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Circumcision and HIV
A lie will be halfway around the world
before the truth has got its pants on.
- Rev. C. H. Spurgeon, 1855
who called it an old proverb
"Scientists
have power by virtue of the respect commanded by the discipline. We may
therefore be sorely tempted to misuse that power in furthering a
personal prejudice or social goal -- why not provide that extra oomph
by extending the umbrella of science over a personal preference in
ethics or politics? But we cannot, lest we lose the very respect that
tempted us in the first place."
- Stephen Jay Gould
Bully for Brontosaurus,
pp 429-30
(But some, it seems, are willing to take that
risk.)
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It
is not, of course, up to the media to decide what is good or bad
science. The media was reporting what it heard from scientists [about
cold fusion]. Only a tiny fraction of all scientific research is ever
covered by the popular media, however, and most scientists go through
their entire career without once encountering a reporter. New results
and ideas are argued in the halls of research institutions, presented
at scientific meetings, published in scholarly journals, all out of the
public view. Voodoo science,
by contrast, is usually
pitched directly to the media, circumventing the normal process of
scientific review and debate. ...
The result is that a disproportionate share of the science seen by the
public is flawed.
- "Voodoo Science" by Robert
Park, pp26-7
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Nail Soup
Renal
and Urology News August 19, 2009
"... circumcision must be combined with other
techniques of HIV
prevention, such as safe sex and voluntary testing. It is not
sufficient to rely on circumcision alone to prevent HIV transmission."
- Ira Sharlip, MD, a
specialist in sexual medicine at Pan Pacific Urology in San Francisco
A traveller came to a farmhouse and offered to
make the occupants
Nail Soup in return for a night's shelter. He threw a large nail in a
pot of boiling water. But he said -
"A nail must be combined with
other soup ingredients, such as onions, carrots, meat and seasonings.
It is not sufficient to rely on the nail alone to make Nail Soup."
In the morning he went on his way, refreshed after
a night in
a comfortable bed, minus the nail, with some gold coins in his pocket
and the thanks of the family ringing in his ears for the wonderful nail
that made such delicious Nail Soup.
So it will be when mass circumcision has been
"rolled out" and if there is any dent at all in HIV transmission.
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Checklist to determine the relationship
between alleged cause and outcome
- What could be other possible causes of an
observation?
- Can they be ruled out?
- If not, could they act in concert with the
alleged cause,
or could they be part of a chain of events with the alleged
cause?
- Is there a plausible mechanism linking the
alleged cause and
outcome?
- Do multiple studies link the alleged cause and
outcome? Is
the relationship consistent across studies?
- Has the relationship held up across different
individuals,
locations, and conditions, and over time? If not, is there a
logical reason that the relationship does not exist in all cases?
- Are the data being used to describe the
relationship
statistically significant, meaningful, free of confounding factors,
and representative of reality rather than some quirk in the way the
data were collected?
- Can the statistics be legitimately applied to
the situation at hand?
Lies, Damned Lies and Science
by Sherry Seethaler
Pearson Education, NJ 2009, p110
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"Therefore
Carthage must be destroyed"
(The
Roman senator Cato was in the habit of ending every speech on any
subject with those words - it helped that "must be destroyed" was a
single splendid Latin word, "delenda". Eventually the Senate agreed to
destroy Carthage, with disastrous consequences for Rome.)
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Recently, several studies have been published, most from
Africa, one
from India, claiming to show a link between having an intact penis and
a higher risk of HIV infection. They tend to have two things in common
- flawed work, and a passage near the end saying "Therefore,
universal male circumcision should be considered as a preventive
measure against HIV infection" or words to that effect.
This advice is folly.
- Any link between circumcision and HIV is
statistically quite
slight, so the protection would be quite inefficient compared to
education in safe-sex practices and a culture of protected or otherwise
safe(r) sex.
- The studies are trumpetted by their Relative
Risk Reduction
(RRR), currently running about 50-60%, but the corresponding Number
Needed to Treat (NNT) is much less impressive. (In the latest Uganda
study it is 56 circumcisions to prevent one HIV infection per year.
That corresponds to 380 circumcisions/infection/year in the US, where
AIDS is less prevalent.)
- As each new study corrects the errors of its
predecessors,
the protection claimed is less. When all the errors are corrected, what
effect will be left?
In the case of randomised controlled trials
(RCTs),
- While large numbers of men enter a trial, only
a very small number are infected, making random errors high.
- The men were randomly assigned to be
circumcised or left intact, but they were not a random sample of the
population.
- They were all HIV-negative, meaning they
were more likely to have any natural immunity than the rest of the
population
- None were circumcised, meaning certain
tribal groups had been selected out.
- All were willing to be circumcised
- They were significantly rewarded for taking
part, skewing the socio-economic status of the sample
It may have been impossible to correct for these (since humans are not
lab rats), but they are issues none the less.
- Significant numbers of men dropped out of the
trials (were "lost to study"). Only those who stay the distance should
be counted.
- Those who are circumcised and contract HIV will
be more likely to drop out than the others because
- they got what they came for but
- circumcision didn't protect them, so they
would be disillusioned with the trial.
- The three RCTs were cut short: this has reduced
their accuracy.
- The control groups were then offered
circumcision, making long-term follow-up impossible.
- Ethical approval for better studies will be
harder to get, making these studies the last word.
- The gold standard of medical testing is the double blind
random controlled trial. Circumcision can not be concealed from the
experimenter or the subject. The control groups were not given a
placebo operation.
- The after-effects of the operation are likely
to alter sexual behaviour.
- In an experimental environment, the subjects
got counselling
and safe-sex advice that would not be available in a mass circumcision
campaign.
- The circumcised group had specific instructions
to abstain from sex and use condoms that the intact control group does
not.
- Experimenter and circumcision advocate Robert Bailey has admitted
that "repeated study visits and intensive behavioural counselling" of
the circumcised men were needed to reduce risk behaviours.
If these results are acted on, with mass
circumcision campaigns:
- Protection, if any, would be extended to a
population, but it would
be impossible to convince the average man that circumcision did not
confer significant protection on him personally.
- The temptation would be irresistible -
especially if he had
submitted to a painful operation in adulthood - for a man to say "I'm
circumcised, I'm safe".
- He would be more likely to lean on partners
for unprotected sex
- This disempowers women
- Transmission from man to woman is easier than
from woman to man. Circumcision has not been shown to protect women
directly.
- Since circumcision desensitises the glans, men
circumcised in adulthood would be less willing to use condoms than
before.
- If they combine mass circumcision with
Abstinence, Be
faithful, Condoms, campaigns, as they propose, it will be impossible to
tell what is responsible for the outcome: circumcision will be given
the credit for any reduction, but will not have to take the blame for
any lack of reduction.
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The latest study
(2006) is the most
careful so far to avoid the mistakes of its predecessors, but it still
falls far short of justifying mass circumcision campagns of men in
Africa, let alone Routine Infant Circumcision. It claims to have found
a less protective effect than the
one before it.
Flawed
Studies
But each of these studies is flawed in one way or
another.
- In the study of
Kenyan truck drivers,
- 95 had intact penises, and of those, eleven men
contracted HIV-1 in
a 20 month period, compared to 32 of the 651 circumcised men in a 21
month period. That is to say, six more intact men
contracted
HIV-1 than the 5 out of 95 than the aggregated rate of 3.34 per hundred
per year would predict. While this might look like a big difference, it
is far too few, outside a laboratory, to draw any meaningful
conclusions. "The law of small numbers" applies. Those six might have
just been unlucky. Applying high-powered statistical methods to such a
small sample as this, and with so many unknown variables, is using a
sledgehammer to crack a nut.
- There were significant unexplained numerical
discrepancies between two different publications of this study.
- The study's authors admit that circumcision is so
closely tied
to ethnicity that it was not possible to assess the effects of
circumcision independently from those of ethnic origin.
- Nor were the effects assessed of ethnic origin or
religion on other practices that might influence HIV-1 transmission,
such as
- anal sex. An analysis of same-sex activity by
the truck drivers,
and how that is affected by ethnicity and religion, might cast a
completely different light on the results. In the nature of things,
membership of a tribe or ethnic group correlates with a variety of
different customs, including sexual practices, and it may be those,
rather than circumcision, that is responsible for any difference in HIV
transmission.
- "dry
sex": the use by women of
herbal and other astringents to dry their vaginas (to increase men's
pleasure, though it decreases their own). This causes micro-tears which
can facilitatte HIV transmission.
- Female Genital Mutilation, which is practised
only where male
circumcision is also (with one exception, the Pokot of Kenya, and they
used to circumcise males, but have given it up).
- A study released in Nairobi compares quite different
populations of men. According to CBS: "The study focused on Benin's
capital Cotonou and Cameroon's capital Yaounde, where circumcision is a
widespread cultural practice, as well as the Zambian town of Ndola and
the Kenyan town of Kisumu, where it is not." That is, the men compared
lived in different countries, as much as 2300 miles (3600 km) apart!
- The Rakai study in
Uganda showed no circumcised men
contracting HIV during its 30 month course, and this fact has been made
much of by the likes of Szabo
and Short. They fail to mention that more than a third of the
circumcised men were infected
before the study started, and hence were not admitted to it. Thus all
the men in the study had been selected in advance for less than average
susceptibility to HIV.
However that selection could in turn be affected by
circumcision
status. Adolescent circumcision may delay the age of onset of
intercourse (in societies where women won't have intercourse with
intact men, unlike women in non-circumcising societies) which in turn
would affect their chance of contracting HIV and being excluded from
the study before it began. The lower HIV rate may have merely been a
result of circumcised men having taken risks for longer than the intact
men, and hence being more likely to have some immunity to HIV when they
entered the study.
- A study published in Scientific
American
used nationality as a marker for circumcision status, yet African
national boundaries are an historical accident arising frm the 19th
Century "carve up of Africa".
- Other studies often rely on self-reporting of
circumcision
status. Where a man was circumcised in infancy, he may very well
imagine he is intact because he looks like all his peers, and studies
have shown a misapprehension of one's own status of as much as 33%.
- Only one of the African studies
claims to have
sufficiently corrected for the fact that circumcision in central Africa
is largely a Muslim rite, and Islam requires
- ritual washing before prayer
- abstinence from alcohol
- periodic abstinence from sex, and
- marital fidelity
- all factors affecting HIV transmission. Islam allows
polygamy, which makes extramarital sex less likely, just by exhaustion,
and encourages female seclusion, which of course makes HIV transmission
less likely.
That one study, confined to
Christians in Kenya,
compared men belonging to churches that encouraged circumcision with
those that discouraged it. It used physical examination to determine
circumcision status, and confined itself to churches that had similar
views on polygamy and widow inheritance (of their late husbands'
brothers as second husbands).
With those precautions, the correlation between
circumcision
status and HIV acquisition fell to 1.5 (20% of circumcised men had HIV,
vs 30% of intact). With "adequate" genital hygiene, the rate among the
intact fell to 26%. The circumcised men were more likely to be married
and to have more than one wife, less likely to have ever been with a
sex worker, or with more than three sex workers. (Equal proportions of
both groups, 10-11%, had been with one or two sex workers.) These
factors could well account for the difference.
The study had a 27% non-participation rate. The
authors
maintain that "because participants did not know their HIV-1 status at
the time of our visit, bias from this source would seem unlikely." But
many would know their HIV-1 status because of AIDS
symptoms.
All would know their circumcision status. There are thus unknown ways
in which men might non-randomly "include themselves out".
This study - unlike others - found no effect of age
of
circumcision on HIV acquistion, even if the circumcision took place
after sexual activity began and after HIV was prevalent. This suggests
that circumcision itself is not the key factor. An unexplored area is
what else the churches advocated or required beside circumcision. Since
the church circumcisions occur on the eighth day after birth, it seems
likely they model themselves on Judaism: what other Jewish practices do
they advocate, and what effect could those have on HIV acquisition?
As controls on "psychic" research are tightened, the
effects
found steadily diminish, and when control is complete, the effects
vanish. We see a similar effect here. These results are certainly
consistent with the null hypothesis, that circumcision has no effect on
HIV acquisition: the confounding factors have just not all been found
yet. Yet as usual, this study advocates that "male circumcision should
be seriously considered as an intervention to slow the spread of HIV-1
in uncircumcised populations". It is hard to escape the conclusion that
this line was written before the study began.
- One study,
of gay men who visited STD clinics in Seattle, relied on
self-reporting, and also found a significant correlation between being
circumcised and intra-venous drug use. This was not commented on (and
the parallel conclusion, that circumcision should be discouraged
in order to prevent IVDU, was of course not drawn). Again, only a small
number of the men (thought they) were intact - 59 out of the 313 HIV+
men and 18 out of the 186 HIV- men.
- A study of men visiting STD clinics (which in itself
skews the
sample) in Pune, India is a classic example of inadvertent sorting by
religion. In India, only Muslim (and Jewish) men are circumcised.
From the lab bench to the
glossies
...you have to be very cautious about how you
extrapolate from
what happens to some cells in a dish, on a laboratory bench, to the
complex system of a living human being, where things can work in
completely the opposite way what laboratory work would suggest.
"Bad
Science" by Ben Goldacre, Fourth Estate, London (2008), p 93
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- Two studies claim to find a mechanism for the
proposed
correlation, involving the Langerhans cells of the foreskin. However
they base their conclusions on diametrically opposed data:
- A study much touted in early 2000, that of Szabo and Short,
is based on a search of the literature (the other flawed studies just
listed) plus a histological examination of the penises of 13 cadavers, all aged over 60,
only 6 of them with
foreskins. It found Langerhans cells
on the inner mucosa and concluded that they facilitated
HIV transmission.
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- That of arch-circumcisionist Gerald Weiss
of seven years earlier
examined the foreskins of a cohort of circumcised babies and found a deficiency of Langerhans cells,
and concluded that their absence
rendered the foreskin vulnerable
to HIV transmission.
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These studies are contrasted
side by side on another page.
- Another
experimental study compares dead, excised foreskin tissue,
with dead excised cervical tissue. It cites both the
Short and Weiss studies without mentioning the contradiction
between them. It cites the Quinn et al.
(Rakai) study in Uganda that found 0 of 40 cut men seroconverting,
compared to 40 out of 137 intact men - but ignores Quinn's reply to one
of this paper's authors explaining why
circumcision was not a factor.
It tests the uptake of HIV by foreskin tissue with
that of uterine
cervical tissue - rather than vaginal, labial or clitero-preputial
mucosa, or the mucosa of the male glans for example - for no apparent
reason. (One reason could be that cervical tissue was easier to obtain,
via hysterectomy).
The dead foreskin and cervical tissue was subjected
to an extraordinary amount of
processing
before it was even ready to be inoculated with HIV or HIV genes. The
experimenters may answer that since the cervical and foreskin tissues
were subjected to the same processing, any experimenter effects would
be cancelled out - but, since they are different tissues, how does
anyone know that?
They use skin from the outside of their sample
foreskins as a
surrogate for the shaft skin of circumcised men, but fail to take into
account that only very low and tight circumcisions will result in a
shaft covered only in skin: the traditional African method of drawing
the foreskin forward on a block and slicing or chopping (as described
by Nelson Mandela in excruciating detail in his autobiography) results
in a circumcision that is low and loose, leaving plenty of mucosa.
Doubtless this study will now be cited again and
again as proof that live
HIV is more likely to infect live intact men than live circumcised men
-
even though no live penile tissue (and no circumcised penile tissue)
was
involved in the experiments.
The paper again proposes mass circumcision as an HIV
preventative measure, considering only "acceptablity and operational
feasibility," not ethics. It throws a sop to the false sense of
security this would engender, recommending
"...counselling parents and men against increasing
sexual
risk behaviours in the belief that circumcision fully protects against
HIV acquisition."
In other words, they propose to persuade men to be circumcised
because that will protect them, and simultaneously tell them not to
have unsafe sex because it won't. A mixed message indeed!
A very limited target population, and far too
few cases to tell
National
Prevention Information Network
September 17, 2008
'Snip' Protects Some Gay Men from HIV: Study
Findings reported at the Australasian Sexual
Health Conference 2008 shed new light on male circumcision’s role in
preventing HIV infection.
“We have shown for the first time that [men who
have sex with
men] who predominantly take on the insertive role in sex are less
likely to contract HIV if they’ve been circumcised,” said Dr. David
Templeton from the National Center for HIV Epidemiology and Clinical
Research in Sydney.
He went on to note, however, “Most HIV infections
are contracted in the receptive role, so what we’re talking about is a
risk reduction for a small group of men who didn’t have a huge risk in
the first place.” In the study, University of
New South Wales researchers recruited 1,400 HIV-negative men,
two-thirds of whom were circumcised. During the four-year study, 53 men
acquired HIV. There was no
evidence that circumcision reduced the HIV risk among gay men in
general. But in looking at the men who
predominantly took the insertive role in intercourse, there was an 85
percent reduction in the risk of HIV infection if they were
circumcised. Only seven of the 53 HIV infections occurred among
insertive partners; the study’s model indicated that five of these
infections could have been avoided if the men had been circumcised.
[No
figure for how many of the seven HIV infections
were among circumcised insertive men. That's
pathetically few to be drawing any statistical conclusions from, and
then only of correlation, not causation. Were any of these men
circumcised for religious reasons? Factors like that might selectively
influence their behaviour, putting them at less risk.]
Templeton was quick to note, however, “That’s only
9 percent of all HIV infections overall that can be attributed to being
uncircumcised, not enough to advocate throwing out condoms or
advocating widespread circumcision.”
Indeed, the study’s model projected [by multiplying by thousands]
that circumcising all Australian gay men would prevent 37 infections a
year in the first decade and 57 per year by 2030, at a cost of $196
million (US $153 million) in the first two years.
[No
studies have been done of
insertive-to-receptive transmission, cut vs intact, but it seems likely
the keratinised circumcised penis is more likely to tear the receptive
anus or rectum, and there is much anecdotal evidence - and visual
evidence from US vs European gay porn - that cut men are rougher,
because their fewer nerve-endings need more stimulation. So
circumcising insertive men could readily increase
HIV transmission to their partners. Yet already this study is being
touted as a reason for gay men to get circumcised.]
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Misreported
Studies
Studies that claim to find a correlation between
intactness and
HIV transmission are not uncommonly misreported in a way that plays up
the "protective effect". In one particularly glaring case, a study that
found no statistical signficance was widely
reported as finding a protective effect.
The study (Gray
R
et al. Male circumcision and the risks of female HIV and sexually
transmitted infections acquisition in Rakai, Uganda. Thirteenth
Conference on Retroviruses and Opportunistic Infections, Denver,
abstract 128, 2006.) was an attempt to find whether circumcised men
were less likely to infect their female partners with HIV.
299 couples where the man was intact were compared
with 44
where the man was circumcised. After 30 months (if the pattern of the
rest of the study was followed), infection rates were 7 per 100
person-years for the wives of circumcised men and 10 for the wives of
intact men. This may look like a protective effect, but in statistical
terms, p=0.22, meaning no statistical significance. In real terms, it
can be back-calculated that 8 of the wives of
circumcised men were infected. If 11
had been, the rate would be the same for both, and that difference of
three infections in 30 months is too few to be considered significant.
But the study was widely reported (by Reuters) as
showing that
all 299 wives of intact men were infected, compared with only 44 wives
of circumcised men, as if these were just the small (infected) samples
of two much larger and equal samples. This makes the supposed
protective effect look much greater.
See the
garbled report and the relevant part of a more accurate report.
Why,
one wonders, was the study ever published, and why in this very
misleading form?
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If at first you don't find significance...
Torture the data
If your results are bad, ask the computer to go
back and see if
any particular subgroups behaved differently. You might find that your
drug works very well in Chinese women aged fifty-two to sixty-one.
'Torture the data and it will confess to anything,' as they say at
Guantanamo Bay.
"Bad
Science" by Ben Goldacre, Fourth Estate, London (2008), p 210
This is commonly called "data-mining" This
cartoon illustrates the principle.
In the following study, the vast majority of the
men showed no
correlation between intactness and HIV. "Known risk" was defined by the
experimenters and left only 50 intact men.
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The
Journal of Infectious Diseases (impact factor: 5.87). 01/2009;
199(1):59-65. DOI: 10.1086/595569
Male Circumcision and Risk of HIV Infection
among Heterosexual African American Men
Attending Baltimore Sexually Transmitted Disease
Clinics
Lee Warner, Khalil G. Ghanem, Daniel R.
Newman, Maurizio Macaluso, Patrick S. Sullivan, and
Emily J. Erbelding
Background. Male circumcision
has received international
attention as an intervention for reducing HIV infection among high-risk
heterosexualmen; however, few US studies have evaluated its association
with the risk of HIV infection.
Methods. We analyzed visit
records for heterosexual
African American men who underwent HIV testing while attending sexually
transmitted disease (STD) clinics in Baltimore, Maryland, from 1993 to
2000. We used multivariable binomial regression to evaluate
associations between circumcision and the risk of HIV infection among
visits by patients with known and unknown HIV exposure.
Results. Overall, 1096 (2.7%)
of 40,571 clinic visits yielded positive HIV test results. Among 394
visits by [385]
patients [fewer than 50 of
whom were intact] with known HIV exposure,
circumcision was significantly associated with lower HIV prevalence
(10.2% vs. 22.0% [i.e.
about 11 intact men compared to
about 5 who might not
have contracted HIV if they had been circumcised];
adjusted prevalence rate ratio [PRR], 0.49 [95% confidence interval
[CI], 0.26–0.93]). [The
question arises, how can you "adjust" {for age, STDs, year of visit,
and clinic location} when you are dealing with only 385 men, and only
50 of them intact.] Conversely, among 40,177 visits by patients with unknown
HIV exposure, circumcision was not associated with reduced HIV
prevalence
(2.5% vs. 3.3%; adjusted PRR, 1.00 [95% CI, 0.86 –1.15]), and age
=>25 years old and diagnosis of ulcerative STD were associated
with
increased prevalence.
Conclusions. Circumcision was
associated with substantially reduced HIV risk in patients with known HIV exposure,
suggesting that results of other studies demonstrating reduced HIV risk
for circumcision among heterosexual men likely can be generalized to
the US context. [The
suggestion does not follow from the evidence.]
[This
study has generated a flurry of headlines like "Circumcision significantly
cuts HIV infection risk in heterosexual men" but the key
phrase "with known HIV exposure" was usually omitted.
]
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Contrary
Studies
A failed prediction is a very solid sign that a
pattern is phony. A pattern allows you to make a prediction: ...
A false pattern has no predictive power: it might seem to give you a
lot of power to understand past data, but it completely breaks down
when tested against new data.
- Charles Seife, Proofiness,
p56f
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No protection to men in Kenya
Elites TV
December 18, 2010
Using a population-based survey we examined the
behaviors, beliefs,
and HIV/HSV-2 serostatus of men and women in the traditionally
non-circumcising community of Kisumu, Kenya prior to establishment of
voluntary medical male circumcision services. A total of 749 men and
906 women participated. Circumcision
status was not associated with HIV/HSV-2 infection
nor increased high risk sexual behaviors. In males, preference
for being or becoming circumcised was associated with inconsistent
condom use and increased lifetime number of sexual partners.
Preference for circumcision was increased with understanding [i.e. indoctrination]
that circumcised men are less likely to become infected with HIV.
[The
study, by Robert Bailey
et al. writes
off the lack of association to "possible ... limitations in sample size
and prevalence." 108 men with sexual experience out of 749 tested HIV+.
The circumcision rate was 25% by self-report and 28% by examination.
Raw figures for circumcision vs HIV are not given.]
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Circumcsion does not protect black South
Africans
A total of 2585 males over the age of 15 were
administered
questionnaires and provided specimens for HIV testing. 916 (35.4%) of
them said they were circumcised. HIV
prevalence among circumcised males was 10.7%
and among uncircumcised males
was 12.1%, p = 0.9 [i.e.
no statistical significance]. Blacks were less
likely to be circumcised (28.8%)
compared to other racial groups, 42.6%, p = 0.002. When the data was
stratified by racial group, circumcised
Blacks showed similar rates of HIV
as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other
racial groups
showed a strong protective effect, (OR: 0.3, p = 0.01) [or rather, a correlation].
When the
data are further stratified by age of circumcision, there is a slight
protective effect [correlation]
between early circumcision and HIV among Blacks, OR:
0.7, p = 0.4.
Conclusion In general, circumcision
offers slight
protection. The effect is much stronger in other racial groups than in
blacks. This racial difference cannot be explained by age of
circumcision.
HIV and circumcision in South Africa
C.A. Connolly, O. Shisana, L. Simbayi, M. Colvin.
Poster at the XV AIDS Conference in Bangkok [MoPeC3491]
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Those "protective effects"
disappeared on further analysis
South African
Medical Journal, October 2008, Vol. 98, No. 10
Male circumcision and its relationship to HIV
infection in
South Africa: Results of a national survey in 2002
Catherine Connolly, Leickness C Simbayi,
Rebecca Shanmugam, Ayanda Nqeketo
Objective. To investigate the
nature of male circumcision and
its relationship to HIV infection.
Methods. Analysis of a sub-sample of 3
025 men aged 15 years
and older who participated in the first national population-based
survey on HIV/AIDS in 2002. Chi-square tests and
Wilcoxon rank sum tests were used to identify factors
associated with circumcision and HIV status, followed by a
logistic regression model.
Results. One-third of the men
(35.3%) were circumcised. The
factors strongly associated with circumcision were age >50,
black living in rural areas and speaking SePedi (71.2%) or
IsiXhosa (64.3%). The median age was significantly older
for blacks (18 years) compared with other racial groups (3.5
years), p <0.001. Among blacks, circumcisions were mainly
conducted outside hospital settings. In 40.5% of subjects,
circumcision took place after sexual debut; two-thirds of
the men circumcised after their 17th birthday were already
sexually active. HIV and
circumcision were not associated
(12.3% HIV positive in the circumcised group v. 12% HIV
positive in the uncircumcised group). HIV was, however,
significantly lower in men circumcised before 12 years of
age (6.8%) than in those circumcised after 12 years of age
(13.5%, p=0.02). When restricted to
sexually active men, the
difference that remained did not reach statistical significance
(8.9% v. 13.6%, p=0.08.). There was no effect when adjusted for
possible confounding.
Conclusion. Circumcision had no protective effect in the
prevention of HIV transmission. This is a
concern, and has
implications for the possible adoption of the mass male
circumcision strategy both as a public health policy and an
HIV prevention strategy.
|
No protection among young South Africans
A
2001 study by Bertran Auvert et al (who also ran the 2005 Random Controlled Study)
of HIV infection among youth in a South African mining town found it is
associated with the Herpes simplex 2 virus
It was "a community-based, cross-sectional study"
of a random
sample of men (n = 723) and women (n = 784) living in a township in the
Carletonville district of South Africa.
Risk factors associated with HIV were recorded by questionnaire and
biological tests were performed on serum and urine.
It
found that women were much more likely to have HIV (34%) than men (9%)
and HSV-2 (53% vs 17%) Two thirds of the 24-year-old women had HIV. Of
the men,
Circumcision
status
|
n
|
HIV+
|
Odds
ratio
|
95% Confidence
interval
|
No
|
498 (89.1%)
|
11.2%
|
1
|
|
Yes
|
61 (10.9%)
|
16.4%
|
1.6
|
0.7-3.2
|
Thus, the
circumcised men in the study were more likely to be
HIV+, but the difference was not statistically significant
(the 95% CI straddles 1.0 - in real terms, 10 of the 61 circumcised men
had HIV, three more than would be expected if they had the same rate as
the intact men) But it certainly casts doubts on the claim that
circumcision protects against HIV infection. Typically, Auvert
expresses this cautiously, in terms of the prevailing mythology - which
he has done so much to promote: "No protective effect of circumcision
on HIV prevalence was shown."
|
No protection to gay men
Gust DA, Wiegand RE, Kretsinger K, Sansom
S, Kilmarx PH, Bartholow BN, Chen RT.
OBJECTIVE: Determine whether
male circumcision would be effective in reducing HIV transmission among
men who have sex with men (MSM).
DESIGN: Retrospective analysis
of the VAXGen VAX004 HIV vaccine clinical trial data. [Since the men were all volunteers
in a vaccine trial, they were not a random sample of the population.]
METHODS: Survival analysis was
used to associate time to
HIV infection with multiple predictors. Unprotected insertive and
receptive anal sex predictors were highly correlated, thus separate
models were run.
RESULTS: Four thousand eight
hundred and eighty-nine
participants were included in this reanalysis; 86.1% were circumcised.
Three hundred and forty-two (7.0%) men became infected during the
study; 87.4% [4209]
were circumcised. [So 680
were intact, of whom only 43 became HIV+, according to this news item, or
6.3%. And the rate among the
circumcised men is (342-43)/4209 or 7.1% ]
Controlling for demographic characteristics and risk behaviors, in the
model that included unprotected insertive anal sex, being uncircumcised was not associated with
incident HIV infection
[adjusted hazards ratio (AHR) = 0.97, confidence interval (CI) =
0.56-1.68]. Furthermore, while having unprotected insertive (AHR =
2.25, CI = 1.72-2.93) or receptive (AHR = 3.45, CI = 2.58-4.61) anal
sex with an HIV-positive partner were associated with HIV infection, the associations between HIV incidence and
the interaction between being uncircumcised and reporting unprotected
insertive (AHR = 1.78, CI = 0.90-3.53) or receptive (AHR =
1.26, CI = 0.62-2.57) anal sex with
an HIV-positive partner were not statistically significant.
Of the study visits when a participant reported unprotected insertive
anal sex with an HIV-positive partner, HIV infection among circumcised
men was reported in 3.16% of the visits (80/2532) and among
uncircumcised men in 3.93% of the visits (14/356) [relative risk (RR) =
0.80, CI = 0.46-1.39]. [This
is data-mining.
The number who knew the HIV+ status of their partners would be a small
and random fraction of the total, as the wide Confidence Intervals
indicate.]
CONCLUSIONS: Among men who
reported unprotected insertive anal sex with HIV-positive partners, being uncircumcised did not confer a
statistically significant increase in HIV infection risk [The possiblity that circumcision increases
the risk is not considered, even though the figures "trend" that way.].
Additional studies with more incident HIV infections or that include a
larger proportion of uncircumcised men may provide a more definitive
result.
PMID: 20168206 [PubMed - as supplied by publisher]
|
No protection to insertive gay men:
"Our finding that 17% of homosexual men with newly
acquired HIV
infection reported insertive UAI [unprotected anal intercourse] as
their highest risk activity suggests that insertive UAI is an important
means of HIV transmission in this population. However, we found no
association between circumcision status and infection by insertive UAI.
In addition, men who had
seroconverted despite no reported event of UAI were also no more likely
to be uncircumcised.
These data strongly suggest that the foreskin is not the main source of
HIV infection in homosexual men who become infected by insertive UAI,
and that other sites, such as the distal urethra, must be important in
HIV infection.
"Our data showing that there is no difference in
the
circumcision status of men infected by receptive or insertive UAI, in a
population with a circumcision prevalence of approximately 75%,
suggests that circumcision is not strongly protective against HIV
infection in homosexual men. Larger studies, preferably of prospective
design, are needed to confirm the absence of a relationship between
circumcision and HIV infection risk in gay men. In the meantime,
educational messages to homosexual men should continue to emphasize
that insertive anal sex is a high-risk activity for HIV transmission
whether or not the insertive partner is circumcised."
- Grulich AE, Hendry O, Clark
E, Kippax S, Kaldor JM.
Circumcision and male-to-male sexual transmission of HIV.
AIDS 2001 Jun 15;15(9):1188-1189.
A longer-term study of the same men
did find significantly less HIV in strictly insertive men ("tops") who
were circumcised, but it is based on
- a grand total of three
intact men who might not have got HIV if they had been circumcised. By
Fisher's exact test, the
two-tailed P-value = 0.1035 and
the association is not significant.
"As the minority of HIV infections in H[ealth] I[n
]M[en -a
prospective cohort study of homosexual men in Sydney] occurred in those
reporting no receptive U[unprotected ]A[mal ]Intercourse ], and most
Australian men are circumcised, circumcision is unlikely to have a
major impact on HIV incidence in homosexual men in Australia.
Nonetheless, 'strategic positioning' when HIV-negative gay men adopt
the insertive role in UAI to reduce their HIV risk is occurring
commonly among Sydney gay men. This coupled with a rapidly declining
prevalence of circumcision in Australian and US homosexual men means
circumcision could play a more important role in reducing gay men's
susceptibility to HIV infection in the future. Randomized trials are
warranted before recommendations can be made regarding circumcision as
an HIV prevention intervention among MSM populations, but the design of
such studies is challenging. [A
Tuskegee-style study would be
required]
Study populations would require high HIV incidence, low baseline
circumcision prevalence and large numbers of participants exclusively
or predominantly practising the insertive role. Such attributes are
necessary for sufficient study power to detect an association of
circumcision status with the relatively infrequent outcome measure of
HIV acquisition via insertive anal intercourse."
- Templeton DJ, Jin F, Mao L,
Prestage GP, Donovan B, Imrie J, Kippax S, Kaldor JMa, Grulich AE
Circumcision and risk of HIV infection in Australian homosexual men
AIDS 2009 Nov 13:23(17): 2347-2351.
|
Arch Sex Behav. 2013 Jan 29. [Epub
ahead of print]
Circumcision and HIV Infection among Men
Who Have Sex with Men in Britain: The Insertive Sexual Role.
Doerner R, McKeown E, Nelson S, Anderson
J, Low N, Elford J.
Abstract
The objective was to examine the association between circumcision
status and self-reported HIV infection among men who have sex with men
(MSM) in Britain who predominantly or exclusively engaged in insertive
anal intercourse. In 2007-2008, a convenience sample of MSM living in
Britain was recruited through websites, in sexual health clinics, bars,
clubs, and other venues. Men completed an online survey which included
questions on circumcision status, HIV testing, HIV status, sexual risk
behavior, and sexual role for anal sex. The analysis was restricted to
1,521 white British MSM who reported unprotected anal intercourse in
the previous 3 months and who said they only or mostly took the
insertive role during anal sex. Of these men, 254 (16.7 %) were
circumcised. Among men who had had a previous HIV test (n = 1,097),
self-reported HIV seropositivity was 8.6 % for circumcised men (17/197)
and 8.9 % for uncircumcised men (80/900) (unadjusted odds ratio [OR],
0.97; 95 % confidence interval [95 % CI], 0.56, 1.67). In a
multivariable logistic model adjusted for known risk factors for HIV
infection, there was no evidence of
an association between HIV seropositivity and circumcision status
(adjusted OR, 0.79; 95 % CI, 0.43, 1.44), even
among the 400 MSM who engaged exclusively in insertive anal sex
(adjusted OR, 0.84; 95 % CI, 0.25, 2.81). Our study provides further
evidence that circumcision is
unlikely to be an effective strategy for HIV prevention among MSM in
Britain.
|
No protection to Seattle men who have sex with
men - even the exclusively insertive
Sex Transm Dis. 2009 Nov 6. [Epub ahead of print]
The [Lack
of] Association Between Lack of Circumcision and
HIV, HSV-2, and Other Sexually Transmitted Infections Among Men Who
Have Sex With Men.
Jameson DR, Celum CL, Manhart L, Menza TW, Golden
MR. BACKGROUND:: Observational studies evaluating
the association of circumcision and HIV infection among men who have
sex with men (MSM) have yielded mixed results. We examined the
relationship between circumcision and HIV, herpes simplex virus type-2
(HSV-2), syphilis, urethral gonorrhea, and urethral chlamydia among MSM
stratified by anal sexual role.
METHODS:: Between October 2001
and May 2006, 4749 MSM who reported anal intercourse in the previous 12
months attended the Public Health-Seattle and King County STD clinic
for 8337 evaluations. Clinicians determined circumcision status by
examination and anal sexual role in the previous year by interview.
Blood samples were used to test HIV, syphilis, and HSV-2 serostatus.
Urethral gonorrhea and chlamydia were tested by culture or nucleic acid
amplification. We used generalized estimating equations to evaluate the
association between circumcision and specific diagnoses, adjusted for
race/ethnicity and age.
RESULTS:: Among the 3828 men
whose circumcision status was assessed, 3241 (85%) were circumcised and
587 (15%) were not. The proportion
of men newly testing HIV-positive or with previously diagnosed HIV did
not differ by circumcision status when stratified by men's
anal sexual role in the preceding year, even
when limited to men who reported only insertive anal intercourse
in the preceding 12 months (OR = 1.45; 95% CI: 0.30, 7.12). Similarly, we did not observe a significant
association between circumcision status and the other sexually
transmitted infections (STI).
CONCLUSIONS:: Our findings suggest that male circumcision
would not be likely to have a significant impact on HIV or sexually
transmitted infections acquisition among MSM in Seattle.
PMID: 19901865 [PubMed - as supplied by
publisher]
|
No protection to US men who have sex with men
AIDS
Patient Care and STDs
Relations Between Circumcision Status, Sexually
Transmitted Infection History, and HIV Serostatus Among a National
Sample of Men Who Have Sex with Men in the United States
Kristen Jozkowski, Joshua G. Rosenberger, Vanessa
Schick, Debby
Herbenick, David S. Novak, Michael Reece. AIDS Patient Care and STDs.
August 2010, 24(8): 465-470.
Abstract
Circumcision's potential link to HIV/sexually transmitted
infections (STI) has been at the center of recent global public health
debates. However, data related to circumcision and sexual health remain
limited, with most research focused on heterosexual men. This study
sought to assess behavioral differences among a large sample of
circumcised and noncircumcised men who have sex with men (MSM) in the
United States. Data were collected from 26,257U.S. MSM through an
online survey. [An online
survey is a population sample of unknown randomness.]
Measures included circumcision status, health indicators, HIV/STI
screening and diagnosis, sexual behaviors, and condom use. Bivariate
and regression analyses were conducted to determine differences between
HIV/STI status, sexual behaviors, and condom use among circumcised and
noncircumcised men. Circumcision
status did not significantly predict HIV testing
(p>0.05), or HIV
serostatus (p>0.05), and [there
were no significant differences based on circumcision status for most
STI diagnosis [syphilis, gonorrhea, chlamydia, human papilloma virus
(HPV)]. Being noncircumcised was predictive of herpes-2 diagnosis,
however, condom use mediated this relationship.]
[That
is, circumcised men were more likely to use condoms, and it was this
that protected them from herpes, not being circumcised. This suggests
that being circumcised increased their risk of the
other STIs.] These data provide one of the first
large national assessments of circumcision among MSM. While being noncircumcised did not
increase the likelihood of HIV and most STI infections,
results indicated that circumcision was associated with higher rates of
condom use, suggesting that those who promote condoms among MSM may
need to better understand condom-related behaviors and attitudes among
noncircumcised men to enhance the extent to which they are willing to
use condoms consistently.
|
No protection to US Black and Latino men who
have unprotected insertive sex with men
JAIDS
December 15, 2007
Circumcision Status and HIV Infection Among Black
and Latino Men Who Have Sex With Men in 3 US Cities.
Millett, Gregorio A; Ding, Helen; Lauby, Jennifer;
Flores, Stephen;
Stueve, Ann; Bingham, Trista; Carballo-Dieguez, Alex; Murrill, Chris;
Liu, Kai-Lih; Wheeler, Darrell; Liau, Adrian; Marks, Gary
Abstract:
Objective: To examine
characteristics of circumcised and uncircumcised Latino and black men
who have sex with men (MSM) in the United States and assess the
association between circumcision and HIV infection.
Methods: Using
respondent-driven sampling, 1154
black MSM and 1091 Latino MSM were recruited from New York City,
Philadelphia, and Los Angeles. A 45-minute computer-assisted interview
and a rapid oral fluid HIV antibody test (OraSure Technologies,
Bethlehem, PA) were administered to participants.
Results: Circumcision
prevalence was higher among
black MSM than among Latino MSM (74% vs. 33%; P < 0.0001).
Circumcised MSM in both racial/ethnic groups were more likely than
uncircumcised MSM to be born in the United States or to have a US-born
parent. Circumcision status was not
associated with prevalent HIV
infection among Latino MSM, black MSM, black bisexual men,
or black or
Latino men who reported being HIV-negative based on their last HIV
test. Further, circumcision was not
associated with a reduced
likelihood of HIV infection among men who had engaged in unprotected
insertive and not unprotected receptive anal sex. [Yet the protection claim is made
exclusively about insertive {vaginal} sex.]
Conclusions: In these
cross-sectional data, there was no
evidence that being circumcised was protective against HIV infection
among black MSM or Latino MSM.
JAIDS Journal of Acquired Immune Deficiency
Syndromes. 46(5):643-650, December 15, 2007.
|
No protection to Scottish men who have sex with
men
Sex
Transm Infect. 2010 Jun 30
Circumcision among men who have sex with
men in Scotland: limited potential for HIV prevention.
McDaid LM, Weiss HA,
Hart GJ.
Abstract
Objective Male circumcision has been
shown to reduce the risk of HIV acquisition among heterosexual men but
the impact among men who have sex with men (MSM) is not known. In this
paper, we explore the feasibility of research into circumcision for HIV
prevention among MSM in Scotland.
Methods Anonymous, self-complete
questionnaires and Orasure oral fluid collection kits were distributed
to men visiting the commercial gay scenes in Glasgow and Edinburgh.
Results 1508 men completed
questionnaires (70.5% response rate) and 1277 provided oral fluid
samples (59.7% response rate). Overall, 1405 men were eligible for
inclusion in the analyses. 16.6% reported having been circumcised. HIV prevalence was similar among
circumcised and uncircumcised men (4.2% and 4.6%, respectively).
Although biologically, circumcision is most likely to protect against
HIV for men practising unprotected insertive anal intercourse (UIAI),
only 7.8% (91/1172) of uncircumcised men reported exclusive UIAI in the
past 12 months. Relatively few men reported being willing to
participate in a research study on circumcision and HIV prevention
(13.9%), and only 11.3% of uncircumcised men did so. Conclusion
The lack of association
between circumcision and HIV status, low levels of
exclusive UIAI, and low levels of willingness to take part in
circumcision research studies suggest circumcision is unlikely to be a
feasible HIV prevention strategy for MSM in the UK. Behaviour change
should continue to be the focus of HIV prevention in this population.
PMID: 20595141
|
No protection to women
The Lancet, Volume 374, Issue 9685, Pages 229 -
237, 18 July 2009
Circumcision in HIV-infected men and its effect
on HIV
transmission to female partners in Rakai, Uganda: a randomised
controlled trial
Dr, Prof Maria J Wawer MD, Frederick Makumbi PhD,
Godfrey Kigozi
MBChB, David Serwadda MMed, Stephen Watya MMed, Fred Nalugoda MHS,
Dennis Buwembo MBChB, Victor Ssempijja ScM, Noah Kiwanuka MBChB, Prof
Lawrence H Moulton PhD, Nelson K Sewankambo MMed, Steven J Reynolds MD,
Thomas C Quinn MD, Pius Opendi MBChB, Boaz Iga MSc, Renee Ridzon MD,
Oliver Laeyendecker MBA, Prof
Ronald H Gray MD
Summary
Background
Observational studies have reported an association between male
circumcision and reduced risk of HIV infection in female partners. We
assessed whether circumcision in HIV-infected men would reduce
transmission of the virus to female sexual partners.
Methods
922 uncircumcised, HIV-infected, asymptomatic men aged 15-49 years
with CD4-cell counts 350 cells per ?L or more were enrolled in this
unblinded, randomised controlled trial in Rakai District, Uganda. Men
were randomly assigned by computer-generated randomisation sequence to
receive immediate circumcision (intervention; n=474) or circumcision
delayed for 24 months (control; n=448). HIV-uninfected female partners
of the randomised men were concurrently enrolled (intervention, n=93;
control, n=70) and followed up at 6, 12, and 24 months, to assess HIV
acquisition by male treatment assignment (primary outcome). A modified
intention-to-treat (ITT) analysis, which included all concurrently
enrolled couples in which the female partner had at least one follow-up
visit over 24 months, assessed female HIV acquisition by use of
survival analysis and Cox proportional hazards modelling. This trial is
registered with ClinicalTrials.gov, number NCT00124878.
Findings
The trial was stopped early because of futility. [That is, it failed to find any
protection. It might have shown increased risk, but they weren't
interested in that.] 92 couples in the
intervention group and 67 couples in the control group were included in
the modified ITT analysis. 17 (18%)
women in the intervention group and eight (12%)
women in the control group acquired HIV during follow-up
(p=0.36). Cumulative probabilities of female HIV infection at 24 months
were 21.7% (95% CI 12.7-33.4) in the intervention group and 13.4%
(6.7-25.8) in the control group (adjusted hazard ratio 1.49, 95% CI
0.62-3.57; p=0.368).
Interpretation
Circumcision of HIV-infected men did not reduce HIV transmission to
female partners over 24 months; longer-term effects could not be
assessed. Condom use after male circumcision is essential for HIV
prevention.
Funding
Bill & Melinda Gates Foundation with additional laboratory and
training support from the National Institutes of Health and the Fogarty
International Center.
A YouTube video of Maria Wawer describing
the experiment
|
Author: Turner AN | Morrison CS
| Padian NS | Kaufman JS | Salata RA
Source: AIDS.
2007 Aug 20;21(13):1779-1789.
Abstract: The objective was to
assess whether male
circumcision of the primary sex partner is associated with women's risk
of HIV. Data were analyzed from 4417 Ugandan and Zimbabwean women
participating in a prospective study of hormonal contraception and HIV
acquisition. Most were recruited from family planning clinics; some in
Uganda were referred from higher-risk settings such as sexually
transmitted disease clinics. Using Cox proportional hazards models,
time to HIV acquisition was compared for women with circumcised or
uncircumcised primary partners. Possible misclassification of male
circumcision was assessed using sensitivity analysis. At baseline, 74%
reported uncircumcised primary partners, 22% had circumcised partners
and 4% had partners of unknown circumcision status. Median follow-up
was 23 months, during which 210 women acquired HIV (167, 34, and 9
women whose primary partners were uncircumcised, circumcised, or of
unknown circumcision status, respectively). Although unadjusted
analyses indicated that women with circumcised partners had lower HIV
risk than those with uncircumcised partners, the
protective effect disappeared after adjustment for other risk factors
[hazard ratio (HR), 1.03; 95% confidence interval (CI), 0.69-1.53].
Subgroup analyses suggested a non-significant protective effect of male
circumcision on HIV acquisition among Ugandan women referred from
higher-risk settings: adjusted HR 0.16 (95% CI, 0.02-1.25) but little
effect in Ugandans (HR, 1.33; 95% CI, 0.72-2.47) or Zimbabweans (HR,
1.12; 95% CI, 0.65-1.91) from family planning clinics. After
adjustment, male circumcision was
not significantly associated with women's HIV risk. The
potential protection offered by male circumcision for women recruited
from high-risk settings warrants further investigation. (author's)
Date Posted: 3 September 2007
|
AIDS. 2009 Dec 29. [Epub ahead of print]
Male circumcision and risk of
male-to-female HIV-1 transmission: a multinational prospective study in
African HIV-1-serodiscordant couples.
Baeten JM, Donnell D, Kapiga SH, Ronald A,
John-Stewart G, Inambao M,
Manongi R, Vwalika B, Celum C; for the Partners in Prevention HSV/HIV
Transmission Study Team.
OBJECTIVE:: Male circumcision reduces
female-to-male HIV-1 transmission risk by approximately 60%. Data
assessing the effect of
circumcision on male-to-female HIV-1 transmission are conflicting, with
one observational study among HIV-1-serodiscordant couples showing
reduced
transmission but a randomized trial suggesting no short-term benefit of
circumcision.
[Suggesting
an increased risk,
actually]
DESIGN/METHODS:: Data collected as part of a
prospective
study among African HIV-1-serodiscordant couples were analyzed for the
relationship between circumcision status of HIV-1-seropositive men and
risk of HIV-1 acquisition among their female partners. Circumcision
status
was determined by physical examination. Cox proportional hazards
analysis
was used.
RESULTS:: A total of 1096 HIV-1-serodiscordant
couples in which
the male partner was HIV-1-infected were followed for a median of 18
months; 374 (34%) male partners were circumcised. Sixty-four female
partners seroconverted to HIV-1 (incidence 3.8 per 100 person-years). [It would be useful to know the raw
figures, circumcised vs intact partners, at this point.]
Circumcision of the male partner was associated with a nonstatistically
significant approximately 40% lower risk of HIV-1 acquisition by the
female partner (hazard ratio 0.62, 95% confidence interval 0.35-1.10, P
= 0.10). [Translation: no
protection.] The magnitude of this effect was
similar when restricted to the
subset of HIV-1 transmission events confirmed by viral sequencing to
have
occurred within the partnership (n = 50, hazard ratio 0.57, P = 0.11),
after adjustment for male partner plasma HIV-1 concentrations (hazard
ratio 0.60, P = 0.13), and when excluding follow-up time for male
partners
who initiated antiretroviral therapy (hazard ratio 0.53, P = 0.07). [Translation: data-mining failed to
find an effect.]
CONCLUSION:: Among HIV-1-serodiscordant couples in
which the
HIV-1-seropositive partner was male, we observed no increased risk and
potentially decreased risk from circumcision on male-to-female
transmission of HIV-1.
[An
attempt to snatch victory from the jaws of defeat. The risk was not
decreased.]
PMID: 20042848 [PubMed - as supplied by publisher]
|
Greater risk to women whose
partners are circumcised:
Int
J Epidemiol. 1994 Apr;23(2):371-80.
Risk factors associated with prevalent
HIV-1 infection among pregnant women in Rwanda.
National University of Rwanda-Johns Hopkins University AIDS Research
Team.
Chao A, Bulterys M, Musanganire F, Habimana P, Nawrocki P, Taylor E,
Dushimimana A, Saah A.
Department of Epidemiology, School of Hygiene and Public Health, Johns
Hopkins University, Baltimore, MD 21205.
Abstract:
This study evaluated risk factors associated with prevalent HIV-1
infection among pregnant women in a semi-rural but densely populated
area surrounding the town of Butare in Rwanda. Overall seroprevalence
was 9.3% in 5690 pregnant women who sought antenatal care at one of
five health centres. Factors associated with higher seroprevalence of
HIV-1 included history of multiple sexual partners, history of at least
one sexually transmitted disease (STD), relatively high socioeconomic
status (SES), being unmarried, young age at first pregnancy, and low
gravidity. Women who
had used oral contraceptives, smoked more than one cigarette per day, whose partners were circumcised,
and had had sex to support themselves were
also at higher risk of being
infected.
A history of blood transfusion in the past 5 years was not associated
with HIV-1 infection. History of multiple sexual partners, history of
STD, high household income, partner
circumcision, and past oral contraceptive use remained strongly associated with HIV-1
infection even when simultaneously controlling for other covariates.
Among legally married women who lacked sexual behaviour risk factors,
history of STD, high SES, young age at first pregnancy, and low
gravidity were significantly associated with HIV-1 seroprevalence.
PMID: 8082965 [PubMed - indexed for MEDLINE]
|
No correlation in a high-risk population
International
AIDS Society
Prevalence of
male circumcision and its association with HIV and sexually transmitted
infections in a U.S. navy population
A G Thomas, L N Bakhireva, S K Brodine, R A Shaffer
Int
Conf AIDS. 2004 Jul 11-16; 15: abstract no. TuPeC4861.
Background:
Lack of male circumcision has been found to be a risk factor for HIV
and sexually transmitted infection (STI) in several studies performed
in developing countries. However, the few studies conducted in
developed nations have yielded inconsistent results. Policy regarding
circumcision of male infants as a prevention measure against HIV/STI
remains a controversial topic. This study describes the prevalence of
circumcision and its association with HIV and STI in a U.S. military
population.
Methods:
This is a case-control study of male HIV infected U.S. military
personnel (n= 232) recruited from 7 military medical centers and male
U.S. Navy controls (n=516) from a general aircraft carrier population.
Cases and controls completed similar self-administered HIV behavioral
risk surveys. Case circumcision status was abstracted from medical
charts while control status was reported on the survey. Cases and
controls were frequency matched on age. Multiple logistic regressions
were constructed separately to evaluate the role of circumcision in the
acquisition of HIV and STI.
Results:
The proportion of circumcised men did not significantly differ between
cases (84.9%) and controls (81.8%). Prevalence of circumcision among
men born in the U.S. was higher (85.0%) than those born elsewhere
(58.1%). After adjustment for demographic and behavioral risk factors lack of circumcision was not found to be a
risk factor for HIV
(OR = 0.9; 95% CI: 0.51, 1.7) or STI (OR = 1.08; 95% CI 0.52, 2.26).
The odds of HIV infection were 2.6 higher for irregular condom users, 5
times as high for those reporting STI, 6.2 times higher for those
reporting anal sex, 2.8-3.2 times higher for those with 2-7+ partners,
nearly 3 times higher for Blacks, and 3.5 times as high for men who
were single or divorced/separated.
Conclusions: Although there may
be other medical or cultural reasons for male circumcision,
it is not associated with HIV or STI
prevention in this U.S. military population.
|
No protection by traditional circumcision
J Acquir Immune Defic Syndr. 2007 Aug
1;45(4):371-9.
The protective effect of circumcision on HIV
incidence in rural
low-risk men circumcised predominantly by traditional circumcisers in
Kenya: two-year follow-up of the Kericho HIV Cohort Study.
Shaffer DN, Bautista CT, Sateren WB, Sawe FK, Kiplangat SC, Miruka AO,
Renzullo PO, Scott PT, Robb ML, Michael NL, Birx DL.
US Army Medical Research Unit, Walter Reed Project HIV Program,
Kericho, Kenya. dshaffer@wrp-kch.org
BACKGROUND: Three randomized controlled trials
(RCTs) have
demonstrated that male circumcision prevents female-to-male HIV
transmission in sub-Saharan Africa. Data from prospective cohort
studies are helpful in considering generalizability of RCT results to
populations with unique epidemiologic/cultural characteristics.
METHODS:
Prospective observational cohort sub-analysis. A total of 1378 men were
evaluated after 2 years of follow-up. Baseline sociodemographic and
behavioral/HIV risk characteristics were compared between 270
uncircumcised and 1108 circumcised men. HIV incidence rates (per 100
person-years) were calculated, and Cox proportional hazards regression
analyses estimated hazard rate ratios (HRs).
RESULTS: Of the
men included in this study, 80.4% were circumcised; 73.9% were
circumcised by traditional circumcisers. Circumcision was associated
with tribal affiliation, high school education, fewer marriages, and
smaller age difference between spouses (P < 0.05). After 2 years
of
follow-up, there were 30 HIV incident cases (17 in circumcised and 13
in uncircumcised men). Two-year HIV incidence rates were 0.79 (95%
confidence interval [CI]: 0.46 to 1.25) for circumcised men and 2.48
(95% CI: 1.33 to 4.21) for uncircumcised men corresponding to a HR =
0.31 (95% CI: 0.15 to 0.64). In one model controlling
for sociodemographic factors, the HR increased and became non-significant
(HR = 0.55; 95% CI: 0.20 to 1.49).
CONCLUSIONS: Circumcision by traditional
circumcisers offers protection [That's
not what "non-significant" means.]
from HIV infection in adult men in rural Kenya. Data from well-designed
prospective cohort studies in populations with unique cultural
characteristics can supplement RCT data in recommending public health
policy. PMID: 17558336 [PubMed - indexed for MEDLINE]
|
No protection to men
Mor Z, Kent CK, Kohn RP, Klausner
JD (2007) Benefit. PLoS ONE 2(9):
The study objective was to describe male
circumcision trends
among men attending the San Francisco municipal STD clinic, and to
correlate the findings with HIV, syphilis and sexual orientation.
Methods and Findings. A cross sectional
study was performed by reviewing all electronic
records of males attending the San Francisco municipal STD clinic
between 1996 and 2005. The prevalence of circumcision over
time and by subpopulation such as race/ethnicity and sexual orientation
were measured. The findings were further correlated
with the presence of syphilis and HIV infection. Circumcision status
was determined by physical examination and disease
status by clinical evaluation with laboratory confirmation.
Among 58,598 male patients, 32,613 (55.7%, 95%
Confidence
Interval (CI) 55.2–56.1) were circumcised. Male circumcision varied
significantly by decade of birth (increasing between 1920
and 1950 and declining overall since the 1960’s), race/ethnicity
(Black: 62.2%, 95% CI 61.2–63.2, White: 60.0%, 95% CI 59.46–
60.5, Asian Pacific Islander: 48.2%, 46.9–49.5 95% CI, and Hispanic:
42.2%, 95% CI 41.3–43.1), and sexual orientation (gay/
bisexual: 73.0%, 95% CI 72.6–73.4; heterosexual: 66.0%, 65.5–66.5).
Male circumcision may [or,
equally, may not] have been modestly protective
against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I.
0.83–1.02, P = 0.06) . [No
correlations were found between circumcision and HIV or syphilis in any
of the groups of men studied, but the paper tries its best to make it
look as if they were]
From the Results:
Table
2. Percent circumcised in those with and without syphilis infection by
HIV status and sexual orientation, as determined during male patient
visits, San Francisco municipal STD clinic, 1996-2005.
|
Sexual orientation
|
Syphilis infection
|
HIV-infected
|
HIV-uninfected
|
|
|
Circumcised %
|
(n/N)
|
PR*
|
(95% CI)
|
Circumcised %
|
(n/N)
|
PR
|
(95% CI)
|
Heterosexual
|
Yes
|
62.5
|
(10/16)
|
0.85
|
(0.40-1.56)
|
66.7
|
(384/576)
|
0.92
|
(0.83-1.02)
|
|
No
|
73.8
|
(1,050/1,423)
|
Ref.
|
|
72.4
|
(36,290/50,128)
|
Ref.
|
|
Gay/ bisexual
|
Yes
|
75.8
|
(214/282)
|
1.0
|
(0.87-1.15)
|
72.7
|
(384/528)
|
0.98
|
(0.88-1.08)
|
|
No
|
75.4
|
(15,910/21,090)
|
Ref.
|
|
74.6
|
(34,210/45,869)
|
Ref.
|
|
*PR = Prevalence ratio of circumcision
status by syphilis infection (Yes/No)
Table 2 shows the proportion of visits by
circumcised men at the
San Francisco municipal STD clinic from 1996 through 2005 by
sexual orientation, syphilis and HIV infection status. There was a trend towards a protective effect of
circumcision for syphilis
infection in heterosexual HIV-uninfected men and in a lesser extent in
HIV-infected men. Among gay/bisexual men, no such protective effect was
seen and also no association was
found between circumcision status and HIV infection (71.1%
circumcised
versus 72.2%, PR = 0.97, 95% CI 0.90-1.0, P =0.52).
|
Conclusions. Male circumcision
was
common among men seeking STD services in San Francisco but has declined
substantially in recent decades. Male circumcision
rates differed by race/ethnicity and sexual orientation. Given recent
studies suggesting the public health benefits of male
circumcision, a reconsideration of national male circumcision policy is
needed to respond to current trends.
[And therefore Carthage must be destroyed. The
conclusion does not follow at all from the data.
"A trend
towards a protective effect" is weasel
wording for no correlation.
Class
|
Prevalence of circumcision ratio
Syphilis : No Syphilis
|
Heterosexual
|
HIV-
|
0.92:1
|
HIV+
|
0.85:1
|
Gay/Bisexual
|
HIV-
|
0.98:1
|
HIV+
|
1.00:1
|
However, none
of the ratios is statistically significant.
Considering
HIV, in every row
except the first, the percentage on the right (circumcised men with
HIV) is greater than the percentage on the left (intact men with HIV),
and in the first row, there are only six intact (heterosexual) men with
HIV (and syphilis). Here is a different presentation of the same data:
Class
|
Prevalence of circumcision ratio
HIV+ : HIV-
|
Heterosexual
|
Syphilis
|
0.94:1
|
No Syphilis
|
1.02:1
|
Gay/Bisexual
|
Syphilis
|
1.04:1
|
No Syphilis
|
1.01:1
|
In all classes
except the first, men with HIV
are very slightly more likely to be circumcised than men without HIV,
but in no class does the difference reach statistical significance.
(And in the first class - because only six of the men with HIV were
intact - if one more HIV+ man had been circumcised, that ratio would
also have been greater than 1:1.)
There are other
problems with this paper.
According to its Table 1 there were 15,515 intact men, while according
to Table 2 intact men paid only 14,409 visits to the clinic.
A published
response to the paper
|
No protection to men who have sex with men in
London
Circumcision Among Men Who Have Sex with Men
in London, United Kingdom: An Unlikely Strategy for HIV Prevention
Abstract
Male circumcision is unlikely to be a workable HIV
prevention
strategy among London MSM, the current study suggests. The team
undertook the research to explore attitudes about circumcision among
MSM in London and to assess the feasibility of conducting research on
circumcision and HIV prevention among these men. In May and June 2008,
a convenience sample of MSM visiting gyms in central London completed a
confidential, self-administered questionnaire. The information
collected included demographic characteristics, self-reported HIV
status, sexual behavior, circumcision status, attitudes about
circumcision, and willingness to take part in research on circumcision
and HIV prevention. Among the 653 participants, 29 percent reported
they were circumcised. HIV
prevalence among the
MSM was 23.3 percent and did not differ significantly between
circumcised (18.6 percent) and uncircumcised (25.2 percent) men
(adjusted odds ratio=0.79; 95 percent confidence interval: 0.50-1.26).
The proportion of participants reporting unprotected anal intercourse
in the past three months was similar in the circumcised (38.8 percent)
and uncircumcised (36.7 percent) groups (AOR=1.06; 95 percent CI:
0.72-1.55). The uncircumcised MSM were [much]
less likely to think there were benefits to being circumcised compared
to the circumcised men (31.2 percent vs. 65.4 percent, P<0.001).
Just 10.3 percent of the uncircumcised men indicated a willingness to
take part in research on circumcision as a strategy to prevent HIV
transmission.
“Most uncircumcised MSM in this London survey were
unwilling to participate in research on circumcision and HIV
prevention,” the authors concluded. “Only a minority of uncircumcised
men thought that there were benefits of circumcision. It is unlikely
that circumcision would be a feasible strategy for HIV prevention among
MSM in London.”
Source
http://www.stdjournal.com
Date of Publication
10//2011
Author
Alicia C. Thornton; Samuel Lattimore; Valerie
Delpech; Helen A. Weiss;
Jonathan Elford
-
|
Circumcision as a risk of
HIV transmission
The Bagisu people of Eastern Uganda circumcise
boys aged 12-18 years. The cultural practices associated with
circumcision are a risk to HIV transmission. HIV transmission awareness
programmes have been running in the local media but the message is
mainly
perceived by urban, literate people. The researchers found it is hard
to change the attitude of the
Bagisu towards their cultural circumcision practices despite the risks.
A. Kataami Moiti. Joint Clinical Research Centre,
Kampala, Uganda
The Importance of education in addressing risk factors associated with
cultural circumcision practices among Bagisu community, Uganda
Poster at the XV AIDS Conference in Bangkok, July 2004 [ThPeC7544]
|
WebmedCentral EPIDEMIOLOGY 2011;2(9):WMC002206
Scarification and Male Circumcision
Associated with HIV Infection in Mozambican Children and Youth
By Dr. Devon D Brewer
Abstract
Background: In sub-Saharan Africa, significant
numbers of children
with seronegative mothers are HIV infected. Similarly, substantial
proportions of African youth who have not had sex are infected with
HIV. These findings imply that some African children and youth acquire
HIV through blood exposures in unhygienic healthcare, cosmetic care,
and rituals. In prior research, male and female Kenyan, Lesothoan, and Tanzanian adolescents
and virgins who were circumcised were more likely to be infected with
HIV than their uncircumcised counterparts.
Methods: I examined the association between male
circumcision,
scarification, and HIV infection in Mozambican children and youth with
data from the 2009 Mozambique AIDS Indicator Survey. I excluded from
analysis children under age 12 who had HIV seropositive biological
mothers. I coded children and youth as exposed to circumcision or
scarification only if it had occurred within the prior 10 years.
Results: Circumcised
and scarified children and youth
were two to three times
more likely to be infected with HIV than children and youth who had not
been circumcised
or scarified, respectively. Circumcision and scarification were each
associated with HIV infection for both virgins and sexually experienced
youth. Males circumcised by medical
doctors were almost as likely to be infected as those circumcised by
traditional circumcisers. Circumcision and scarification
were also independently associated with HIV infection in males.
Conclusions: To determine modes of HIV
transmission with confidence,
researchers must employ more rigorous research designs than have been
used to date in sub-Saharan Africa. In the meantime, Mozambicans and
other Africans should be warned about all risks of blood-borne HIV
transmission, including scarification and medical and traditional
circumcision, and informed about how these risks can be avoided.
-
|
No protection to Australians
Australian and New Zealand Journal of Public
Health, 35: 459–465.
doi: 10.1111/j.1753-6405.2011.00761.x
Not a surgical vaccine: there is no case
for boosting infant male
circumcision to combat heterosexual transmission of HIV in Australia
Robert Darby, Robert Van Howe
Abstract
Objective: To conduct a
critical review of recent proposals
that widespread circumcision of male infants be introduced in Australia
as a means of combating heterosexually transmitted HIV infection.
Approach: These arguments are
evaluated in terms of their
logic, coherence and fidelity to the principles of evidence-based
medicine; the extent to which they take account of the evidence for
circumcision having a protective effect against HIV and the
practicality of circumcision as an HIV control strategy; the extent of
its applicability to the specifics of Australia's HIV epidemic; the
benefits, harms and risks of circumcision; and the associated human
rights, bioethical and legal issues.
Conclusion: Our conclusion is
that such proposals ignore
doubts about the robustness of the evidence from the African
random-controlled trials as to the protective effect of circumcision
and the practical value of circumcision as a means of HIV control;
misrepresent the nature of Australia's HIV epidemic and exaggerate the
relevance of the African random-controlled trials findings to it;
underestimate the risks and harm of circumcision; and ignore questions
of medical ethics and human rights. The notion of circumcision as a
‘surgical vaccine’ is criticised as polemical and unscientific.
Implications: Circumcision of
infants or other minors has no
place among HIV control measures in the Australian and New Zealand
context; proposals such as these should be rejected.
|
J Sex Med. 2012 Aug 15. doi:
10.1111/j.1743-6109.2012.02871.x. [Epub ahead of print]
More than Foreskin: Circumcision Status,
History of HIV/STI, and Sexual Risk in a Clinic-Based Sample of Men in
Puerto Rico.
Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG,
Vargas-Molina RL, Goldsamt LA, García H.
Abstract
Introduction. Circumcision
among adult men has been widely
promoted as a strategy to reduce human immunodeficiency virus (HIV)
transmission risk. However, much of the available data derive from
studies conducted in Africa, and there is as yet little research in the
Caribbean region where sexual transmission is also a primary
contributor to rapidly escalating HIV incidence.
Aim. In an effort to fill the
void of data from the
Caribbean, the objective of this article is to compare history of
sexually transmitted infections (STI) and HIV diagnosis in relation to
circumcision status in a clinic-based sample of men in Puerto Rico.
Methods. Data derive from an
ongoing epidemiological study
being conducted in a large STI/HIV prevention and treatment center in
San Juan in which 660 men were randomly selected from the clinic's
waiting room.
Main Outcome Measures. We
assessed the association between
circumcision status and self-reported history of STI/HIV infection
using logistic regressions to explore whether circumcision conferred
protective benefit.
Results. Almost a third (32.4%)
of the men were circumcised
(CM). Compared with uncircumcised (UC) men, CM have accumulated larger
numbers of STI in their lifetime (CM = 73.4% vs. UC = 65.7%; P =
0.048), have higher rates of previous diagnosis of warts (CM = 18.8%
vs. UC = 12.2%; P = 0.024), and were
more likely to have HIV infection (CM = 43.0% vs. UC = 33.9%; P = 0.023). Results
indicate that being CM predicted the likelihood of HIV infection (P
value = 0.027).
Conclusions. These analyses represent
the first assessment of
the association between circumcision and STI/HIV among men in the
Caribbean. While preliminary, the data indicate that in and of itself,
circumcision did not confer significant protective benefit against
STI/HIV infection. [Actually,
what the the data indicate is that intactness
confers significant protection, compared to being circumcised.]
Findings suggest the need to apply caution in the use of circumcision
as an HIV prevention strategy, particularly in settings where more
effective combinations of interventions have yet to be fully
implemented. [They
actually suggest that circumcision should not
be used because it is not
a prevention strategy.]
...
|
Journal of the International AIDS Society Vol 18, No 1 (2015)
Risk factors for HIV infection among circumcised men in Uganda: a
case-control study
Michael
Ediau, Joseph KB Matovu, Raymond Byaruhanga, Nazarius M Tumwesigye,
Rhoda K Wanyenze
[None of the usual suspects for
Uganda, Bailey, Quinn or Wawer]
Abstract
Introduction: Male circumcision (MC) reduces the risk of
HIV infection. [Om mane padme hum] However, the risk reduction effect
of MC can be modified by type of circumcision (medical, traditional and
religious) and sexual risk behaviours post-circumcision. Understanding
the risk behaviours associated with HIV infection among circumcised men
(regardless of form of circumcision) is critical to the design of
comprehensive risk reduction interventions. This study assessed risk
factors for HIV infection among men circumcised through various
circumcision approaches.
Methods: This was a case-control study which enrolled 155
cases (HIV-infected) and 155 controls (HIV-uninfected), all of whom
were men aged 18–35 years presenting at the AIDS Information Center for
HIV testing and care. The outcome variable was HIV sero-status. Using
SPSS version 17, multivariable logistic regression was performed to
identify factors independently associated with HIV infection.
Results: Overall, 83.9% among cases and 56.8% among
controls were traditionally circumcised; 7.7% of cases and 21.3% of
controls were religiously circumcised while 8.4% of cases and 21.9% of
controls were medically circumcised. A higher proportion of cases than
controls reported resuming sexual intercourse before complete wound
healing (36.9% vs. 14.1%; p<0.01). Risk factors for HIV
infection prior to circumcision were:being in a polygamous marriage
(AOR: 6.6, CI: 2.3–18.8) and belonging to the Bagisu ethnic group (AOR:
6.1, CI: 2.6–14.0). After circumcision, HIV infection was associated
with: being circumcised at >18 years (AOR: 5.0, CI: 2.4–10.2);
resuming sexual intercourse before wound healing (AOR: 3.4, CI:
1.6–7.3); inconsistent use of condoms (AOR: 2.7, CI: 1.5–5.1); and
having sexual intercourse under the influence of peers (AOR: 2.9, CI:
1.5–5.5). Men who had religious circumcision were less likely to have
HIV infection (AOR: 0.4, 95% CI: 0.2–0.9) than the traditionally
circumcised but there
was no statistically significant difference between those who were
traditionally circumcised and those who were medically circumcised
(AOR: 0.40, 95% CI: 0.1–1.1).
[So much for the claim
that medical genital cutting protects more than traditional - which was
used to explain the complete lack of connection between cutting and HIV
that USAID found.]
Conclusions: Being circumcised at adulthood, resumption of
sexual intercourse before wound healing, inconsistent condom use and
having sex under the influence of peers were significant risk factors
for HIV infection. Risk reduction messages should address these risk
factors, especially among traditionally circumcised men.
[Why especially them? They've
just
established that traditional cutting is no different from medical
cutting! Or are they admitting that it's the accidental circumstances
around medical cutting, the setting, the indoctrination, the "medical
ritual" that impresses the safe sex message on those men, and it is
really acting on that message that protects them, and not the cutting
itself?]
|
PLOS Medicine
HIV Shedding from Male Circumcision Wounds in
HIV-Infected Men: A Prospective Cohort Study
Aaron A. R. Tobian,
Godfrey Kigozi,
Jordyn Manucci,
Mary K. Grabowski,
David Serwadda,
Richard Musoke,
Andrew D. Redd,
Fred Nalugoda,
Steven J. Reynolds,
Nehemiah Kighoma,
Oliver Laeyendecker,
Justin Lessler,
Ronald H. Gray,
[ ... ],
Published: April 28, 2015
DOI: 10.1371/journal.pmed.1001820
Abstract
Background
A randomized trial of voluntary medical male circumcision (MC) of
HIV—infected men reported increased
HIV transmission to female partners
among men who resumed sexual intercourse prior to wound healing. We
conducted a prospective observational study to assess penile HIV
shedding after MC.
Methods and Findings
HIV shedding was evaluated among 223 HIV—infected men (183
self—reported not receiving antiretroviral therapy [ART], 11
self—reported receiving ART and had a detectable plasma viral load
[VL], and 29 self—reported receiving ART and had an undetectable plasma
VL [<400 copies/ml]) in Rakai, Uganda, between June 2009 and
April 2012. Preoperative and weekly penile lavages collected for 6 wk
and then at 12 wk were tested for HIV shedding and VL using a real—time
quantitative PCR assay. Unadjusted prevalence risk ratios (PRRs) and
adjusted PRRs (adjPRRs) of HIV shedding were estimated using modified
Poisson regression with robust variance. HIV shedding was detected in
9.3% (17/183) of men not on ART prior to surgery and 39.3% (72/183) of
these men during the entire study. Relative to baseline, the proportion
shedding was significantly increased after MC at 1 wk (PRR
= 1.87, 95%
CI = 1.12–3.14, p = 0.012), 2 wk (PRR = 3.16, 95% CI = 1.94–5.13, p
< 0.001), and 3 wk (PRR = 1.98, 95% CI = 1.19–3.28, p = 0.008)
after MC. However, compared to baseline, HIV shedding was decreased by
6 wk after MC (PRR = 0.27, 95% CI = 0.09–0.83, p = 0.023) and remained
suppressed at 12 wk after MC (PRR = 0.19, 95% CI = 0.06–0.64, p =
0.008). Detectable HIV shedding from MC wounds occurred in more study
visits among men with an HIV plasma VL > 50,000 copies/ml than
among those with an HIV plasma VL < 400 copies/ml (adjPRR =
10.3, 95% CI = 4.25–24.90, p < 0.001). Detectable HIV shedding
was less common in visits from men with healed MC wounds compared to
visits from men without healed wounds (adjPRR = 0.12, 95% CI =
0.07–0.23, p < 0.001) and in visits from men on ART with
undetectable plasma VL compared to men not on ART (PRR = 0.15, 95% CI =
0.05–0.43, p = 0.001). Among men with detectable penile HIV shedding,
the median log10 HIV copies/milliliter of lavage fluid was
significantly lower in men with ART—induced undetectable plasma VL
(1.93, interquartile range [IQR] = 1.83–2.14) than in men not on ART
(2.63, IQR = 2.28–3.22, p < 0.001). Limitations of this
observational study include significant differences in baseline
covariates, lack of confirmed receipt of ART for individuals who
reported ART use, and lack of information on potential ART initiation
during follow—up for those who were not on ART at enrollment.
Conclusion
Penile HIV shedding is significantly reduced after healing of MC
wounds. Lower plasma VL is associated with decreased frequency and
quantity of HIV shedding from MC wounds. Starting ART prior to MC
should be considered to reduce male-to-female HIV transmission risk.
Research is needed to assess the time on ART required to decrease
shedding, and the acceptability and feasibility of initiating ART at
the time of MC.
Editors' Summary
Background
About 35 million people are currently infected with HIV, the virus that
causes AIDS by destroying immune system cells, and every year, 2
million more people become HIV-positive. Antiretroviral therapy (ART)
can keep HIV in check, but there is no cure for AIDS. Consequently,
prevention of HIV acquisition and transmission is an important
component of efforts to control the AIDS epidemic. Because HIV is most
often spread through unprotected sex with an infected partner,
individuals can reduce their risk of becoming HIV-positive by
abstaining from sex, by having only one or a few partners, and by using
male or female condoms. In addition, three trials undertaken in
sub-Saharan Africa a decade ago showed that male circumcision—the
surgical removal of the foreskin, a loose fold of skin that covers the
head of the penis—can halve the HIV acquisition rate in men. Thus,
since 2007, the World Health Organization (WHO) has recommended
voluntary medical male circumcision for individuals living in countries
with high HIV prevalence as part of its HIV prevention strategy.
Why Was This Study Done?
With the rollout of voluntary medical male circumcision programs,
circumcision has become more normative (regarded as acceptable), and
HIV-positive men are increasingly requesting circumcision because they
want to avoid any stigma associated with being uncircumcised and
because circumcision provides health benefits. WHO recommends that,
although circumcision should not be promoted for HIV-positive men,
voluntary circumcision programs should operate on HIV-positive men if
they request circumcision. However, in a trial of circumcision of
HIV-infected men, HIV transmission to their female partners increased
if the couples had sexual intercourse before the circumcision wound had
healed. Moreover, in studies of current male circumcision programs,
two-thirds of married men and a third of all men reported that they
resumed sexual intercourse before their circumcision wounds had healed.
Thus, better understanding of how male circumcision increases HIV
transmission to female partners is essential, and improved ways to
prevent transmission in the post-surgical period are needed. Here, in a
prospective observational study (an investigation that collects data
over time from people undergoing a specific procedure), the researchers
assess HIV shedding from the penis after circumcision.
What Did the Researchers Do and
Find?
The researchers evaluated penile HIV shedding among 223 HIV-infected
men (183 men who self-reported not being on ART and 40 men who
self-reported being on ART, 29 of whom had no detectable virus in their
blood) living in Rakai, Uganda, by examining preoperative and
postoperative penile lavage (wash) samples. Viral shedding was detected
in 9.3% of the men not on ART before surgery and in 39.3% of these men
during the entire study. Relative to baseline, a greater proportion of
men shed virus at one, two, and three weeks after circumcision, but a
lower proportion shed virus at six and twelve weeks after circumcision.
HIV shedding was more frequent among men with a high amount of virus in
their blood (a high viral load) than among men with a low viral load.
Moreover, the frequency of HIV shedding was lower in visits from men
with healed circumcision wounds than in visits from men with unhealed
wounds, and in visits from men on ART with no detectable virus in their
blood than in visits from men not on ART men. Finally, among men with
detectable penile HIV shedding, men on ART with no detectable virus in
their blood shed fewer copies of virus than men not on ART.
What Do These Findings Mean?
The findings suggest that healed circumcision wounds are associated
with reduced penile HIV shedding in HIV-positive men compared to
unhealed circumcision wounds and HIV shedding prior to circumcision. [They only consider male HIV
shedding in transmission to women, not any possible effect of the
keratinised glans rubbing over the vaginal surface on HIV reception.]
In
addition, they suggest that a lower HIV viral load in the blood is
associated with a decreased frequency and quantity of HIV shedding from
circumcision wounds. Because this was an observational study, these
findings cannot prove that healed wounds or reduced blood viral load
actually caused reduced penile HIV shedding. Moreover, the accuracy of
these findings may be affected by the lack of information on ART
initiation during follow-up among men not initially on ART and by
reliance on ART self-report. Nevertheless, these
findings highlight the importance of counseling HIV-positive men
undergoing circumcision to avoid sexual intercourse until their
circumcision wound heals. In addition, these findings
suggest that it might be possible
to reduce HIV transmission among HIV-positive men immediately after
circumcision by starting these individuals on ART before circumcision.
Further research is needed to assess how long before circumcision ART
should be initiated and to assess the acceptability and feasibility of
initiating ART concurrent with circumcision.
[But never for
a moment do they consider NOT CUTTING HIV-POSITIVE MEN! It is TOO
LATE to protect them. One reason they have given for doing so is that
they do not want the men to be stigmatised as HIV-positive if they are
not cut. But if people refuse to have sex with them, that too will help
to prevent the spread of HIV. The question arises "What is their true
motivation - to prevent the spread of HIV, or to promote the spread of
male genital cutting?]
|
Insufficient evidence of protection before the RCTs
A Cochrane
Review of HIV-circumcision studies finds:
"Despite
the positive results of a number of observational studies, there are
not yet sufficient grounds to conclude that male circumcision, as a
preventive strategy for HIV infection, does more good than harm."
"Circumcision
itself may be a proxy measure of the knowledge and behaviour learnt
during initiation, when young men are taught about traditional sexual
practices, including monogamy and penile hygiene."
"Selection
bias was problematic in all studies, and results were potentially
confounded by other risk factors for transmission of HIV such as sexual
behaviour and religion. Circumcised and uncircumcised groups (in cohort
and cross-sectional studies) and HIV-positive and HIV-negative groups
(in case-control studies) were seldom balanced for all or most of the
10 risk factors that we identified as potential confounders prior to
quality assessment."
- "Age
- Sexual behaviour
- Location of trial
- Religion
- Education, occupation, socio-economic status
- Sexual behaviour – measured by age at first
intercourse, number of sexual
partners, contact with sex workers
- Any sexually transmitted infections
- Condom use
- Migration status, travel to different countries
- Other possible exposures, e.g. injection, blood
transfusions"
"As HIV is related
to sexual behaviour, which may in turn be partly determined by culture
and religion, strong confounding factors in these studies seem likely."
"It is
important to note that observational
studies, unlike R[andom] C[ontrolled] T[rial]s, can only adjust for
known confounders, and only then if they are measured without error.
The effect of unknown confounders may
well be operating in either direction within and across all of the
included
studies."
The
Medical Research Council of South Africa has a
good summary of it.
|
Only cautious support after the RCTs
Another Cochrane review cautiously supported a
protective effect:
Siegfried
N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of
heterosexual acquisition of HIV in men. Cochrane Database of Systematic
Reviews 2009, Issue 2. Art. No.: CD003362. DOI:
10.1002/14651858.CD003362.pub2
There
is strong evidence that medical male circumcision reduces the
acquisition of HIV by heterosexual men by between 38% and 66% over 24
months. Incidence of adverse events is very low, indicating that male
circumcision, when conducted under these conditions, is a safe
procedure. Inclusion of male circumcision into current HIV prevention
measures guidelines is warranted, with further
research required to assess the feasibility, desirability, and
cost-effectiveness of implementing the procedure within
local contexts.
While the Cochrane
reviews are highly regarded, this one appears to have done no more than
added in, at face value, the three RCTs, whose faults are detailed on another page.
|
A warning against excessive reliance on RCTs
BMC Medical Research Methodology 2011, 11:34
doi:10.1186/1471-2288-11-34
What counts as reliable evidence for
public
health policy: the case of
circumcision for preventing HIV infection
Reidar K Lie and Franklin G Miller
Abstract (provisional)
Background
There is an ongoing controversy over the relative merits of randomized
controlled trials (RCTs) and non-randomized observational studies in
assessing efficacy and guiding policy. In this paper we examine male
circumcision to prevent HIV infection as a case study that can
illuminate the appropriate role of different types of evidence for
public health interventions.
Discussion
Based on an analysis of two Cochrane reviews, one published in 2003
before the results of three RCTs, and one in 2009, we argue that if we
rely solely on evidence from RCTs and exclude evidence from
well-designed non-randomized studies, we limit our ability to provide
sound public health recommendations. Furthermore, the bias in favor of
RCT evidence has delayed research on policy relevant issues.
Summary
This case study of circumcision and HIV prevention demonstrates that if
we rely solely on evidence from RCTs and exclude evidence from
well-designed non-randomized studies, we limit our ability to provide
sound public health recommendations.
[The
authors
are at (excessive?) pains not
to challenge the circumcision-HIV claims, but they point to many of the
same holes in the RCTs that Intactivists do, and make the point that
the second Cochrane review simply ignored all studies prior to the RCTs
and hence the negative conclusion of the first Cochrane review.]
|
Hospital-cut
men more likely to have HIV
PLOS Published: August 1, 2018
https://doi.org/10.1371/journal.pone.0201445
Are circumcised men safer
sex partners? Findings from the HAALSI cohort in rural South Africa
Molly S. Rosenberg,
Francesc X. Gómez-Olivé,
Julia K. Rohr,
Kathleen Kahn,
Till W. Bärnighausen
Abstract
Introduction
The real-world association between male
circumcision and HIV status has important implications for policy and
intervention practice. For instance, women may assume that circumcised
men are safer sex partners than non-circumcised men and adjust sexual
partnering and behavior according to these beliefs. Voluntary medical
male circumcision (VMMC) is highly efficacious in preventing HIV
acquisition in men and this biological efficacy should lead to a
negative association between circumcision and HIV. However, behavioral
factors such as differential selection into circumcision based on
current HIV status or factors associated with future HIV status could
reverse the association. Here, we examine how HIV prevalence differs by
circumcision status in older adult men in a rural South African
community, a non-experimental setting in a time of expanding VMMC
access.
Methods
We analyzed data collected from a population-based
sample of 2345 men aged 40 years and older in a rural community served
by the Agincourt Health and socio-Demographic Surveillance System site
in Mpumalanga province, South Africa. We describe circumcision
prevalence and estimate the association between circumcision and
laboratory-confirmed HIV status with log-binomial regression
models.
Results
One quarter of older men reported circumcision,
with slightly more initiation-based circumcisions (56%) than
hospital-based circumcisions (44%). Overall, the evidence did not suggest differences in
HIV prevalence between circumcised and uncircumcised men;
however, those who reported
hospital-based circumcision were more likely [than intact men]
to test HIV-positive [PR (95% CI): 1.28 (1.03, 1.59)]
while those who reported initiation-based circumcision were less likely
to test HIV-positive [PR (95% CI): 0.68 (0.51, 0.90)]. Effects were
attenuated, but not reversed after adjustment for key
covariates.
[Notice
that the first two bars by themselves are very misleading, in view of
what the next three show.]
Conclusions
Medically
circumcised older men in a rural South African community had higher HIV
prevalence than uncircumcised men, suggesting that the effect of selection into circumcision
may be stronger than the biological efficacy of circumcision [if
any] in
preventing HIV acquisition. The impression given from
circumcision policy and dissemination of prior trial findings that
those who are circumcised are safer sex partners may be [no, is, dangerously]
incorrect in
this age group and needs to be countered by interventions, such as
educational campaigns.
|
Other
studies
showing no correlation, or a negative correlation between intactness
and HIV.
Where
circumcision doesn't prevent AIDS
Country
|
% of men
circumcised
|
% HIV prevalence in
|
Adults
|
Circumcised
men
|
Uncircumcised
men
|
Burkina Faso
|
88
|
1.8
|
1.8
|
2.9
|
Cameroon
|
93
|
5.5
|
4.1
|
1.1
|
Cote d'Ivoire
|
96
|
4.7
|
2.8
|
3.8
|
Ethiopia*
|
91
|
1.4
|
0.9
|
1.1
|
Ghana
|
95
|
2.2
|
1.6
|
1.4
|
Kenya
|
83
|
6.7
|
3.0
|
12.6
|
Lesotho
|
49
|
23.5
|
22.8
|
15.2
|
Malawi
|
20
|
11.8
|
13.2
|
9.5
|
Rwanda
|
9
|
3.0
|
3.5 (2010 2.5)
|
2.1 (2010 2.2)
|
Swaziland
|
8.1
|
25.9
|
21.8
|
19.5
|
Tanzania
|
69
|
7.0
|
6.5
|
5.6
|
Uganda
|
25
|
6.4
|
3.8
|
5.6
|
Source: National surveys, available at: www.measuredhs.com/countries/
|
* The HIV rate for Ethiopia is probably underreported,
according to the UN. Circumcision is almost universal.
Swaziland, with its low circumcision rate and high HIV
rate,
is
often cited as place where circumcision is urgently needed, but these
figures show circumcision would do little good and might do harm.
A more recent survey, with more countries
United States Agency for International
Development (USAID)
February 2009
LEVELS AND SPREAD OF HIV
SEROPREVALENCE AND ASSOCIATED
FACTORS: EVIDENCE FROM NATIONAL
HOUSEHOLD SURVEYS
DHS COMPARATIVE
REPORTS 22
There appears to be no
clear pattern of association between male circumcision and HIV
prevalence. In 8 of 18 countries with data, as expected,
HIV prevalence is lower among circumcised men, while in the remaining 10 countries HIV
prevalence is higher among circumcised men ...
Findings from the 18 countries with data present a
mixed
picture of
the association between male circumcision and HIV prevalence (Table
9.3). In eight of the countries (Burkina Faso, Cambodia, Côte d'Ivoire,
Ethiopia, Ghana, India, Kenya, and Uganda), HIV prevalence is higher
among men who are not circumcised, although the
difference between circumcised and non-circumcised men is slight,
except in Kenya,
where the difference is substantial (HIV prevalence of 11.5 percent for
non-circumcised men compared with 3.1 percent for circumcised men)
(Figure 9.1). In 10 of the countries (Cameroon, Guinea, Haiti, Lesotho,
Malawi, Niger, Rwanda, Senegal, Tanzania, and Zimbabwe) HIV prevalence
is higher among circumcised men.
p123
|
Table 9.3. HIV
prevalence
among men age 15-49, by male circumcision |
|
Male circumcision |
Country/sex |
No |
Yes |
Total |
Burkina Faso 2003 |
Male [%] |
2.9 |
1.7 |
1.9 |
Number |
334 |
2,731 |
3,065 |
Cambodia 2005 |
Male [%] |
0.6 |
0.0 |
0.6 |
Number |
6,517 |
138 |
6,656 |
Cameroon 2004 |
Male [%] |
1.3 |
4.3 |
4.1 |
Number |
317 |
4,298 |
4,615 |
Côte d'Ivoire 2005 |
Male [%] |
3.5 |
2.8 |
2.9 |
Number |
173 |
3,850 |
4,023 |
Ethiopia 2005 |
Male [%] |
1.2 |
0.9 |
0.9 |
Number |
384 |
4,420 |
4,804 |
Ghana 2003 |
Male [%] |
1.7 |
1.4 |
1.5 |
Number |
181 |
3,864 |
4,045 |
Guinea 2005 |
Male [%] |
0.0 |
1.0 |
0.9 |
Number |
18 |
2,558 |
2,577 |
Haiti 2005 |
Male [%] |
1.9 |
3.9 |
2.0 |
Number |
4,071 |
243 |
4,321 |
India 2005/06 |
Male [%] |
0.4 |
0.2 |
0.4 |
Number |
40,340 |
5,818 |
46,506 |
Kenya 2003 |
Male [%] |
11.5 |
3.1 |
4.6 |
Number |
475 |
2,372 |
2,851 |
Lesotho 2004/05 |
Male [%] |
15.4 |
23.4 |
19.2 |
Number |
1,046 |
951 |
2,001 |
Malawi 2004 |
Male [%] |
9.4 |
13.2 |
10.2 |
Number |
1,906 |
500 |
2,405 |
Niger 2006 |
Male [%] |
0.0 |
0.8 |
0.8 |
Number |
14 |
2,841 |
2,856 |
Rwanda 2005 |
Male [%] |
2.1 |
3.8 |
2.3 |
Number |
3,908 |
418 |
4,348 |
Senegal 2005 |
Male [%] [%] |
0.0 |
0.5 |
0.5 |
Number |
56 |
3,124 |
3,183 |
Tanzania 2003/04 |
Male [%] [%] |
5.6 |
6.5 |
6.3 |
Number |
1,529 |
3,463 |
4,994 |
Uganda 2004/05 |
Male [%] [%] |
5.5 |
3.7 |
5.1 |
Number |
5,613 |
1,858 |
7,477 |
Zimbabwe 2005 |
Male [%] |
14.2 |
16.6 |
14.5 |
Number |
5,235 |
597 |
5,848 |
Note: HIV prevalence estimates
for
‘not circumcised’ men for Guinea and Niger are based on small numbers
of cases |
... data has since become available for Mozambique
and
Zambia.
In both cases, HIV prevalence is higher among those uncircumcised. Data
also became available for Swaziland,
which showed that HIV prevalence is
higher among those who are circumcised.
Second, in the case of Tanzania, the earlier USAID
report states
that prevalence is higher among those who are circumcised. A more
recent study indicates the opposite, with HIV prevalence being 3.7%
among the circumcised and 6.4% among the uncircumcised.
Third, of the 14 countries where male circumcision
is
being promoted
(Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia,
Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and
Zimbabwe), there is no recent DHS data about male circumcision and HIV
prevalence for 3 of them (Botswana, South Africa and Namibia). Of the
11 countries where there is data, 5
of them have higher HIV prevalence among the circumcised
(Lesotho, Malawi, Rwanda, Swaziland and Zimbabwe) and 6 have higher HIV
prevalence among the uncircumcised (Ethiopia, Kenya, Mozambique,
Tanzania, Uganda and Zambia).
Those who support circumcision argue that at least
in
Lesotho and
Malawi, partial circumcision is practiced, which may explain the
results in those two countries. Also in Rwanda, the data indicates that
if you look only in urban areas, circumcision is actually partially
protective (even though in the country as a whole, it appears not to
be). [More data-mining.]
- LSTM1 in ZimEye, December 29, 2011
[Clearly
the
results are still mixed, with
nothing like the clear correlations you would expect if circumcision
really did reduce HIV by anything like "60%"]
|
Between
Correlation and Recommendation
"Circumcision
status should be viewed as a proxy for other aspects of human behavior.
Unless one can control for these aspects, one cannot draw reliable
conclusions about the causative status of the presence or absence of a
foreskin on the course of medical disease processes."
-
Dr Anne Laumann
in a letter
to Archives of Dermatology
|
Several intermediate steps need to be taken, between the
association
shown in some (not all) studies and recommending general circumcision
as a preventative measure. Married men in Africa have a higher rate of
HIV infection than single men, but so far no one has called for the
abolition of marriage. The proofs of links to circumcision and to
marriage are similar, but first
- the association needs to be clearly
established (in the case of circumcision, some think it has been, but
many think it has not). Then
- a case for causality needs to be made (it falls
short).
Then
- a cost-utility estimate needs to be done to see if it
is
feasible, and, if so,
- under what conditions. Then
- a randomised trial needs to be performed. Finally, if
all
of those items fall into place, only then can one reasonably
- make the call for universal or selective
circumcision.
J Med Ethics 2010;36:798-801
doi:10.1136/jme.2010.038695
HIV/AIDS and circumcision: lost in translation
Marie Fox and Michael Thomson
Abstract
In April 2009 a Cochrane review was published assessing the
effectiveness of male circumcision in preventing acquisition of HIV. It
concluded that there was strong evidence that male circumcision,
performed in a medical setting, reduces the acquisition of HIV by men
engaging in heterosexual sex. Yet, importantly, the review noted that
further research was required to assess the feasibility, desirability
and cost-effectiveness of implementation within local contexts. This
paper endorses the need for such research and suggests that, in its
absence, it is premature to promote circumcision as a reliable strategy
for combating HIV. Since articles in leading medical journals as well
as the popular press continue to do so, scientific researchers should
think carefully about how their conclusions may be translated both to
policy makers and to a more general audience. The importance of
addressing ethico-legal concerns that such trials may raise is
highlighted. The understandable haste to find a solution to the HIV
pandemic means that the promise offered by preliminary and specific
research studies may be overstated. This may mean that ethical concerns
are marginalised. Such haste may also obscure the need to be attentive
to local cultural sensitivities, which vary from one African region to
another, in formulating policy concerning circumcision.
|
A
Vaccine? Hardly!
Australian
Doctor
November, 2005
Circumcision equal to a vaccine for HIV
by Rebecca Jenkins
CIRCUMCISION offers the same level of protection
against
HIV
infection in heterosexual men as a highly effective vaccine, according
to a landmark study. In the first randomised controlled trial of its
kind, researchers found circumcision provided 60%
protection against the virus, confirming the results of a large body of
observational studies.
|
A vaccine of high efficacy is expected to offer
long-term protection of 95%
or above.
Smallpox was eradicated with such a highly efficient vaccine. If
control
of tetanus, measles, and poliomyelitis has been largely achieved in the
world, it has been a result of high-efficacy vaccines. ...
A 96%-efficient measles vaccine
means that 96% of vaccinated persons exposed to measles are indeed
protected against infection. Protection lasts for many years, and
revaccination permits dealing with loss of immunity over time. What
Auvert
and colleagues show is ... a
60% reduction in disease
incidence over an 18-month period among circumcised men compared with
uncircumcised men with similar exposure. To our knowledge, this does
not
mean that those men are really "protected" against HIV, especially in
the
case of repeated exposure. It simply means "reduced risk," or reduced
probability of contamination.
- Michel Garenne, Male Circumcision and
HIV Control in Africa
In a text for upper division and/or graduate study
of
immunology, a table
gives the percentage of reduction obtained by vaccines for the diseases
modern societies associate with successful
immunization programs.
Smallpox,
diphtheria,
and polio vaccinations
resulted in 100%
reduction
of incidence. Vaccination against measles,
Mumps, and rubella (German
measles) resulted in >99%
reduction of incidence. Tetanus
(lockjaw) was
reduced by more than 98%;
Pertussis
(whooping cough) by more than 87%.
(No vaccines that reduced incidence by as little
as 70%
were
included in the table.)
- Kindt, Thomas J, Goldsby,
R.A.,
and Osborne, B.A.
(Kuby) Immunology (6th
Ed), New York: W.H. Freeman, 2007.
[Kindt - NIH, Goldsby - Amherst
College, Osborne - UMass, Amherst]
|
A
Solution Looking For A Problem
The question arises, why have so many studies been done
apparently looking for this correlation (and prematurely making the
recommendation)? For over a hundred years, circumcision has been a
solution looking for a problem, and the problem has typically been the
most frightening disease (or "disease") of the day -
- "masturbation insanity" in the 19th century,
- then tuberculosis,
- Sexually Transmitted Diseases (then called Venereal
Disease
or VD) after World War I,
- penile cancer
in the 1930s, and
- cervical
cancer
in the 1950s, when cancers were terrifyingly untreatable,
- Urinary Tract
Infections
from 1982 onward,
- and now HIV.
Today's calls are just the latest in a long series, and
no
better founded than those.
Ethics
As ethicist Dr Margaret Somerville (Gale professor of
law and
a
professor in the faculty of medicine at the McGill Centre for Medicine,
Ethics and Law) says:
"...even
assuming that reducing the risk of HIV transmission could be a
justification for infant male circumcision, this justification would
not be available until it became at least more likely than not that
circumcision would reduce the risk of HIV transmission.
"...even assuming that circumcision could help to
protect
against HIV infection, it would not be necessary to carry it out on
unconsenting infants. One could wait until the person was about to
become sexually active and could decide for himself.
"...one is ethically required to use the least
harmful,
least
invasive means of achieving a good, the achievement of which involves
harm. Consequently, a surgical intervention aimed at preventing the
spread of HIV could only be justified if there were no other reasonable
way to achieve this. And, even if circumcision helped to
protect people in developing countries from the spread of HIV, we would
not be justified in carrying this out for this purpose in developed
countries, where other, better means of protection are much more
readily available."
- The Gazette,
Montreal, October 24, 1998, pB6
|
the Role of
the
Mucosa
Circumcisionists have added to the meme-pool the
"explanation"
that
the foreskin has a peculiar role in HIV transmission. (This focuses on
the Langerhans cells, yet on scanty evidence and through contradictory mechanisms.)
Yet the genital mucosa have an important role in preventing
transmission:
Models of
Protection Against HIV/SIV: Avoiding AIDS in Humans and Monkeys
Edited by Gianfranco Pancino, Guido Silvestri and
Keith
Fowke
Chapter 5 – The Genital
Mucosa, the Front Lines in the Defense Against HIV
T. Blake Ball, Kristina Broliden
Summary
Mucosal sexual transmission of HIV now accounts for the majority of
transmission worldwide, and occurs at the genital tract. However,
relative to what is known about systemic correlates of protection, less
is known about innate and adaptive immune responses capable of
affecting HIV transmission at this site. The
protective efficacy of immune mechanisms at the genital tract,
especially the female genital tract, has been estimated to stop the
vast majority of HIV transmission across an intact and uninflamed
mucosal surface, indicating a protective efficacy of almost 99 percent
– much greater than any biomedical intervention described to
date.
There is considerable evidence that individuals who appear to be
naturally protected from HIV infection may be protected from HIV
infection at this site. In this
chapter we will
discuss the physiologic features of the genital mucosa, the underlying
cells susceptible to HIV transmission and replication, and the role of
innate and adaptive immune responses at this site in protecting against
HIV infection in highly HIV-exposed, uninfected subjects.
|
"Dry
Sex"
Meanwhile, an explanation seems to be to hand: "dry sex"
- the
use by women of herbal and other astringents to dry their vaginas.
Wet, Dry, Man, Woman: Heterosexuals and Anal Sex
formerly at http://hivinsite.ucsf.edu/
Wet/Dry and Tight/Loose
DH: We ... encountered a notion
of
"dry sex" that appears to be shared in Haiti, the
country with which the Dominican Republic shares an island, as well as
various parts of Africa. It's complex and it varies from place to
place,
but the basic idea is that sex should be very tight and should be dry.
In
the Dominican Republic, I couldn't help but begin to think that maybe
that
was part of the appeal for anal sex, both bisexual male anal sex and
heterosexual anal sex. Particularly if, as you say, women have given
birth
and so on. A lot of women there and in countries like Brazil will have
operations to tighten the vaginal opening. There's actually a surgical
procedure in the Dominican Republic that translates as "the cut that
makes
the husband happy." It's basically a tightening of the vagina after the
woman has given birth.
Given this notion that sex should be tight,
there's
potentially an interaction with the foreskin there, because we seem to mainly find dry sex practices in
areas where most men are not circumcised. One explanation
may be that circumcised men don't have the lubricative mechanism of the
foreskin rolling back and forth across the glans. Presumably, it would
be quite painful and uncomfortable for most men to
have dry sex if they are circumcised. But uncircumcised
men in the
Domincan Republic and in parts of Africa commonly report tearing and
bleeding of the foreskin during dry sex. ...
|
"Dry sex practices appear to be primarily
restricted to certain predominately non-male[-]circumcising regions of
eastern and southern Africa, including many of the countries reporting
the world's highest HIV seroprevalence (for example, Zimbabwe,
Botswana, Zambia, Malawi). Presumably, such practices would appear to
be less appealing to the drier (non-prepucial secreting) circumcised
males of western Africa or other regions. Reportedly, very few men in
the Dominican Republic or Haiti [where dry sex is also widely
practised] have been circumcised . . . ."
Halperin,
Daniel T. Dry sex practices and HIV infection in the Dominican Republic
and Haiti. Sexually Transmitted Infections 1999; 75:445-446.
|
The role of delayed washing after sex
April 16, 2012
16 April 2012
By David
Gisselquist
In 2003-06, a study team funded by the US National
Institutes of
Health (NIH) recruited HIV-negative intact (uncircumcised) men in
Rakai, Uganda, circumcised some, and then followed and retested both
circumcised and intact men to see who got HIV.[1] The most widely
reported data from this study say that men in the intervention
(circumcised) group got HIV at the rate of 0.66% per year vs. 1.33% per
year for men in the control (intact) group. These data have been used
to motivate efforts to circumcise 20 million African adults by 2015 as
well as to introduce routine infant circumcision.
Circumcise vs. wait and wipe
However, other data from the same study show a more effective, less
dangerous, less culturally intrusive, and less expensive option for
intact men to protect themselves from HIV after sexual contact – simply
waiting at least 10 minutes after coitus before doing anything to clean
one’s penis, and then just wiping it with a dry cloth, without water
(Table). (Condom use reliably protects men from acquiring HIV from
sexual partners; this note discusses waiting and wiping as an
alternative to circumcision, not as an alternative to condom use.)
|
Alcohol
One confounding factor that the circumcisionists haven't
noticed
(because they weren't looking), is alcohol usage. An eight-year study
in Uganda has shown a
correlation between alcohol consumption and HIV infection
(because people who have been drinking are less likely to practise safe
sex). Islam prohibits alcohol and also prescribes circumcision. It is
at least as reasonable that the prohibition as the prescription
protects against HIV.
Circumcisionists are fond of claiming that their
statistics
have been "adjusted" to correct for this kind of confounding error, but
Ted Goertzel
argues that such "adjustments" are just an attempt to blind us with
science.
Sexual
selection
People don't have sex with just anyone, they tend to do so within their
own social groups, so HIV stays within social groups. (The clearest
case is that in the US, gay men have sex with gay men, heterosexual men
with heterosexual women. So once it started with them, HIV would have
spread mainly among gay men regardless of other factors.) So in Africa,
if HIV first spread in societies where men were intact, it would
continue to do so, and not in societies where men were cut.
Female
Genital Mutilaton
Abstract: Female
circumcision and HIV infection in Tanzania: for better or for
worse? Stallings R.Y, Karugendo E. (PowerPoint)
Introduction: ...The
authors sought to
explain an unanticipated significant crude association of lower HIV risk among circumcised women
[R{isk} R{atio}=0.51; 95% C{onfidence} I{nterval} 0.38,0.70] in a
recent survey by examining other factors which might confound this
crude association.
Methods: Capillary blood was
collected ... from a
nationally representative sample of women age 15 to 49 during the 2004
Tanzania Health Information Survey. Eighty-four percent of eligible
women
gave consent for their blood to be anonymously tested for HIV antibody.
Interview data was linked ... to final
test results for 5753
women. The chi-square test of association was used to examine the
bivariate relationships between potential HIV risk factors with both
circumcision and HIV status. Restricting further analyses to the 5297
women who had ever had sexual intercourse, logistic regression models
were
then used to adjust circumcision status for other factors found to be
significant.
Results: By self-report, 17.7
percent of women were
circumcised. Circumcision status varied significantly by region,
household
wealth, age, education, years resident, religion, years sexually
active,
union status, polygamy, number of recent and lifetime sex partners,
recent
injection or abnormal discharge, use of alcohol and ability to say no
to
sex. In the final logistic model, circumcision
remained highly significant
[O{dds} R{atio}=0.60; 95% C{onfidence}
I{nterval}
0.41,0.88]
while adjusted for region, household wealth, age, lifetime partners,
union status, and recent ulcer.
Conclusions: A lowered risk of HIV infection among
circumcised women was not attributable to confounding with
another risk factor in these data. Anthropological
insights on female circumcision as practiced in Tanzania may shed light
on
this conundrum.
Will
there be Randomised Controlled Trials of 3000 HIV-negative women, where
1500 are circumcised and they see how many seroconvert - followed by
calls for mass circumcision of women to prevent the spread of HIV? Of
course not.
|
Kanki et al. reported that, in Senegalese
prostitutes,
women who
had undergone female genital cutting had a significantly decreased risk
of HIV-2 infection when compared to those who had not.
Kanki P, M'Boup S, Marlink R, et al. "Prevalence
and
risk
determinants of human immunodeficiency virus type 2 (HIV-2) and human
immunodeficiency virus type 1 (HIV-1) in west African female
prostitutes Am. J. Epidemiol. 136 (7): 895-907. PMID
|
The correlation one way between FGM and MGM is almost 100%.
That is, females are circumcised only if males are.
So if FGM reduced the incidence of HIV, it could be mistaken for an
effect of MGM.
Only one
exception
has been found, the Pokot tribe in Kenya - but they used
to circumcise males (and have begun to again - to prevent HIV...).
Wife
Inheritance
Among the Luo people of Kenya (who do not practise
circumcision), when
a man dies, his wife is "inherited" by his brother. She is required to
have intercouse with him, and that intercourse must
be unprotected. Otherwise the husband's spirit is not free, and the
wife is
not free to remarry. The rate of HIV among
people tested in that region was 2/3. One man said it makes no
difference if they know
the woman is HIV positive. They do not believe AIDS is caused by a
virus:
"If a man dies, it is because he has done something wrong."
There can be no doubt that wife-inheritance is a
potent
factor in HIV
transmission - especially where the death rate from HIV is high: it's a
vicious circle. Wife inheritance is seldom if ever mentioned as a
confounding factor in studies of HIV transmission.
If there should be a correlation between
intactness and
wife-inheritance, or between circumcision and the shunning of
wife-inheritance, that might go a long
way toward explaining the supposed intactness-HIV link.
- A BBC
story 18 November 2003.
- The
Washington Post November 8, 1997
- Christianity
Today August 28, 2000
"The Luo people are often polygamous, and several widows may be
inherited by a single family member. Another element of the tradition
is
the practice of holding a "cleansing" ritual in which the
widow has sex
with an outsider before being given to her brother-in-law or
other family
member."
|
Heterosexual
transmission, Europe vs the United States
A common criticism of "Circumcision prevents HIV" is
"But HIV
is
very common in the US, where circumcision is prevalent." A common reply
from the pro-circumcision lobby is that HIV is primarily transmitted
homosexually in the US, heterosexually in Africa, and anal receptivity
of HIV is unaffected by circumcision. This can be countered by
comparing the United States with Europe, where homosexual and
heterosexual rates of transmission are comparable, but circumcision
rates are very different. The US proves to have a much higher rate of
HIV than Europe, and a disproportionate rate of male to female
transmission.
Advocates of circumcision then have to put considerable
spin
on the statistics. For example, Bailey and Halperin write:
Remarkably,
there is consistent evidence that female-to-male HIV transmission,
compared with male-to-female transmission, is much higher in Europe
than in the USA . . . Data from the European Multicenter Partners Study
and comparable research from the USA suggest that the ratio of
female-to-male transmission (compared with male to female transmission)
is about 10 fold higher in Europe.3
[3 De Vincenzi I. Heterosexual transmission of
HIV. JAMA 1992; 267: 1919.]
|
The implication is that intact European men are being
infected
with
HIV at an alarming rate compared to their circumcised counterparts in
the US.
This is assisted by the straightforward but false
interpretion
that the rate of female-to-male transmission is
higher in Europe. Bailey and Halperin actually mean the ratio
of the ratios of (female-to-male vs male-to-female in) Europe
vs (female-to-male vs male-to-female in) the US.
Yet if the four sets of data are compared, standardising
the
US
total to 100, M-to-F amounts to 95, F-to-M to 5, and in Europe, M-to-F
20 and F-to-M 10. So Halperin's extraordinary ratio is
(10/20)/(5/95) = (1/2)/(1/19) = 9.5
(In exact figures,(10.10/20.20)/(4.76/95.24)=10.0)
Expressed pictorially:
Clearly, what needs to be explained is not a high
female-to-male HIV transmission rate in Europe, but the high
male-to-female rate in the US.
Could the reason be the rougher action of dry, circumcised US penises,
creating micro-tears on US women's vaginal walls? Perhaps not, perhaps
it is is the different strains of HIV prevalent in the US and Europe,
but this kind of difference between fact and interpretation illustrates
that simple correlations do not necessarily translate into simple
solutions.
"Russian
Roulette with two bullets rather than three"
Male
circumcision and HIV infection
For several years, researchers have been debating
the
relationship
between male circumcision and HIV. Several studies have indicated
that circumcised men are less likely to become infected with HIV than
uncircumcised men. However, because circumcision is usually linked to
culture or religion, it has been argued that the apparent protective
effect of the procedure is likely to be related not to removal of the
foreskin but to the behaviours prevalent in the ethnic or religious
groups in which male circumcision is practised. In addition, some
researchers have assumed that any association between circumcision
and HIV must be complicated by the presence of other sexually
transmitted infections, which have been found to be more common among
uncircumcised men.
Clearly, the correlations are not straightforward.
In
the higher
income countries, the rates of HIV infection among men who have sex
with men do not vary greatly even though the circumcision rates do:
few men in Europe and Japan but four-fifths of men in the United
States are circumcised. In Africa, however, circumcision seems to
confer some protection. A study in Nyanza Province, Kenya, among men
from the same ethnic group, the Luo, found that one-quarter of
uncircumcised men were infected with HIV, compared with just under
one-tenth of circumcised men. The protective effect remained even
after other factors, such as sexual behaviour and sexually
transmitted infections, had been taken into account. A study of
over 6800 men in rural Uganda has suggested that the timing of
circumcision is important: HIV infection was found in 16% of men who
were circumcised after the age of 21 and in only 7% of those
circumcised before puberty. A recent review of 27 published studies
on the association between HIV and male circumcision in Africa found
that, on average, circumcised men were half as likely to be infected
with HIV as uncircumcised men. When African men with similar
socio-demographic, behavioural and other factors were compared,
circumcised men were nearly 60% less likely than uncircumcised
men to be infected with HIV.
Even though the weight of evidence increasingly
suggests
that
circumcising men before they become sexually active does provide
some protection against HIV, the practical implications for AIDS
prevention are not obvious. Circumcision, where it is practised,
usually has links to religious or ethnic identities and life-cycle
ceremonies, and may customarily be done after puberty. If the same
scalpel were used without sterilization on a number of boys, this
could actually contribute to the transmission of HIV. Finally, if
circumcision were promoted as a way of preventing HIV infection,
people might abandon other safe sexual practices, such as condom
use. This risk is far from negligible - already, rumours abound in
some communities that circumcision acts as a "natural condom". A sex
worker interviewed in the city of Kisumu in Kenya summed up this
misconception, saying: "I can sleep with circumcised men without a
condom because they don't carry a lot of dirt on their penis". While
circumcision may reduce the likelihood of HIV infection, it does not
eliminate it. In one study in South Africa, for example, two out of
five circumcised men were infected with HIV, compared with three out
of five uncircumcised men. Relying on circumcision for protection is,
in these circumstances, a bit like playing Russian roulette with
two bullets in the gun rather than three. [...assuming
the gun has only five chambers - or, if it had the more usual six, 2.4
bullets rather than 3.6.]
- Report
on the global HIV/AIDS epidemic
UNAIDS, June 2000
A large file, >275KB.
In the wake of three incomplete Random Controlled
Tests
of circumcision, the head of UNAIDS, Dr
Peter Piot, has chosen to forget these wise words.
|
A
British survey of gay men found slightly more of the circumcised
men were HIV-positive.
Know
the
score
Findings from
the
National
Gay Men’s
Sex Survey
2001
David Reid
Peter Weatherburn
Ford Hickson
Michael Stephens
...
Introduction and
methods
1.1 CONTENT OF THE REPORT
This research report outlines the main findings of
Vital Statistics 2001 – which was the fifth annual national Gay
Men’s Sex Survey
(henceforth GMSS). The survey was carried out during the summer of 2001
by Sigma Research in partnership with 73 health promotion agencies
across England
and Wales.
...
Chapter
2 gives a brief description of the sample of 14,616 men living in
England and Wales who either had sex with another man in the last year
or expected to have sex with a man in the future.
...
1.2 BACKGROUND TO THE FIFTH NATIONAL GAY
MEN’S SEX SURVEY
The Gay Men’s Sex Survey uses a short
self-completion questionnaire to collect a limited amount of
information from a substantial number of men. ...
1.3 PRIDE EVENTS: RECRUITMENT DATES,
EVENTS AND RETURNS
Recruitment occurred at seven community-based events in the summer of
2001. ...
4.5 CIRCUMCISION
It has been suspected for some time that when uninfected men are
insertive in UAI with positive men, whether or not the uninfected man
is circumcised has a bearing on the probability of HIV transmission
occurring. The hypothesis is that the cells of the fore-skin are more
susceptible to infection by HIV and therefore circumcision has a
protective function.
Men were asked Are you circumcised?
and were asked to tick No, Yes
or Don’t Know. Overall, 0.9%
said Don’t know
by which we think they mean they do not know the word rather than not
knowing whether they have a foreskin. Excluding this small group, 22.1%
of men indicated that they were circumcised. The proportion rose with
increasing age, from 16.1% among the under 20s, through 18.8% (in the
20s), 21.3% (in the 30s), 24.8% (in the 40s) and 40.2% among the over
50s.
Circumcision
also significantly varied by ethnicity, being highest among Bangladeshi
men (100%, 5/5), Pakistani men (97.5%, 39/40), other Asian men (77.3%,
68/88) and Black African men (76.1%, 35/46). Of all sixteen ethnic
groups, White British men had the lowest level of circumcision (18.7%,
2201/11764).
If
circumcised men are less likely to acquire HIV than men with foreskins,
then we should expect fewer of the circumcised men to have tested
positive than the men with a foreskin. However, more of the circumcised men had tested
positive for HIV
(6.1%) than had those with a foreskin (5.0%). This small but
significant difference is in the opposite direction than predicted if
foreskins are contributing to transmission, and was observed in all ethnic groups and across the age range.
The
survey found no evidence to support the adoption of ‘the proportion of
HIV uninfected men who are not circumcised’ as a population level
target for HIV prevention programmes for gay and
bisexual men. [... let
alone evidence to support the promotion of circumcising anyone]
[The
only
possible confounder remaining
is selection bias. The results would not reflect the actual position if
circumcised men who have HIV (and know it), or intact men who don't,
are more likely to take the survey than intact men who have HIV (and
know it) or circumcised men who don't, but it is very hard to see why
that might be.
Only a
small
proportion of
these men with HIV would have been infected trans-penilely, compared to
the proportion infected tran-anally, so the small surplus of those
HIV-positive men who are circumcised should not be taken as suggesting
that circumcision makes HIV-infection more likely.]
|
The hazards of unblinded studies
"Scientists must constantly be on guard against
this
sort of
self-deception [picking and choosing data to agree with the
preconception that electromagnetic fields, as from power lines, cause
leukaemia]. Unless studies are
carefully
designed to avoid it, the biases of the epidemiologist have a way of
creeping into the results. To minimize the opportunity for bias,
scientists rely on double-blind studies. An independent researcher
might be given a list including both the homes of victims
of
childhood leukemia and an equal number of addresses of nonvictim
children matched in age, gender, race, family income, etc., but without any indication of which are which.
Without knowing which were the homes of victims and which were
"controls," the researcher would rate them by whatever criteria were
used to estimate the field strength. Someone
else would then apply the key after the judgments were made.
[Double-blinding
a
study involving
circumcision is hardly practicable, but much more could have been done
to make the circumcised experimental groups and the intact control
groups equivalent.]
But even if the
study
had been double blind, a "risk ratio" of only three for a rare disease
such as childhood leukemia would be
regarded by many epidemiologists as barely credible.
The risk ratio for lung cancer from smoking, for example, is well over
thirty^ that is, a 3,000 percent increase in the incidence of lung
cancer among smokers. Yet it took years of checking and rechecking the
figures, as well as a highly plausible mechanism in terms of known
carcinogens in tobacco smoke and, finally, confirming laboratory
studies on animals before the cancer link was firmly nailed down."
- "Voodoo Science" by Robert
Park,
pp 150-1
"The estimated reduction in the relative risk of
infection with HIV
[between circumcised and intact men in the Kenyan and Ugandan trials]
was 51% (unadjusted modified intention-to-treat analysis) to 55%
(as-treated analysis)."
Editorial comment in The
Lancet.
|
No effect on HIV prevalence in Zambia
J Biosoc Sci. 2019 Oct 14:1-13. doi: 10.1017/S0021932019000634. [Epub ahead of print]
Voluntary medical male circumcision and HIV in Zambia: expectations and observations.
Garenne M, Matthews A5.
Abstract
The study analysed the HIV/AIDS situation in Zambia six years
after the onset of mass campaigns of Voluntary Medical Male
Circumcision (VMMC). The analysis was based on data from Demographic
and Health Surveys (DHS) conducted in 2001, 2007 and 2013. Results show
that HIV prevalence among men aged 15-29 (the target group for VMMC) did not decrease
over the period, despite a decline in HIV prevalence among women of the
same age group (most of their partners). Correlations between male
circumcision and HIV prevalence were positive for a variety of
socioeconomic groups (urban residence, province of residence, level of
education, ethnicity). In a multivariate analysis, based on the 2013
DHS survey, circumcised men were found to have the same level of infection as uncircumcised men,
after controlling for age, sexual behaviour and socioeconomic status.
Lastly, circumcised men tended to have somewhat riskier sexual
behaviour than uncircumcised men. This study, based on large
representative samples of the Zambian population, questions the current
strategy of mass circumcision campaigns in southern and eastern Africa.
PMID:
31608845
DOI:
10.1017/S0021932019000634 |
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