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This post was published on 28/07/09 in Ideology and HIV, Science, War on drugs.

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  1. Comment by peripheries, 28/07/09, 01:54:

    If you don’t believe them it may well be because that degree of role separation is unusual in many gay communities.

    I think you are poking a region where you have not been… just check a few websites, start with http://www.gayromeo.com

  2. Comment by Thabo, 16/08/09, 12:31:

    Circumcision and HIV transmission.
    Are the results based on unprotected sex or sex using condoms?
    If condoms are used consistently in sexual practice, is there a vast difference in HIV transmission depending on whether the man is cuircumcised or not?
    Just a question, hope you can help.

  3. Comment by Theo, 21/08/09, 06:16:

    Re your post about circumcision in MSM.

    Interesting that you rather glibly trash a poster you didn’t seem to have looked at. Were you at IAS?

    Even in the abstract, they mention that a recent meta-analysis (FYI: Millett Jama 300(14):1674-1684, 2008) had already shown that circumcision has little or no effect on the risk of transmission among gay men in the West for all the reasons you mention (we tend to flip a lot). It is for this very reason that you don’t see campaigns to get gay men circumcised in the West. (I don’t think they’d be very successful anyway). It would be silly.

    But the entire point of the IAS poster was that in many other cultures where epidemiologists are using the term MSM, men may indeed be more likely to stick to insertive or receptive roles. So — if roles are indeed more separate in other settings, closer to the heterosexual model — scaling up circumcision to MSM could potentially make a difference among the entire MSM population overall IN THAT PARTICULAR SETTING. And that’s indeed what the group at PHRU found. This study provides evidence not simply that circumcision works for insertive partners (which as you point out, we already know) but that the roles really are separate in this African setting. And it should be added, this finding was also observed in men who were *exclusively* having sex with men — a separate group from the men who report (mind you, *report*) also having sex with women. Indeed, this degree of role separation may not be so unusual among MSM and transgenders in many other cultures. Whether it protects their receptive partners to the same extent has yet to be seen, but if it is a closed network, it could, potentially.

    Your assertion that this tells us nothing of use in prevention programming comes off a bit heterosexist — or maybe you are making assumptions based upon what you know about ‘gay culture.’ Anyway, as I am sure you know, data are showing that there are large parallel epidemics among MSM in most settings including those with generalised epidemics, and there is a movement to begin addressing them. Since many MSM do not feel welcome in often hostile public health systems, separate services are being developed to reach them. PHRU is pioneering MSM targeted programmes in South Africa, so the point of this study was to see whether circumcision would be a service that makes sense in this context. Its better than just installing a programme based upon what works or doesn’t with gay men in London. And they weren’t trying to say whether this would make sense anywhere else.

    My concern is that the effectiveness of the intervention may be time limited — that, as African society becomes more accepting of MSM (or the MSM accessing these dedicated services become more accepting of themselves), that they may become more inclined to adopting the more flexible Westernised ‘gay culture’ and the separation of roles could break down. But it may take a very long time for that to happen in Africa, and in the meantime, we need to find out what prevention interventions work in this marginalised and vulnerable group.

    BTW, I read some excerpts of your book in a magazine I stumbled upon in Namibia. It looks quite good and am eager to pick up a copy.

    Oh, and just a plug for IAS — unlike CROI, it isn’t controlled by a cabal, isn’t US-centric, and doesn’t despise the community. Yeah, the World AIDS Conferences are a zoo, but at least you remember that it isn’t just about a disease, it is about people. CROI? The distaste for the community is palpable.

  4. Comment by TL, 21/08/09, 06:36:

    You raise some interesting questions here. It *is* hard to tell much from an abstract. Presumably if you were really interested in the answers and engaging in anything like a productive debate you’d have contacted the authors directly.

    To answer your question, if circumcision protects the tops, then over time, it would conceivably protect the bottoms and versatiles. And maybe even the heteros since, as you point out, “80% of these blokes are also shagging women.” Isn’t the whole reason we’re asking men to give up their foreskins to protect women anyhow?

    Bottom line is, the evidence may not support excluding MSM in this part of the world from the only biomedical prevention strategy that exists for men (a real concern in resource-constrained setting), and if you’re the type of person who needs a clinical trial to prove anything, then the evidence suggests that it’s feasible to recruit for one. If you’re happy to promote it on the basis of one observational study in one community, go for it.

    But describing anal sex as “Taking it up an orifice not designed for the purpose”? Sigh. You really disappoint.

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