AIDS and Circ Study - Page 2

[Papai]

I would hardly call the circ studies irrefutable or rock solid. I've seen valid scientific rebuttals to the studies. I don't have the links on-hand but challenging the studies does not mean you're anti-science.

[Quirky]

Originally Posted by jenP

Excellent video, thank you for the link.
As he point out, these RCT's were not done by HIV/AIDS researchers, but were done by long-time circumcision promoters who were able to get massive funding to push their agenda.

And, the studies are absolutely being used not to promote voluntary adult circumcision to at-risk individuals in Africa. In Africa AND IN THE USA the results are being used to push for universal infant circumcision. Has anyone done an analysis comparing the small risk reduction for HIV acquisition vs. the complication rates, including deaths, that will be seen if infant circ rates skyrocket? Will there be a net saving of lives?

Also, what of the fact that the longest study was 22 months? Surely part of the reason that the circumcised group saw fewer HIV infections was that they spent a good percentage of that time "out of commission" sexually speaking. I've read the claim that the IRB stopped the studies early because due to the "wild success" it would be "unethical" to not offer the intervention to the control group. BUT I see no reason why they could not have continued to collect data even after doing so. Let's see five or more years down the road what became of those who were originally circumcised, those who were originally in the control group but opted to get circumcised later, and those who remained intact throughout. I can think of no reason to not collect such data except the fear that it would not fit their desired results.

Another question to ask is, if it is ethical to study foreskin amputation as an HIV preventative, and if researchers are truly ONLY interested in stopping the spread of HIV and are willing to study ANY possible solution, then WHY are there no RCT's being done on female circumcision? Some may call female circumcision mutilation, but hey, the ends justify the means, right? After all, what does it matter if thousands of women (and girls!) have their genitals surgically reduced, if it may possibly prevent a certain number of HIV infections, right?

Jen

Yep. On the last point -- one of the reasons the RCTs on MC went forward was that the hypothesis that MC lowers HIV incidence was based on epidemiological studies showing an association between regions with mostly circed men and lower HIV rates. (Never mind that there are studies to the contrary, showing lower HIV rates in intact regions.)

In point of fact, at one of the World AIDS conferences several years ago, there was an epidemiological study showing that, *all other factors being controlled for,* circumcised women had a lower incidence of HIV than intact women.

And it's not possible in my mind to argue that "oh, well, male circumcision is pretty harmless while female circumcision is SO MUCH WORSE." That's true in some cases but not in all cases -- as Type I FGM is the mildest form and the most widely practiced, whereas infibulation, which is much worse, is not nearly as widespread.

Especially because as Jen mentioned, many AIDS advocates have called for universal INFANT male circumcision in Africa, I think it's horribly hypocritical to pursue what is still a harmful, destructive surgery on boys' genitals while completely ignoring whether female circumcision could decrease HIV transmission.

The ends simply do not justify the means for either gender.

[Papai]

Notice that the new line of attack, when the studies have been challenged with data from intact nations with lower rates of HIV than circumcising nations, is that circumcision is a valid HIV prevention tool in Africa. Why? What's so unique about the African penis that makes circumcision so effective?

Funny, in other countries, they go about reducing HIV without removing any part of anyone's genitals. See Brazil: http://www.pri.org/health/global-hea...egies1826.html

[Ron_Low]

Originally Posted by Mama Metis

These were all very large studies with good retention rates.

About three times as many men dropped out of the studies - status unknown - than contracted HIV.

Originally Posted by Mama Metis

And the fact that several studies were done in several different contexts and yeilded very similar results is a good indication that the findings can be considered valid.

Or maybe it's a good indication that the long-time circumcision justifiers who conducted them may have been talking to each other about what the results needed to look like.

Originally Posted by Mama Metis

the reason that the studies were stopped early was that the results were so overwhelming that it would have been unethical to continue to study the intervention

It was unethical to start the studies amidst overwhelming evidence that condoms were already far better and more cost effective than the wildest hopes for circumcision.

Funny, though because when the Wawer/Gray team in Uganda did a follow-up and showed in July 2009 that the HIV+ men they cut were 50% MORE LIKELY to infect their partners than the HIV+ men they left intact were, that didn't usher in three large random controlled trials to verify the finding. Rather that too was pitched by the researchers as a reason to halt the study early. It was halted due to "futility" - not due to risk to the participants. (Futility with respect to furthering the aim of justifying circumcision apparently).

It's all in their report. Their report didn't say HIV+ men should not get cut due to the increased risk to their partners. Rather it said everyone should have access to circumcision because intactness would be seen as a stigma.

Ethics these guys ain't got.

[Ron_Low]

Originally Posted by Mama Metis

the fact that the trial was stopped early probably underestimates the protection, if anything

NOT AT ALL.

The cut men had several more visits to chat with the friendly man in the white coat than the intact men got. At each visit they were offered as as many condoms as they could carry and told about the importance of safe sex.

The cut men were told they absoluetly must abstain for 6 weeks. The intact men got no such counsel. Cutting the study short had an especially dramatic over-estimating effect for the men enrolled late. The assay used to detect HIV in the blood was also incapable of catching very recent aquisition, another count against stopping early.

The test subjects were not at all "random" either. Every one sought circumcision for cultural reasons. It's reasonable to speculate that when such men had finally undergone what was for them an important coming-of-age ritual that it would affect the nature and quality of their dating prospects.

Most of the US men who have died of AIDS were cut at birth. Many places with very high circumcision rates are near the top of the HIV incidence table.

[glongley]

Here is an excellent medical journal article summarizing the problems with the "circumcision as a prevention for HIV in Africa" issue.

http://www.circumcisionandhiv.com/fi...otavaccine.pdf

[Mama Metis]

I haven't glanced at the thread in a few days and now there are too many responses for me to address them all! But I'd like to say thanks for your energy toward this issue. I am usually in the position of arguing against these studies to my colleagues (at least in the US) who are more inclined toward RIC and try to make a connection to the US. So it's interesting and a bit odd to be on the other side for a change!

Anyway, I'll see if I can address a few things:

I cant help but think if circ was really helpful in preventing HIV then why didnt that make a difference back in the 80's here in the USA when thousands died from HIV. Knowing circ rates where upwards of 80% or even higher.

Interesting point! In fact, the high rates of circ in the US are consider one of the reasons that we didn't see a generalized epidemic here in the same way as southern Africa did. The other reason is that Americans tend to be serial monogomists, whereas Africans are part of "sexual networks." In other words, it's common to have more than one partner at a time, which speeds the spread of the virus because infecting one person infects the entire network. Interestingly, the total lifetime number of sex partners is fairly similar in the US and most places in southern Africa.

Notice that the new line of attack, when the studies have been challenged with data from intact nations with lower rates of HIV than circumcising nations, is that circumcision is a valid HIV prevention tool in Africa. Why? What's so unique about the African penis that makes circumcision so effective?

It's not the penises that are different, but the prevelance and transmission patterns of HIV. In southern Africa, most transmission is between heterosexual partners. In the US, homosexual transmission and IV drug use plays a much larger role. Also, one's chances of being exposed to HIV are obviously significantly higher in southern Africa.

The test subjects were not at all "random" either. Every one sought circumcision for cultural reasons. It's reasonable to speculate that when such men had finally undergone what was for them an important coming-of-age ritual that it would affect the nature and quality of their dating prospects.

The trials I am most familiar with were performed in places where circ was NOT done for cultural reasons and was not part of the local tradition at all.

The cut men had several more visits to chat with the friendly man in the white coat than the intact men got. At each visit they were offered as as many condoms as they could carry and told about the importance of safe sex.

As I've mentioned, the intact men were required to come in for the same visits. In fact, the health workers they met with did not know their circ status unless the men happened to disclose it during the visit. Men in both groups got the same information and the same access to condoms.

As he point out, these RCT's were not done by HIV/AIDS researchers, but were done by long-time circumcision promoters who were able to get massive funding to push their agenda.

Well, all I can say is that this is incorrect because I know some of these folks personally. They are lifetime HIV researchers. To be honest, few of them are even American and I doubt that RIC in America is something they would consider relevant to their work at all. (Of course, this is not to say that others aren't using the data inappropriately to push a circ agenda in the US!)

I've read the claim that the IRB stopped the studies early because due to the "wild success" it would be "unethical" to not offer the intervention to the control group. BUT I see no reason why they could not have continued to collect data even after doing so. Let's see five or more years down the road what became of those who were originally circumcised, those who were originally in the control group but opted to get circumcised later, and those who remained intact throughout. I can think of no reason to not collect such data except the fear that it would not fit their desired results.

They did continue to collect data! And actually, most are still collecting to this day because the men were already part of an epidemiologic cohort. Of course, the groups are no longer randomized because most of the men in the non-circ group elected to receive circ after the official trial ended.

So, taking this in the proper context, a man (or his guardian) can choose to get circ'd or not. Then one should compare these two alternatives by looking at the advantages and disadvantages. If he gets circ'd, he:

Loses the function of his penis for both himself and his partner

Loses the a great deal for feelings during sex

Risks complications

Is subjected to pain

Has an odd looking penis

Gains soem resistence to aquiring HIV

Maybe less likely to use condomd, due to the great loss of feeling that Circ causes

And he still must use safe sex and condoms to avoid getting HIV, just like an intact person.

Agreed. These were among the potential risks that were outlined to the participants in the study. Many of the trial follow-up studies focused on these issues to understand how men felt about their circumcision and whether they experienced any negative outcomes. Luckily, circ was extremely well-tolerated in these populations. Personally I wonder if these men sufffer from fewer sexual side effects than men circ'ed as infants because their penises were protected by the foreskin while they were still developing. I don't know if this hypothesis has ever been investigated.

Anway, I'll stop here. Thanks again for all the discussion!

Metis

[Papai]

But Metis there are African nations in which the intact population has lower HIV prevalence than the circ'd. This "protection" circ allegedly affords hardly appears to be universal.

Malawi and Ghana come to mind.

[buckeyedoc]

I think the 60% figure sounds a lot better than the actual comparison of numbers of infected men from the circumcised and uncircumcised groups (3-ish vs. 1.5-ish percent). While statistically significant, I don't believe these data are biologically significant. That is, even if circumcised men are less likely to contract the disease on a per exposure basis (which we don't even know based on these data, since we don't know who was exposed or how many times), repeated exposure to HIV-positive partners is going to result in HIV transmission. Thus, over many years or a lifetime, circumcision probably doesn't matter at all. Once a man is infected, he's infected. It doesn't matter if it took him one exposure or two to get that way. If there are no lifestyle modifications and no consistent condom use, he is doomed in an HIV endemic area. And if there is condom use, well, then, there is no added benefit to being circumcised.

[NSmomtobe]

Originally Posted by Mama Metis

Personally I wonder if these men sufffer from fewer sexual side effects than men circ'ed as infants because their penises were protected by the foreskin while they were still developing. I don't know if this hypothesis has ever been investigated.

I wouldn't be surprised if this was the case. In any case, I would guess that when a man gets circumcised as an adult, the loss of sensation to the glans would take a while so any sexual side effects wouldn't be immediately noticeable. Also, he is far less likely to have complications from the removal of too much skin and/or the body's efforts to refuse to the glans, creating skin bridges, etc.

Originally Posted by Greg B

If he gets circ'd, he:

Maybe less likely to use condoms, due to the great loss of feeling that Circ causes

And he still must use safe sex and condoms to avoid getting HIV, just like an intact person.

On the other hand, if he stays intact, he:

Has a fully functioning penis for both himself and his partner

Gets to enjoy the full feelings that sex should provide

Maybe more likely to wear condoms

And must use safe sex and condoms to avoid getting HIV.

Thank you for making the point about condom use and circumcision. My DH is circumcised and cannot feel anything when he uses a condom. Most of the time, he would choose no sex over sex with a condom, because what's the point? And it is not a problem with his attitude either. Before he became sexually active, he thought that there was no good reason not to use a condom and he couldn't understand why anyone wouldn't. Now he knows. He blames condoms for sucking. I blame circumcision for dulling his senses.

[Claire and Boys]

Originally Posted by Mama Metis

Interesting point! In fact, the high rates of circ in the US are consider one of the reasons that we didn't see a generalized epidemic here in the same way as southern Africa did. The other reason is that Americans tend to be serial monogomists, whereas Africans are part of "sexual networks." In other words, it's common to have more than one partner at a time, which speeds the spread of the virus because infecting one person infects the entire network. Interestingly, the total lifetime number of sex partners is fairly similar in the US and most places in southern Africa.

Can you explain why Europe hasn't got much higher rates of HIV than the US, then? I would say culturally there are more similarities between Europe and the US than between the US and Africa.

It's my opinion that the sexual networks and high number of infected prostitutes in Africa are the main reasons behind the epidemic. NOT lack of circumcision.

[Fyrestorm]

Wasn't there also a study done showing that circumcised men are more likely to participate in less safe sexual practices because they are looking to make up for the lack of sensitivity?

[NSmomtobe]

Originally Posted by Fyrestorm

Wasn't there also a study done showing that circumcised men are more likely to participate in less safe sexual practices because they are looking to make up for the lack of sensitivity?

I would be VERY interested in this study if anyone happens to know more about it.

[serendipity22]

Buckeyedoc said

I think the 60% figure sounds a lot better than the actual comparison of numbers of infected men from the circumcised and uncircumcised groups (3-ish vs. 1.5-ish percent).

60% sounds really impressive, but it was a 1.5% reduction (per 18 months - 2 years ) in real terms. Doesn't sound so impressive. Worse still, the numbers are tiny. About 25 more intact men out of 5,000 got HIV than the circumcised group. Because of a few dozen men, the whole of Africa must be circumcised? If this is overwhelming evidence then I am a monkeys uncle.

Some of the intact who caught HIV said they had no sex in that period.
Quite possible because its likely 20%+ of HIV infections in Africa are through dirty medicine.

HIV spreads more easily if a person has an existing STD. Chanchroid is not a problem in developed countries but chanchroid, tropical ulcers etc is a problem in Africa, and may be one reason why in Australia, the African studies were considered relevant.

The study that found that HIV+ circumcised men infected 18% of their partners compared to only 12% of intact men, heck - thats 18% in a much shorter time period than the 3% of intact men infected by women. Unfortunately we dont know how many of the men were exposed to hiv in the 3 studies. This study didn't make headline news like the 25 intact men who got hiv did. The male to female infection is much much higher in the US than Europe. So much for circumcision protecting women.

I think it makes much more sense to look at stats for whole countries than stats for a few dozen men. Ethiopia, male circ nearly 100%, millions of people with HIV. hmmm doesn't look like it stopped there.

There are several African countries where HIV is more common among circumcised men, there could be confounding factors but its more likely there are not. There are other countries where the rates are about the same.

Anyway I don't think much of the studies, though admittedly they would be very difficult to implement effectively.

[brant31]

OK, every person who is the least bit concerned about the circumcision/HIV link being played up by WHO and UNAIDS -- and possibly driving future pronouncements in the USA by the CDC and AAP -- needs to know this basic fact:

Other things work better. Much better. Circumcision is entirely unnecessary.

Here are some alternatives, and why we haven't maximized their potential:

1. Education. Because PEPFAR (the President's Emergency Plan for AIDS Relief) formerly stressed abstinence above all other approaches, there was never much of a realistic open discussion in the worst affected countries. Now the muzzle has come off the funding and more approaches can be discussed.

2. Condom use. Several program directors and field workers have emphasized that condom usage has never seriously been tried in East and Southern Africa because there are only a couple of styles available, and they're awful. Heck, back in the mid-1980's in the US there were few varieties, and uptake was dreadful even as the AIDS crisis was identified; many service organizations lamented this openly. Then the free market responded, and now there are many dozens, possibly hundreds, of condom sizes and styles available, and usage has soared. No one has even given Africa this chance. Under the Bush administration condom usage was not emphasized, believing it led to greater promiscuity. Yet every single circumcision researcher in Africa has stressed that even after the surgery, a condom must be worn every time you have intercourse without the intent to conceive. But this is not realistic until condom choice and availability become realistic.

3. HAART (or ARV). Highly active anti-retroviral therapy, or anti-retrovirals. This is the miracle news, not circumcision.

http://news.bbc.co.uk/2/hi/science/nature/8526690.stm

Most people understand that starting HIV meds will help contain the replication of the virus in a body and allow the immune system to largely rebuild, at least enough to stave off most opportunistic infections.

What many don't know, and even scientists didn't know for sure until about 3 years ago, is that once you get your viral load down below a certain level, you are statistically-speaking only remotely infectious. You still have the virus; but the risk of passing it through the traditional bodily fluids methods becomes miniscule. Below about 75 [copies per milliliter of blood] there is not enough HIV to routinely infect a healthy partner (healthy meaning neither partner has other complicating STIs or open wounds). This was shown with great promise in studies of Spanish, Italian and Swiss couples trying to conceive.

http://i-base.info/guides/pregnancy/swiss-statement

The trick is testing and treating people for all other diseases, including TB, before commencing HAART.

Even more exciting and encouraging is that studies have shown that Africans are even more compliant with taking their meds than Americans. One DC-based pharmacist who has been working in Africa told me in Vienna that on average, strict adherence to HAART is about 92% in the African communities studied, vs. about 73% in Washington, DC. In the past, many have argued that giving meds to poor Africans is a waste of money since they won't take them, which is not only racist and wrong, but a potential death sentence. There is far more family, work and community support for maintaining your drug regimen in those communities; no one wants to leave their children orphaned, lose an employee or lose the family farm.

HIV can be virtually halted in half a dozen years with HAART and condoms. Thailand and Brazil already did it. No reason Africa can't, especially with the billions they want to pour in there for mass circumcision.

Even circumcision's biggest cheerleaders don't suggest that approach would have anywhere near this efficacy in 6 years. Surgery is an extreme option, unless you happen to believe all males should be circumcised.

[buckeyedoc]

Frankly, it always seems to me that since condoms are the most effective way of preventing spread of HIV from M-F and F-M and M-M (aside from abstinence or very careful selection of partners), and there is no added benefit to being circumcised if you are wearing a condom, what is the point of using circumcision at all for HIV prevention? It's minimally effective, at best, on its own, and it shows no added benefit to condoms.

I work on a lot of drug/therapeutic studies that eventually go to the FDA for review if they look promising, and the FDA scientists always want to see proof of efficacy that some compound is superior to whatever is on the market or offers an added benefit when given in combination with something that is already on the market. I have no idea why the standards should be different with circumcision surgery for HIV prevention.