Excellent article in the Australian.

[Fellow Traveler]

Most of what is said is applicable to the US too.

http://www.theaustralian.news.com.au...-23289,00.html

[glongley]

This really is a very good article. A good link to keep or print out, when you need to educate someone about why the African studies have next to nothing to do with circing babies in the US - since it's so similar to the epidemiology in Australia.

Thanks for finding this!

Gillian

[Ron_Low]

This article makes a very rational case, as in it doesn't name-call against the lousy Africa research authors like Bailey and Halperin. Even using their own assertions, it buries infant circ.

When it said of Africa:
"HIV testing is not routinely available. Given that finding out you are HIV-positive will not provide access to antiretroviral therapy but will often make you an outcast from family, friends and society in general, it means that there is a large number of HIV-infected individuals who do not know they are infected, who do not modify their behaviour and for whom their risk of HIV transmission is therefore high."

..I expected it would also allude to the fact that many African cultures make admitting homosexuality an outright crime, a severe social stigma, or an unofficial but very real death sentence. This HAD to affect the HIV research. How else could it be that AIDS is so differently transmitted there and here? It's not like they really have an exclusive on a whole different strain of HIV that we - in this jet age - somehow never see.

The researchers know that heterosexual transmission is much scarier to the typical American, so they deliberately overlooked this not-admitting-to homosexual-activity effect to exaggerate their findings, and I haven't seen them called out on that.

[needhelpplease]

That's good, much nicer and more logical than the stupid Wodak article in the same paper calling for circ of all boys.

Didn't like the last line though where he said routine male circ may be considered for other reasons, just not HIV

I'm really worried Australia is going backwards on this - though at the moment most of the commentaries are by cut guys, hopefully in 10 years the younger intact generation will be in charge of stuff and realise how silly it all is

[Fellow Traveler]

Originally Posted by Ron_Low

This article makes a very rational case, as in it doesn't name-call against the lousy Africa research authors like Bailey and Halperin. Even using their own assertions, it buries infant circ.
...
How else could it be that AIDS is so differently transmitted there and here?

The down low homosexual activity might contribute but it's thought that the interlocked concurrent sexual networks are the main reason for HIV's wildfire spread in that population. The problem is that this is a cultural artifact of the region and it would actually take hard work to change it so it's generally ignored.

Originally Posted by needhelpplease

That's good, much nicer and more logical than the stupid Wodak article in the same paper calling for circ of all boys.

Didn't like the last line though where he said routine male circ may be considered for other reasons, just not HIV

I'm really worried Australia is going backwards on this - though at the moment most of the commentaries are by cut guys, hopefully in 10 years the younger intact generation will be in charge of stuff and realise how silly it all is

I think Wodak, and people like him (older circumcised men), are nervous about the Australia situation with regard to circumcision and are using HIV to scare people back into line. These men feel threatened by the decline of circumcision in about 10 more years most of them will be out of the loop. Circumcision is something that people do out of fear of one thing or another and is rarely the result of rational thinking. The last paragraph was a bit of a disappointment but I think I know why it's there.

[Dave2GA]

This is a very significant article. It is by an epidemiologist right in Brian Morris' backyard. This is very, very good for us.

[Papai]

Originally Posted by needhelpplease

That's good, much nicer and more logical than the stupid Wodak article in the same paper calling for circ of all boys.

Didn't like the last line though where he said routine male circ may be considered for other reasons, just not HIV

I'm really worried Australia is going backwards on this - though at the moment most of the commentaries are by cut guys, hopefully in 10 years the younger intact generation will be in charge of stuff and realise how silly it all is

I didn't like that last line either, but it shuts down what I think is the loudest pro-circ piece of propaganda right now.

[Contented73]

But here's what I don't understand: does circ ACTUALLY reduce the transmission of HIV by 60%?! There is no way this is true....but it keeps getting repeated and repeated by every article.

So is it true? And if not, where's the evidence that it isn't?

Edited to add: it's important for me to understand what I'm arguing when I talk to people. Either it does reduce HIV, but here is why that shouldn't factor into your decision (different culture, different situation, etc etc); OR, circ does not affect STD's or HIV, the studies are bogus, and here's how I know that.

[Fellow Traveler]

Originally Posted by Contented73

But here's what I don't understand: does circ ACTUALLY reduce the transmission of HIV by 60%?! There is no way this is true....but it keeps getting repeated and repeated by every article.

So is it true? And if not, where's the evidence that it isn't?

Edited to add: it's important for me to understand what I'm arguing when I talk to people. Either it does reduce HIV, but here is why that shouldn't factor into your decision (different culture, different situation, etc etc); OR, circ does not affect STD's or HIV, the studies are bogus, and here's how I know that.

It is your first statement: "Either it does reduce HIV, but here is why that shouldn't factor into your decision" whether or not they are flawed or not is not relevant even if you take what they purport to present at face value and here is why.

To determine the probability of not becoming infected you can use the following formula:

(1 - [chance of transmission from sex])^[sexual encounters]

Now for the estimates, let's assume that there is a risk reduction of 50% for circumcised men. This is the number most often banted around by the popular media and those clowns at the UN and WHO in their reports from Africa. The probability of infection in any one encounter with an HIV positive partner varies depending on viral load, co-infection, and numerous other reasons. For example, people are most infectious soon after being infected. Infectiousness lessens after a few weeks which is one reason HIV spreads so fast in Africa, read The Invisible Cure: Africa, the West, and the Fight Against AIDS, by Helen Epstein, to find out why it's so infectious in Africa but not anywhere else.

Anyway, I've seen numbers for women infecting men range from 1/700 - 1/2500 and interestingly enough, a recent publication in the Lancent of Infectious Diseases and reported at Aidsmap, put the risk of an HIV infected woman infecting her male partner at 0.04%.

From Aidsmap:

Researchers conducting a meta-analysis of studies of the risk of HIV transmission during heterosexual sex have found that, in high-income countries prior to the introduction of combination therapy, the risk per sexual act was 0.04% if the female partner was HIV-positive, and 0.08% when the male partner was HIV-positive. However these rates were considerably higher in lower-income countries, if the source partner was in either the very early or the late stage of HIV infection, or if one partner had genital ulcer disease, write the researchers in the February issue of The Lancet Infectious Diseases.

They continue:

Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner’s risk of acquiring HIV was 0.04% per sexual act – in other words, once every 2500 sexual acts.

It's been well known that people were more infectious in early and late stages or if they had genital ulcer diseases I don't know why they included that. Also note that they said prior to the introduction to therapy which means the true rate may actually be lower now but we'll go with it.

So based on that, we'll start the estimate that the chance of infection is 0.06% a bit higher than published in the Lancet article. That means a male having unprotected sex with an HIV positive women has about a bit more than 1 in 1800 chance of being infected. Base line risk intact men vs circumcised men 1 random heterosexual contact with an HIV+ partner.

[1 - 0.0006]^1 99.94% ~= 0.06%
[1 - 0.0006 * 0.5]^1 ~=99.97% ~= 0.03%

But the HIV distribution in the US population is about 5 in 1000 or 1/200 so, in general, there is only a 1 in 200 chance that I'll encounter someone who is HIV positive. Actually the risk is much lower but we'll discuss that in a bit. Given that as a fact, a closer estimate of the risk of becoming HIV infected after the 1 encounters is more like:

The chance of event A (encountering an HIV positive individual in the general population) * the chance of event B the likely hood of getting infected during that encounter.

1/200 * 0.0006 = 0.000003 --- 1 - 0.000003 = 99.9997% = 0.0003%
1/200 * 0.0003 = 0.000006 --- 1 - 0.0000015 = 99.99985% = 0.00015%

Of course, the number of sexual encounters is important too. For 1,000 encounters, the difference is 1.5 hundreths of a percent. That's is what circumcision bought you, big deal. Over the course of 1,000 random encounters an intact guy has 1.5 hundreths of a percent larger chance of becoming HIV positive. Circumcised guys, party on!

Of course there are some caveats to this. First, your per-exposure risk might change based on other factors and the 1/200 is quite high since 75% of the HIV positive population are men. If women only account for about 1/4 of the total, this reduces the 1/200 to between say 1/700 or 1/1000. This is what it looks like when we adjust the prevelence among women:

1/700 * 0.0006 = 0.0000008571 --- 1 - 0.0000008571 ~= 99.99992% = 0.00008%
1/700 * 0.0003 = 0.0000004286 --- 1 - 0.0000004286 ~= 99.99996% = 0.00004%

That's a whole order of magnitude. Now we're talking about a difference of 4 thousandths of a percent if we have 1,000 random partners. Party on.

For Doctors, especially in the US (or Australia where the prevalence is much lower), to entertain the notion that circumcision is going to in anyway impact a boys chances of acquiring HIV is very misleading, not truthful, or ethical. The commonly cited 50% has to be understood in context. Circumcision as a prophylaxis for any STD is, if it is even true, over stated especially in first world countries like the US.

Does that help?

[Contented73]

I don't know if that really helps. What I guess I want to try to understand is....does circumcision truly help reduce HIV transmission, even by a miniscule percentage? My problem is that I can't imagine how it possibly could! But if it does, I'd like to understand where and how this was proven, and what theories there are to explain why. I think the only way I'm going to get satisfactory answers for myself is to actually read the studies. Anyone know where I can find those?

My bigger problem is that I teach childbirth ed and work as a doula, so I come into contact with many many couples who ask me about this. I need to understand it well enough to have a short, coherent type of answer for them that helps them sort through the information. If the studies are total bunk, I'd like to be able to say that with certainty. If there is truth to them, then I'd like to be able to say something concise to help them understand why it doesn't apply to the US. As it stands now, I usually will say something about how we don't cut off body parts, especially not from a newborn baby, to prevent an otherwise preventable or treatable disease. But sometimes I feel cornered and I don't know how to respond.

Sorry, I know I'm kind of rambling. I think this is a tough issue because even though I think it is crazy, it does seem that the research points to a small reduction in HIV transmission in circ'd men. Blech.

[yd66]

Originally Posted by Contented73

I don't know if that really helps. What I guess I want to try to understand is....does circumcision truly help reduce HIV transmission, even by a miniscule percentage? My problem is that I can't imagine how it possibly could! But if it does, I'd like to understand where and how this was proven, and what theories there are to explain why. I think the only way I'm going to get satisfactory answers for myself is to actually read the studies. Anyone know where I can find those?

My bigger problem is that I teach childbirth ed and work as a doula, so I come into contact with many many couples who ask me about this. I need to understand it well enough to have a short, coherent type of answer for them that helps them sort through the information. If the studies are total bunk, I'd like to be able to say that with certainty. If there is truth to them, then I'd like to be able to say something concise to help them understand why it doesn't apply to the US. As it stands now, I usually will say something about how we don't cut off body parts, especially not from a newborn baby, to prevent an otherwise preventable or treatable disease. But sometimes I feel cornered and I don't know how to respond.

Sorry, I know I'm kind of rambling. I think this is a tough issue because even though I think it is crazy, it does seem that the research points to a small reduction in HIV transmission in circ'd men. Blech.

bump i second this question

[robertandenith]

Please read article from mothering magazine edition July-Aug 2008
Circumcision DOES NOT prevent HIV

[robertandenith]

And also check out this new article published by the UK News responding to a US article about STD's prevention through circ.

"Dr Colm O'Mahony, a sexual health expert from the Countess of Chester Foundation Trust Hospital in Chester, said the US (has) an "obsession" with circumcision being the answer to controlling sexually transmitted infections."

http://news.bbc.co.uk/2/hi/health/7960798.stm

[robertandenith]

Originally Posted by Contented73

I don't know if that really helps. What I guess I want to try to understand is....does circumcision truly help reduce HIV transmission, even by a miniscule percentage? My problem is that I can't imagine how it possibly could! But if it does, I'd like to understand where and how this was proven, and what theories there are to explain why. I think the only way I'm going to get satisfactory answers for myself is to actually read the studies. Anyone know where I can find those?

My bigger problem is that I teach childbirth ed and work as a doula, so I come into contact with many many couples who ask me about this. I need to understand it well enough to have a short, coherent type of answer for them that helps them sort through the information. If the studies are total bunk, I'd like to be able to say that with certainty. If there is truth to them, then I'd like to be able to say something concise to help them understand why it doesn't apply to the US. As it stands now, I usually will say something about how we don't cut off body parts, especially not from a newborn baby, to prevent an otherwise preventable or treatable disease. But sometimes I feel cornered and I don't know how to respond.

Sorry, I know I'm kind of rambling. I think this is a tough issue because even though I think it is crazy, it does seem that the research points to a small reduction in HIV transmission in circ'd men. Blech.

I will definitely know how to respond: "So do you really believe that circumcision is more effective than a condom?"

And this is a valid question people! Even my husband, before I could convinced him not to cut our son, he didn't even buy the HIV argument. This is way before I could actually convinced him, so there you go. NO rational or intelligent person will believe that circumcision prevents HIV or STD's.

Read one of the sentences of that article I just posted.

"And it allows men who don't want to change their irresponsible behaviour to continue to sleep around and not even use a condom."

[Fellow Traveler]

Originally Posted by yd66

bump i second this question

The answer to the question is in post 9. Do you have a specific question about it?

[Greg B]

Originally Posted by Contented73

I don't know if that really helps. What I guess I want to try to understand is....does circumcision truly help reduce HIV transmission, even by a miniscule percentage? My problem is that I can't imagine how it possibly could! But if it does, I'd like to understand where and how this was proven, and what theories there are to explain why. I think the only way I'm going to get satisfactory answers for myself is to actually read the studies. Anyone know where I can find those?
.

Perhaps I can simplify it for you. The 50 or 60% number is alwys taken out of context, so it does not reflect the incidence in the study population. In the correct context, the number should be more like:

circ’d men had a 1.6% chance of contracting aids, while the normal men had a 3.4% chance. Or if you were circ’d you had an incidence of 16 men out of a 1,000, while normal men had an incidence of 34 men out of 1,000.

So yes there is a small affect in terms of contracting HIV. However, the studies were not done in a way that shows the cause and effect, so it is arguable that other factors may have been at work, such as the amount of unprotected sex each group had during the course of the study, etc. And it could well be that there is not really "protection" but rather a reduction in efficiency of transmssion, so that circ simply gives you more sexual encounters before you get infected, statisitically speaking.

More importantly, that is only one thing that needs to be considered. Even if you feel that is a strong benefit, it must be weighed against the costs of doing it. Those costs include: loss of sexual function & feelings, violation of well accepted human rights & medical legal guidelines, unacceptable pain incurred during the procedure, impacts of that pain later in life, risk of complications, and risk of infection.

Finally, alternatives for reaching the same level or better reduction in HIV transmission must be considered. Condoms and other safe sex practices are far more effective than RIC. In fact, if you read the studies you will find that the authors state that everything still needs to be done even if you are circ'd.

When all these issues/factors are considered, RIC simply does not provide enough benefit to justify its high costs.

Regards

[Fellow Traveler]

I think I would add that post 9 really illustrates that even if we were to assume it was true, that the benefit to someone in a place like the US would be very very small. Much less than the popular media would have you believe.

[dancindoula]

What continues to boggle me is the fact that even in Africa, or perhaps more especially in Africa, the dangers of RIC far outweigh the quite small protection offered from HIV/AIDS. It is far, far more likely for babies with genital wounds in that area of the world to die from infection, blood loss, or other complications due to lack of good water and safe hygiene practices in caring for a fresh wound, or even in incurring the wound in the first place. In a place where infant mortality is already alarmingly high why add to it with a ridiculously inaffective procedure. Ultimately, even if RIC did actually reduce the occurence of HIV/AIDS more than a miniscule percentage, the most effective, practical and least costly method of protection is found in education and provisions for safe sex and good hygiene.

[glongley]

Originally Posted by Contented73

My bigger problem is that I teach childbirth ed and work as a doula, so I come into contact with many many couples who ask me about this. I need to understand it well enough to have a short, coherent type of answer for them that helps them sort through the information.

Please see a compilation of talking points on the HIV/circ issue here:
http://www.coloradonocirc.org/files/...ing_Points.pdf

I'd keep it simple. You don't have to get tangled up in trying to debunk the details of the studies. Reframe it. Eg. Behavior is far more important than circ status in preventing STDs. Others have made good suggestions above...

Gillian