Getting to the bottom of HIV’s silly season

It’s usually safe to take time off in July to move house — in a previous existence in the newroom we used to call the European summer the “silly season”. In the weeks I’ve been painting walls, unpacking boxes and not blogging, we’ve had some HIV silliness, but some good sense too.

The IAS conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa produced its usual crop of second rate abstracts on issues currently fashionable in the HIV industry — gender, health systems strengthening, scaling up — along with the inevitable calls for more cash. The IAS also runs the biennial international AIDS conferences — giant circuses full of amusing but expensive set-pieces: protesting sex workers, singing orphans, earnest celebs. There’s so little science at those conferences that a lot of researchers have abandoned them in favour of low-key, high-science meetings such as CROI. It seems IAS is trying to claw its way back on to the scientific platform with the pathogenisis sub-conferences. Perhaps we’ll see more good sense from the organisation now that it is coming under the spell of the inimitable Robin Gorna.

Among the conference’s silliness was a study of the protective effect of circumcision in anal sex between men in Soweto. It’s hard to tell much from an abstract and this came from a good research team so perhaps I’m being unfair. This cross-sectional study (picked up by IRMA) reports results for men who only ever act as tops in anal sex with other men. Not one iota surprisingly, the results are exactly the same as for men who only ever act as tops in vaginal sex with women (i.e. all men who have vaginal sex): uncircumcised men are four times more likely to be infected with HIV.

What does that tell us? Almost nothing of any use in HIV prevention programming. Over 13% of the guys in the study had HIV. In the very high prevalence settings of Southern Africa, guys (and boys and infants) should be getting snipped regardless of their eventual sexuality. We don’t need more clinical trials of exclusively insertive MSM to prove that, especially since 80% of these blokes are also shagging women. But the South African study doesn’t mean gay guys in other parts of the world will necessarily be protected by circumcision. In this study, three quarters of respondents said they were only ever tops. (If you believe them, spare a thought for the remaining quarter; they must be getting poked painfully frequently just to make the numbers add up.) If you don’t believe them it may well be because that degree of role separation is unusual in many gay communities. Indeed one of the reasons HIV spread so rapidly among gay men is that the very people who are most likely to get infected (because they’re taking it up an orifice not designed for the purpose) are also most likely to infect others (because they give as good as they get). Heteros don’t have that flexibility, and that slows transmission down.

For practical purposes what we’d like to know from the Soweto data is: does circumcision protect men who have anal sex against HIV regardless of whether they are a top, a bottom, or “versatile”?

More silliness from Canada on needle exchange, but some good news from the States on that front, too. Of which more after I’ve unpacked more boxes. In the meantime, this comment on trafficking hysteria from another member of the Silliness Police over at Preipheries.

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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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