Respone to David Wilton @mc_hiv

 This is a response to David Wilton's summary of his trip to UNAIDS Rome, where in the end he asks for responses from the intactivist community, my responses will be in bold, David Wilton's article has been reproduced in plain text:

I perceived our interaction with the delegates who chose to come by our booth as mostly positive. Excellent  A few wanted to argue. A few said they agreed with us, but felt powerless to oppose the juggernaut. Almost none knew anything about foreskin anatomy or the purpose of the foreskin. Thats our/your job to educate., and you educated, even though some did not want to listen.  Those who said they agreed with us were from non-circumcising countries, including Cambodia, Russia, Brazil, Colombia, Italy, South Africans descended from non-South African tribes, Australians, and really anyone who has had or experienced a foreskin outside of Africa.  You provided an alternative voice, as the circumcision promoters want to use this platform as a way of arguing for infant circumcision, and therefore your presence was strategically important.
The ones who know what a foreskin is and how it impacts comfort, health, and sexual pleasure were with us. Of Course its just common sense. Those who did not have this experience or knowledge where skeptical. I concluded somewhere through the middle of the four days of the conference that our message was not going to succeed on refuting the risk reduction impact of circumcision, but on informing about the benefits of the foreskin. Ignorant people, including Auvert, Piot, Fauci, Bailey, Westercamp, Gray, Weiss, and others, cannot be expected to provide informed consent in their circumcision consent generating interviews when they know little about the appendage they propose to cut off - and couldn't care less anyway. This is the ethical issue, that we must fight for and insist on, informed consent, of all the facts, including the anatomy and function of the foreskin, and the limitations of the protective effect of circumcision.
Worse still is the possibility that the information told to circumcision candidates is inaccurate or may trivialize foreskin anatomy and function. Truthful & Factual information is important in providing informed consent and ethical, this needs to be highlighted in peer review journals, that the ethics of this program need to be questioned. One argument that came up with a group of Ugandans was that a little bit of pleasure was worth losing for the benefit gained. They are entitled to take this position, as adults they can trade part of their functional anatomy for another gain.  Obviously they need to be fully informed about the limits of the gain, because if they are trading their foreskin for completet protection from HIV then that is a fraud.  So accurate informed consent is the ethical issue here.  Clearly, this common counterargument had been subsumed in the discussion and discounted long before IAS 2011. Not once but often we heard the refrain, do you have any evidence to support your position? Our answer was to refer to the myriad published studies that support our contentions usually through reinterpretation. This was not often convincing to a skeptical scientific audience.  Your job is to provide truthful accurate information and not the impossible which is to convince those that do not want to believe. You need to clarify what arguments you want to make, at one level it is a bit unclear to me also.
The question is how can we provide any plausible counterarguments if we are not in Africa, not doing the research, not involved in the roll out or planning phases of circumcision campaigns, and generally confined behind our screens and keyboards. That is the crux of the issue.  The circumcision lobby has gone into Africa, and whatever their motivations, they have bought 100's of millions of dollars of medical resources, to combat a disease that has cost 10's of millions of lives. How can you possibly be expected to compete with that.  If we could get a wealthy benefactor such as Gates to donate hundreds of millions of dollars and provide healthcare and education, retroviral medication, offering a non-surgical solution for Africa's HIV epidemic, then we may have earned greater influence. At the very least, we need to present something even if it is only within our booth and not part of the official program. With the resources you had, you did brilliant, just need to have realistic expectations about what is possible with only a small percentage of the resources you had. We either get involved or sit it out and let the circumcisers continue to drive developments. This conference clarified this for me.  Clarify your goals what are they?  Is it to end infant ciircumcision in America or to end HIV/AIDS epidemic in Africa? What adult volunteers decide to do with their bodies is different to what you do to a baby that cannot consent!  This is the key argument.  Proper Informed  consent is a valid criticism, and you can make points here.  Only adults can make proper informed consent.  Babies cannot become informed or consent.  Babies havent yet decided what life-style options they will pursue, and are not yet aware of the circumstances of their environment  = such as do they live in a high risk hiv prevalance area or a low risk low hiv prevalance area?
I call on the community of intactivists to think this through and come up with a strategy that will arm us with better information and counterarguments to face this threat to genital integrity and informed consent in Africa and ultimately the United States.  From a scientific point of view, intactivist who are peers of the scientists making claims of 70% reductions in HIV infections, have to examine the methodology and results of the published work and write to peer review journals, identifying the scientific/methodological floors if there are any.  Superficially, there appears to be many confounding factors in what is being reported.

The well known evidence/arguments are established and as follows;

How is HIV sexually acquired and  sexually spread, & How can we reduce or eliminate infections.  The further question = Does circumcision reduce HIV sexually acquired and spread infections and if so how?

Sexually acquied HIV is acquired through sexual activity, hypothesised to be least likely via dermal (skin) absorption, and most likely via blood exposures, through micro-tears in genital/human skin.  The greatest risk factor in the spread of the disease is unprotected sex spread via multiple sex partners. 

Well established and universally recognised prevention methods are Education and behaviour change.  Using condoms appear the most effective way of reducing skin and blood exposures.   Behaviour change can be very challenging though.  Changing sexual practices such as having sex with multiple sex partners is difficult as there are powerful cultural variables at play.  Long term education is required here.  Unfortunately one of the greatest risk factors is the possibility of behavioural disinhibition, with circumcision becoming a licence for unprotected sex with multiple sex partners.  One auther quoted a non-statistically significamt figure of 0.84 condom use of circumcised men compared to intact men.

What has science found that works :
1. Condoms are very effective, however the reality is humans dont consistently use them. The key here would be how to get humans to use condoms more consistently. Europe which has the lowest HIV infections in the western world also has the highest condom usage.  If its education wealth and healthcare that are the variables here, Africa is a long way from Europe and may require additional strategies.
2. Current HIV vaccines have only proven partial effectiveness. More work needs to be done here, and its hope lies in the future.
3. HIV Viral medication appears promising.  More research and money needed here to up-scale these programs.
4. Controversially male circumcision has been found to have an effect in partially reducing exposures for males who have sex with females, but does not protect females, or men who have sex with men.  Controversially because there have been many criticisms of the male circumcison trials and the methodology used, and some then use this data to advocate universal infant circumcision, which has issues of consent, and whose body is it.  Some of the confounding factors include how much has the education, attention, clinical input, and being part of these campaigns reduced HIV infections versus the circumcision itself.
5. If circumcision is partially effective how does it work. Removing the foreskin removes a large area of genital skin, and therefore reduces skin absorption and micro-tears in genital skin and potential blood exposures.  So in a way it has to work in part.  The questions here are as follows?  Why just stop at male genital skin, why not offer the same partial protection option to females? The vulva will have the same risk factors as the male foreskin, research has found a correlation between lower hiv infections in circumcised African women.  Western values of course will intervene.  However, if adult males can be fully informed about the limitations of the protection of circumcision, and the anatomical losses of the foreskin, they are aware of whether they live in a high or low hiv prevalence are, then it is an option for them to choose for themselves.
6.  Ethics, it is one thing for an adult male to make a fully informed consent decision, versus infant circumcision where the human being has no say over their body or future lifestyle options, not to mention the risks of complications of the surgery on a baby who cannot consent.
7. In the end Africans need to decide for themselves, we just need to make sure American, Australian, European  Asian and Latin Maerican babies arent circumcised because of what Africans decide to do for themselves.