.

Speaking during the launch of the results of the third rapid results initiative on male circumcision, Kioko said the taskforce will conduct a study to ascertain post-male circumcision sexual behaviour. During the launch of the exercise, its critics including the Luo Council of Elders said the program will be disastrous if not well packaged and the beneficiaries sensitised on its implication.

The council of elders argued that marketing male circumcision on the platform of preventing HIV was going to erode the overall goal since many men will take it as complete immunity. Studies conducted in Rabai in Uganda, Orange Farm in South Africa and Kisumu indicate that male circumcision can prevent HIV infection by over 60 per cent. The studies, however, warn that male circumcision should not be relied upon as a stand-alone intervention against HIV/AIDS.

[So if you still have to use a condom after getting circumcised, why get circumcised at all?]

Samuel Otieno, “Kenya: Cut Men Have Many Mates”, AllAfrica.com, 24 January 2012





Kenya: Circumcised men and partners more promiscuous, less likely use condoms

NAIROBI, 23 January 2012 A small Kenyan study has found that more women than men feel HIV is a less serious threat after their male partners are circumcised. The University of Illinois Chicago School of Public Health study of 51 young women was presented in December 2011 in Addis Ababa, Ethiopia, at the 16th International Conference on AIDS and Sexually Transmitted Infections in Africa. It found that more women than men were likely to perceive HIV as a less serious threat: 51 per cent of men compared with 76 per cent of female participants. Women were also more likely to believe that condoms were ‘less necessary” after circumcision: 4 per cent of men compared with 51 per cent of female participants.

Significantly more women than men said after circumcision, they were more likely to have more than one sexual partner: (22 per cent of women compared with 2 per cent of men) and to have sex without a condom (28 per cent of women compared with 2 per cent of men.

PlusNews, 23 January 2012





Zimbabwe: Circumcision a “canal for new HIV infections”

HARARE - Male circumcision is becoming a canal for new HIV infections as men are now reluctant to use condoms on the basis that they are 60 percent safe, a government official has said. MDC deputy spokesman and legislator for Bulawayo East Thabitha Khumalo said while circumcision was good in reducing the risk of HIV infections in men, the emphasis should be on the use of condoms [rather] than circumcision in order to save both men and women.

Circumcision and the use of condoms, Khumalo said, should be used together if Zimbabwe’s goal of Zero to new HIV infections and Zero to HIV related deaths by 2015 is to be attainable. “We have a huge challenge where male circumcision has created a canal to those who do not want to use condoms. People should understand that circumcision is not a cure, it is just a way to help reduce the risk of infections, together with the use of condoms,” said Khumalo. Women will be the most affected because they have limited methods of protecting themselves.

According to Khumalo, sub-Saharan Africa still records the highest figures of new infections with about 7,000 estimated infections, despite the increase in the numbers of men who are getting circumcised. More than 40,000 Zimbabwean adult men, according to reports, have been circumcised since the program began in 2010 and 100,000 more are expected to undergo circumcision by the end of 2012.

Zimbabwe has set a goal of circumcising 1.2 million men by 2015. Sinokuthemba Xaba, Zimbabwe’s national male circumcision co-ordinator told the state media that approximately 11,000 men were circumcised by December 2010, with over 20,000 having been circumcised this year alone. He said preparations were under way for the launch of a neo-natal circumcision program, where the medical procedure will be performed free of charge on male babies as soon as they are born. In August, government started an ambitious program aimed at male cabinet ministers, MPs and councilors to undergo circumcision. Deputy Prime Minister Thokozani Khupe said research had shown that circumcised men are eight times less likely to contract HIV.

Daily News (Zimbabwe), December 15, 2011

Comment

The fact that Zimbabwe is a crumbling semi-fascist kleptocracy run by a crazed dictator may help explain why the government is so confident that these targets will be met. If persuasion and bribes don’t work, there is always coercion, at the point of a gun if necessary. One wonders where Mr Khupe cooked up his wild claim that circumcised men are 8 times more likely to contract HIV; even at their most extravagant, the promoters of the African circumcision trials never claimed more than a 60 per cent reduction in risk – meaning that a circumcised man who continued to practise unprotected intercourse with infected partners would take a bit more than twice as long to get infected. But in a dictatorship, of course, as Jo Stalin convincingly showed, statistics are simply manufactured for any purpose for which they may temporarily be required.

Epidemiological studies show that in Zimbabwe 2005-06 the incidence of HIV among circumcised men was 20 per cent, but only 19 per cent among uncircumcised men. In fact, throughout Africa, as French epidemiologist Michel Garenne has shown, there is no consistent evidence that uncircumcised men are more vulnerable to HIV infection.



