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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.
|
No
protection to more than half a million men in Ontario
J Urol 2021 Sep 23
doi:
10.1097/JU.0000000000002234. Online ahead of
print.
Circumcision and Risk of HIV Among Males From
Ontario, Canada
Madhur Nayan, Robert J Hamilton, David N Juurlink,
Peter C Austin, Keith A Jarvi
PMID: 34551593 DOI: 10.1097/JU.0000000000002234
Abstract
Purpose: Randomized trials from Africa
demonstrate that circumcision reduces the risk of
acquiring HIV among males. [This
should read, three non-placebo-controlled,
non-double-blinded trials of paid volunteers in
Africa claimed to find an inverse correlation
between being genitally cut and HIV among the men
who completed the trial. Study after study, like
this one, repeats the original claim, then goes on
to refute it.] However, few
studies have examined this association in Western
populations. We sought to evaluate the association
between circumcision and the risk of acquiring HIV
among males from Ontario, Canada.
Materials and methods: We conducted a
population-based matched cohort study of residents in
Ontario, Canada. We identified males born in Ontario
who underwent circumcision at any age between 1991 and
2017. The comparison group consisted of age-matched
males who did not undergo circumcision. The primary
outcome was incident HIV. We used cause-specific
hazard models to evaluate the hazard of incident HIV.
We performed several sensitivity analyses to evaluate
the robustness of our results: matching on institution
of birth, varying the minimum follow-up period, and
simulating various false-negative and false-positive
thresholds.
Results: We studied 569,950 males, including 203,588 who underwent
circumcision and 366,362
who did not. The vast majority (83%) of
circumcisions occurred prior to age 1 year. In the
primary analysis, we found no
significant difference in the risk of HIV
between groups (adjusted hazard ratio 0.98 (95%
confidence interval 0.72 to 1.35)). In
none of the sensitivity analyses did we find an
association between circumcision and risk of HIV.
Conclusions: We found that circumcision
was not independently associated with the risk of
acquiring HIV among males from Ontario, Canada.
Our results are consistent with clinical guidelines
that emphasize safe-sex practices and counselling over
circumcision as an intervention to reduce the risk of
HIV.
|
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.
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"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. ...
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"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.
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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.
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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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