Male circumcision overstated as prevention tool against AIDS

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The new study finds that the number of infected prostitutes in a country is the key to explaining the degree to which AIDS has infected the general population. Prostitute communities are typically very highly infected with the virus themselves, and because of the large number of sex partners they have each year, can act as an engine driving infection rates to unusually high levels in the general population. The new study is entitled "Size Matters: The Number of Prostitutes and the Global HIV/AIDS Pandemic" and is freely available online at the PLoS ONE publication website at http://plosone.org/doi/pone.0000543.

The study has a number of important findings that should impact policy decisions in the future. First, male circumcision, which in previous studies had been found to be important in controlling AIDS, becomes statistically irrelevant once the study controls for the number of prostitutes in a country. The study finds that the more Muslim countries of North Africa do indeed suffer much less AIDS than southern and western Africa, but this lower prevalence is not due to higher numbers of circumscribed males in these Muslim communities, but rather results from the fact that there are significantly fewer prostitutes in northern Africa on a per capita basis. It appears that religious families in the north, specifically concerned fathers and brothers, do a much better job protecting their daughters from predatory males than do those in the south. A history of polygamy in these Muslim communities does not appear to contribute to hi gher AIDS prevalence as previously speculated. In a frequently cited academic paper, Daniel Halperin, an H.I.V. specialist at the Harvard Center for Population and Development and one of the world's leading advocates for male circumcision, weighted results from individual countries by their population. When this artificial weighting was removed Talbott found that circumcision was no longer statistically significant in explaining the variance in AIDS infection rates across the countries of the World.

Second, to date, there has not been an adequate explanation as to why Africa as a continent is experiencing an AIDS epidemic far in excess of any other region of the world with some African countries' prevalence rates exceeding 25% of the adult population and tens of millions dying from the disease on the continent. Talbott's new study suggests that the reason is that Africa as a whole has four times as many prostitutes as the rest of the word and they are more than four times as infected. Some southern Africa countries have as many as 7% of their adult females infected and working as prostitutes while in the developed world typically this percentage of infected prostitutes is less than .1%. If these 7% of infected prostitutes in Africa sleep with five men in a week that means they are subjecting 35% of the country's male population to the virus weekly. The virus is not easy to transmit heterosexually, b ut over time with multiple exposures, infection is inevitable. These men then act as a conduit to bring the virus home to their villages, their other casual sex partners and to their wives.

The study has important policy implications. Several international AIDS organizations have begun to provide funding for male circumcisions as a deterrent to AIDS. While male circumcision may indeed reduce the risk of transmission by some 50% to 60% in each sexual encounter, reducing single encounter transmission rates alone cannot control the epidemic. The reason is that individuals in highly infected countries have multiple contacts with the infected so reducing transmission rates only defers the inevitable.

The real question is what can be done with the prostitute community. Outlawing the world's oldest profession would most likely prove to be ineffective. If the profession can be legalized and treatment and care provided to the practitioners, there would be much more reason to be hopeful. But, and this is the key, programs of action can not just be voluntary. Too many innocent people are dying and there is too much disregard for human life among infected prostitutes to leave treatment decisions solely up to them. A program of testing and treatment for prostitutes must be mandatory and those that refuse treatment must be held liable.

Many international aid organizations are against such mandatory treatment programs for prostitutes as they find them to be discriminatory, violate the individual's human rights and are perceived as an attack on female prostitutes who are viewed as victims of gender and income inequality. Such organizations do not properly weigh the loss of human rights and life itself that this virus, unleashed on a community, is causing. This virus, itself, is a violation of human rights and we must do everything in our power to stop it. To argue we should do nothing about infected prostitutes during an AIDS epidemic because of a fear of creating a stigma against the infected would be like an animal rights activist claiming that a rabid dog must be allowed to run free in a neighborhood regardless of how many men women and children he infected and killed.

It is not surprising that computer models rarely show the virus reaching epidemic proportions; it is very hard to transmit this illness heterosexually. Only when model building researchers introduce a highly sexually active infected subset of "prostitutes" to their mathematical models does the infection spread exponentially to the general population.

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