Where Circumcision Doesn't Prevent HIV II

UPDATE: Now with graphical representations (2/24/2013).

I had already published a post titled "Where Circumcision Doesn't Prevent HIV." Readers can see to the left, it ranks 5th as one of my most popular posts.

I recently had a conversation with one Juan Pistolas (an online intactivist persona) concerning HIV transmission rates in Mexico. It was touched off by an article I posted on my Facebook wall, titled "Sexually transmitted infection epidemic ravaging the US", to highlight the fact that having a primarily circumcised male population (over 80%, according to Dr. Schoen), most of which are men who are circumcised from birth, has not helped in the US.

It is often touted by circumcision advocates that circumcision reduces the transmission of STDs. The fact is that STD transmission rates are higher here, than in Europe, where circumcision is rare.

Juan wanted to tell me that American intactivists always point to Europe as a prime example, but that we always seem to forget our Mexican brother to the south.

I couldn't understand what he was talking about. I had always assumed that Mexico would be a poor example, with a high HIV transmission rate, being a third world country.

He replied:

"That's the problem with the majority of persons that believes that just because a third world country is cataloged as such, in this case Mexico, then they automatically assume the country lacks of everything. Hollywood movies have created false stereotypes of many cultures and countries in the world that people adopt as truth, when many times is quite the contrary.

In Mexico we may not have a super infrastructure like the US or Europe has, but despite that, we have a much more less rate of HIV. Much less.

Also, in Mexico you can have access to free condoms if any person goes to any government health clinic and request a few. Of course they aren't Trojans or Sico's, but free condoms are given. We also have free access to sex education in these same health clinics. Just go, see schedules or make an appointment."

I couldn't believe what he was saying.

I wanted numbers.

Enter the CIA World Factbook.

The intactivist organization Saving Our Sons had also just recently published an article titled "HIV in the Circumcised U.S. Up to 500% Higher than Intact Nations," which was no surprise to me, as I had already known for the longest time that the US had the highest rate of HIV transmission in the industrialized world, despite its high prevalence of male circumcision. I had already known that knowing the truth was simply a matter of looking at HIV transmission rates around the world, but I had never actually sat down to look through them. I saw in this article, for the first time, where exactly the US stood as compared to other nations in terms of HIV transmission.

So touched off by Juan's comments, and remembering that I had just recently read the Saving Our Son's article referencing the CIA World Factbook, I decided to look through it to see where Mexico stood.

Sure enough, while America hovers at No. 64, Mexico is way below at No. 79.

I couldn't believe it.

Mexico?

Really?

But I started seeing other countries which also fell well below America, countries that I would expect to have terrible HIV transmission rates, and I was floored.

Juan provided his own source IndexMundi.

Juan's source, though, does not list countries by percentage of HIV prevalence, but by actual numbers of people living with AIDS. Doing this shifts the order around quite a bit.

For example, reporting Swaziland's HIV prevalence rate by percentage (25.90%) puts it at No.1 in the CIA Factbook. But looking at the actual number of people living with HIV puts it way below. In fact, many African countries fall below the US when actual numbers of people living with HIV are compared.

I began to make observations that I thought should be posted in this blog.

HIV prevalence rates and circumcision rates in other countries
I started talking to another online intactivist acquaintance to whom I shall refer using his online persona, "dreamer," about what I saw in the CIA factbook. He suggested we look up the rate of circumcision prevalence of these countries, to see what countries with a lower HIV transmission rate than the US have high and/or low circumcision prevalence rates.

He suggested we look at the Wikipedia page on world circumcision prevalence, a suggestion with which I was rather hesitant, because Wikipedia users with a pro-circumcision bias have made circumcision-related pages at Wikipedia unreliable. I went along because I couldn't think of a better source.

Even going with Wikipedia numbers, what we found kept blowing our minds.

Using adult HIV prevalence rates from the CIA Factbook, and circumcision prevalence rates in Wikipedia, dreamer created a spreadsheet that maps out countries by circumcision and HIV prevalence rates.

We were able to see what countries had higher and lower HIV prevalence rates than the US, and which of those had high and low circumcision prevalence rates.

Why the US?
Why should the US be used as any sort of benchmark?

Because America is the driving force behind the resolve to circumcise Africa, and the drive to circumcise boys and men in cultures within its own population that do not practice circumcision. American doctors, "researchers," medical organizations and charity funds are currently placing much time, effort and precious funds in trying to make circumcision prevalence levels as high as ours.

With an adult circumcision prevalence rate of 80% or greater, the United States should serve as a prime example of the "benefits" of circumcision, or lack thereof.

As highlighted on Saving Our Sons, American circumcision "researchers" keep trying to use fear-mongering tactics to shore up support for circumcision, and to get administrators of state Medicaid programs who have stopped paying for routine male infant circumcision to change their minds.

In a recent "study," it was claimed by "researchers" at Johns Hopkins that if circumcision rates drop to the level seen in Europe, that there would be a 12% increase in HIV cases in men.

Comparing HIV/circumcision statistics between the United States and Europe, one must wonder how exactly did the "researchers" arrive at their conclusion.

Researchers claim that that circumcision cuts HIV transmission rates by 55 to 65 percent, based on three African trials. Promoters of circumcision in Swalizand (with funding from PEFPAR and others) seek to circumcise 80% of the male population as a step towards the United Nations goal of zero new HIV infections by 2020. Similarly, the W.H.O. in concert with the U.N., the World Bank, the President’s Emergency Plan for AIDS Relief (PEPFAR) and several other very well funded and influential N.G.Os (including the Bill & Melinda Gates Foundation), with visible leadership from Hillary Clinton, are funding, supporting and administering a multinational effort to circumcise over 28 million men in Sub Saharan Africa by 2015.

An increased rate of HIV transmission and/or prevalence should be expected in non-circumcising countries, and a decreased rate in circumcising countries, but this is simply not observed.

The following are observations from the CIA World Factbook, and circumcision prevalence rates as found in Wikipedia.


How many countries have a higher HIV prevalence than the US? What are the circumcision rates in these countries?
There are 63 countries with a higher HIV rate than the US. Of these, 26 countries are primarily circumcising countries (e.g., have a circumcision rate over 80%). 26 countries have a low circumcision rate (eg, have a circumcision rate under 20%).

Observation: The number of primarily circumcising countries, and countries with a low circumcision rate, that have a higher HIV prevalence than the US, is about the same. (26 vs. 26)

How many countries have a lower HIV prevalence than the US? What are the circumcision rates in these countries?
There are 102 countries with a lower HIV rate than the US. Of these, 30 countries are primarily circumcising countries (e.g. have a circumcision rate over 80%). 53 countries have a low circumcision rate (have a circumcision rate under 20%).

Observation: The number of countries with a circumcision rate under 20%, and a lower HIV prevalence rate than the US, is greater than the number of circumcising countries with a lower HIV prevalence rate than the US. The number of circumcising countries with a lower HIV prevalence rate than the US, is lesser than the number of intact countries with a lower HIV prevalence rate than the US. (53 vs 30)

HIV prevalence is lower in the US, where 80% of the adult male population is circumcised from birth, than 26 countries where circumcision is rare (circumcision rate is under 20%), but higher than 56 countries where circumcision is rare.

How many other countries in the world have a high circumcision rate? Is HIV prevalence higher, or lower than the US, where circumcision prevalence is high?

56 countries other than the United States have circumcision rates greater than 80%; HIV is more prevalent than the US in 26 of these countries, while less prevalent in 30 of them.

Observation: Of the countries where the circumcision rate exceeds 80%, the number of countries where HIV prevalence is lower than that of the US, is in fact greater than the number of countries  where HIV prevalence is higher than the US.

In other words, there are more circumcising countries with a HIV prevalence rate lower than the US, than there are circumcising countries with a higher HIV prevalence rate. (30 to 26)

The US does better than 26 circumcising countries, but worse than 30.

How many countries in the world have a low circumcision rate? Is HIV prevalence higher, or lower than the US, where circumcision prevalence is high?
79 countries in the world have circumcision rates under 20%. Of these, 26 have a higher HIV prevalence rate than the US, and 56 have a lower HIV prevalence rate than the US.

Observation: Of the countries where the circumcision rate falls below 20%, the number of countries where with a lower prevalence rate than the US is greater than the number of countries with a higher prevalence rate than the US.

The number of countries where the circumcision rate falls below 20% and the HIV prevalence rates are lower than the US, far exceeds the number of countries where the circumcision rate is greater than 80% and HIV prevalence rates are lower than the US. (53 to 30)

In other words, there are more countries where circumcision is rare, and have a lower HIV prevalence rate than the US, than there are circumcising countries with a lower HIV prevalence rate than the US.

Countries where circumcision rates exceed 80%, and HIV is more prevalent than the United States (By rank in HIV prevalence)

Kenya, Cameroon, Gabon, Equatorial Guinea, Nigeria, The Republic of Congo, Cote d’Ivoire, Chad, Togo, Djibouti, Guinea-Bissau, The Gambia, Angola, Ghana, Sierra Leone, Liberia, Guinea, Burkina Faso, Benin

Observation: These are all African countries.

Countries where circumcision rates exceed 80%, and HIV is less prevalent than the United States (By rank in HIV prevalence)

Libya, Kyrgyzstan, Madagascar, Israel, Bahrain, Iran, Tajikistan, United Arab Emirates, Algeria, Azerbaijan, Bangladesh, Brunei, Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan, Philippines, Quatar, Syria, Tunisia, Turkey, Turkmenistan, Yemen, Saudi Arabia, Afghanistan

Observation: Many of these countries are countries in the Middle East, where Islam is prevalent and children are circumcised as a matter of religious practice.

Countries where circumcision rates fall below 20%, and HIV is more prevalent than the United States (By rank in HIV prevalence)

Swaziland, Botswana, Zimbabwe, Zambia, Namibia, Malawi, Burundi, Rwanda, Belize, Haiti, Jamaica, Trinidad and Tobago, Thailand, Estonia, Guyana, Ukraine, Russia, Papua New Guinea, Dominican Republic, Panama, El Salvador, Honduras, Guatemala, Latvia, Burma, Portugal

Observation: The majority of countries in the first row are African countries. A good number of these countries lie along the Caribbean Sea. European countries are rare and appear sporadically.

Countries where circumcision fall below 20%, and HIV is less prevalent than the United States (By rank in HIV prevalence)

Colombia, Argentina, Uruguay, Cambodia, Peru, Nepal, Switzerland, Vietnam, Ecuador, France, Chile, Spain, Moldova, Mexico, Italy, India, Iceland, Costa Rica, Canada, Belarus, Austria, Paraguay, Netherlands, Ireland, Denmark, Bolivia, Bhutan, United Kingdom, Belgium, Nicaragua, Laos, Bulgaria, China, Cuba, Cyprus, Czech Republic, Finland, Georgia, Germany, Greece, Hong Kong, Hungary, Japan, Lithuania, Mongolia, New Zealand, Norway, Poland, Romania, Serbia, Slovakia, Sri Lanka, Sweden

Observation: There is a prevalence of European, South American and Asian countries. Countries where one might expect a higher HIV prevalence rate have a surprisingly low prevalence rate. Colombia and Costa Rica border Panama, which falls above the US in HIV prevalence, yet, they have a lower HIV prevalence rate than the US. Similarly, Nicaragua borders both Honduras and El Salvador, where HIV prevalence rates are higher than the US.

I expected countries to the south of the United States, have a high prevalence of HIV. I was surprised to find Peru, Ecuador, Chile, Mexico, Paraguay, and Bolivia in this number.

Observe how low many of these countries fall along the list as well.

Problems With This Analysis
One of the problems with this analysis is the way circumcision percentages are reported on Wikipedia. They are reported on three major ranges, which are "less than 20%," "between 20 and 80%," and "above 80%." The problem with a range between 20% and 80% is that a country may have a circumcision rate of 21% or 79%. Additionally, percentages could hide relevant numbers.

In Lesotho, for example, 23% of adult men are circumcised, so it falls within that "between 20 and 80%" range. Promoters of circumcision may try to make an example of Lesotho, because it ranks number 3 in the CIA fact book, with an HIV prevalence rate of 23.6%. Closer analysis, however, reveals that, actually, HIV  is more prevalent among the circumcised. (The ratio of circumcised men vs. intact men who contracted HIV was 22.8 vs 15.2, according to the latest demographic health survey.)

Malawi is yet another country circumcision promoters might try to make an example of, with its rank of No. 9 in the CIA fact book (11% HIV prevalence rate), and its circumcision rate below 20%. Here too, HIV is more prevalent amongst the circumcised. (The ratio of circumcised vs. intact men who contracted HIV was 13.2 vs 9.5, according to this demographic health survey.)

Rwanda is further down on the CIA fact book at No. 25, with an HIV prevalence rate of 2.9%. The low circumcision rate (less than 20%) makes Rwanda fodder for circumcision advocates, however here too, HIV  is actually more prevalent among the circumcised. (The ratio of circumcised vs. intact men who contracted HIV was 3.8 vs 2.1, according to this demographic health survey.)

Circumcision advocates are trying to make Swaziland their ultimate example, ranking No. 1 in the CIA fact book, with an HIV prevalence rate of 25.9%, and a circumcision rate that falls below 20%. What they fail to report is the fact that, yet again, HIV was actually found to be more prevalent among the circumcised. (See this demographic health survey.)

Tanzania’s circumcision rate is listed as being “between 20 and 80,” but this hides a circumcision rate of 69%. It ranks No. 12 in the CIA fact book, with an HIV transmission rate of 5.3%. And here again, HIV was more prevalent among the circumcised. (See chart here.)

Malaysia’s circumcision rate is listed as being “between 20 and 80.” However, it is a known fact that approximately 60% of the Malaysian population is Muslim, where close to 100% of the men are circumcised (circumcision is uncommon in the non-Muslim community). According to MalaysianAIDS Council vice-president Datuk Zaman Khan, more than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims, which means that HIV is spreading in the community where most men are circumcised at an even faster rate, than in the community where most men are intact.

It would appear that The Philippines is a model country for promoters of circumcision. It ranks No. 147 in the CIA fact book, and a circumcision rate of over 80%. (The majority of the male population is circumcised, as it is seen as an important rite of passage.) In the 2010 GlobalAIDS report released by UNAIDS, the Philippines was one of seven nations in the world which reported over 25 percent in new HIV infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh (another circumcising country, No. 112 in the CIA Factbook) are reporting increases in HIV cases, with others either stable or decreasing.

Conclusion

Researchers in Africa claim that circumcision reduces the transmission of HIV by 60%. They purport to have discovered a lower rate of HIV transmission in the circumcised men in their "studies." These studies were used by the WHO to endorse circumcision as a prevention measure for HIV, and are currently being used to instate "mass circumcision campaigns" in different countries in Africa, where HIV transmission rates are high, but circumcision rates are low.

These include countries where HIV is more prevalent among the circumcised!

Real world data reveals, however, that results from studies do not necessarily correlate with reality.

An analysis of data from the CIA Factbook, and circumcision rates as reported on Wikipedia reveals that a population where the majority of males are circumcised does not necessarily translate to a lowered rate of HIV transmission. A circumcision rate of 80% or greater does not necessarily equate to a lowered rate of HIV transmission, and a low circumcision rate does not necessarily mean that HIV will run rampant.

Further analysis reveals that just because a nation has both a low circumcision, and a high HIV transmission rate, this doesn't necessarily mean more men with foreskins have HIV; the majority of men with HIV may in fact be circumcised.

If circumcision is such a great way to prevent HIV, why isn't it obvious in this country? Why does America have an HIV transmission rate that is far greater than a good number of nations where circumcision prevalence is low? Why is it at the top of a list of 30 countries where circumcision prevalence high? What about all these other countries that are supposed to be "inferior" to us, and have both low circumcision AND an HIV prevalence rates? And why aren't "researchers" interested in what's happening there? Perhaps such countries are doing something that we aren't to keep HIV transmission low, but it seems "researchers" aren't that interested.

It needs to be explained how something that never worked in this country, is going to suddenly start working miracles in Africa. America should start fixing its own HIV problem before pretending like they can go to other countries and try to solve theirs.

My thanks to  Juan Pistolas and dreamer for their great help and inspiration for this blog post.