Africa study on HIV transmission and circumcision

[Blumbosa]

I keep reading about a recent study about HIV transmission in Africa being linked to uncircumcised men. It seems to be the new completely accepted mainstream idea. The NY Times magazine even ran a story about how circumcision may turn out to *be* the "AIDS vaccine" everyone is searching for. I have not found any refutation of this idea, or this study. I was hoping to see some information here on this board. Please, friends, help me understand this.

[Yoshua]

you will shortly....


I can paraphrase without proof but the study was flawed. they cut it short. they started it the day the men were circumcized which gave the intact men 6 months of sex when the circed men were healing.



Study was highly flawed and no major medical publication gave it credence or published it. The backers PAID to have it published, if it was not flawed it would have been published in something like the lancet.


People will come in with proof, but basically they are condeming africa to a slow painful death by spreading this misinformation.


Look at america, one of the highest infection rates in the industrialized world and also the highest circ rate.


That alone should show the study is flawed.

[Daisyuk]

From the Pasteur Institute on the first one.

Correspondence
Male Circumcision and HIV Control in Africa

Michel Garenne

In a recent article, Auvert and colleagues present the results of their randomized controlled trial on male circumcision to prevent HIV transmission [1]. They conclude that male circumcision reduced the risk of HIV infection by some 60% (95% confidence interval, 32%–76%). The trial was certainly well conducted, and it nicely confirmed observational studies, which came to the same conclusion [2]. However, a number of their concluding statements deserve a comment.

Auvert and colleagues claim a “degree of protection equivalent to a vaccine of high efficacy” [1]. This is obviously overstated. 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. Furthermore, the analogy with vaccines appears misleading. 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 different: they show 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.

A closer analogy of the “reduced risk” offered by male circumcision is that offered by contraception. Modern and efficacious methods such as hormonal contraceptives (pill, injectables, implants) or intra-uterine devices (IUDs) do offer high protection, usually 99% or above for women who are exposed repeatedly (every month) to risk of pregnancy. Highly efficacious methods do protect these women against unwanted pregnancy. On the contrary, a less efficacious method such as rhythm method (periodic abstinence) reduces fecundity by some 50%, but offers little protection against unwanted pregnancy. Even though women using consistent rhythm methods will have a lower number of pregnancies over their lifetime than women who use no contraceptive methods at all, they will be unlikely to achieve their desired family size, as could women using highly effective methods.

Similarly, for persons who are highly exposed to risk of HIV infection, as are the young men of South Africa, a 60% reduction in annual risk will ultimately protect only a smaller proportion. Basic probability calculations show that in discordant couples exposed for 30 years, some 74% will contract the HIV virus if circumcised, compared with 97% if uncircumcised (with incidence of 11% per year)—a small reduction indeed if compared with a highly efficacious vaccine (comparable figures would be 4% versus 97% for children vaccinated against measles who are exposed between 1 and 15 years of age).

One could argue that the population effect could exceed the individual risk for a variety of reasons ranging from herd immunity to prevention of other sexually transmitted diseases (STIs). If all men are circumcised, then prevalence among women will be lower, and men will have lower risk of being exposed and infected. However, several natural experiments do not confirm this argument. For instance, Tanzania has some 110 ethnic groups, some groups using universal male circumcision, others not circumcising. After controlling for urbanization, there was no difference in male HIV prevalence between the two groups: in urban areas, HIV seroprevalence was 9.5% in circumcised groups and 9.7% in uncircumcised groups, and conversely, 4.6% and 5.2%, respectively, in rural areas—none of the differences being significant [3]. In South Africa, the KwaZulu-Natal province, where few are circumcised, has a higher HIV seroprevalence than other provinces, reaching 37% among antenatal clinic attendants in 2003. But, in the Eastern Cape, where circumcision is the rule, the dynamics of the epidemic are almost the same, simply lagging a few years behind, increasing from 4.5% in 1994 to 27% in 2003. Finally, it was argued that the large epidemic in Abidjan, Côte d'Ivoire, and surrounding areas in the late 1980s was largely due to the lack of male circumcision of the local ethnic groups. This, however, did not impede the rapid increase in HIV infection among migrant workers from Burkina Faso and Mali living in Abidjan, who were circumcised.

For highly exposed men, such as men living in southern Africa, the choice is either using condoms consistently, with extremely low risk of becoming infected, or being circumcised, with relatively high risk of becoming infected. This is quite similar to women's choice to either use a highly efficacious contraceptive method or use a folk method. Some women make the second choice for religious reasons, with the obvious consequences. Is there a rationale for promoting the idea of circumcision when better choices are available? Regular condom use was found to be protective at the individual level and also effective for stopping HIV epidemics, as in Thailand [4,5].

Concluding that “male circumcision should be regarded as an important public health intervention for preventing the spread of HIV” [1] appears overstated. Even though large-scale male circumcision could avert a number of HIV infections, theoretical calculations and empirical evidence show that it is unlikely to have a major public health impact, apart from the fact that achieving universal male circumcision is likely to be more difficult than universal vaccination coverage or universal contraceptive use.

Michel Garenne
Institut Pasteur
Paris, France
E-mail: [e-mail]
References

1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Med 2: e298 DOI: 10.1371/journal.pmed.0020298. Find this article online
2. Weiss HA, Quigley MA, Hayes RJ (2000) Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS 14: 2361–2370. Find this article online
3. Tanzania Commission for AIDS, National Bureau of Statistics, ORC Macro (2005) Tanzania HIV/AIDS indicator survey 2003-04. Calverton (Maryland): Tanzania Commission for AIDS, National Bureau of Statistics, ORC Macro. Available: http://www.measuredhs.com/pubs/pdf/F...rontMatter.pdf. Accessed 15 December 2005.
4. De Vicenzi I (1994) A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med 331: 341–346. Find this article online
5. Zenilman JM (2005) Behavioral interventions: Rationale, measurement, and effectiveness. Infect Dis Clin North Am 19: 541–562. Find this article online

Competing Interests: The author has declared that no competing interests exist.

Published: January 31, 2006

DOI: 10.1371/journal.pmed.0030078

Copyright: © 2006 Michel Garenne. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation: Garenne M (2006) Male Circumcision and HIV Control in Africa. PLoS Med 3(1): e78


PLoS Medicine is an open-access journal published by the nonprofit organization Public Library of Science.
Creative Commons License All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution License.

http://medicine.plosjournals.org/per...l.pmed.0030078

Unfortunately, once again, they've released the two new ones' "results" to the media before any kind of peer review or publication - so no one has any idea of how they got them. It's all media hype once again. How do you fight something that has nothing based on anything more than a lot of biased scientists say so's?

Try common sense. SINCE WHEN WAS A BABY AT RISK OF HIV FROM SEX?

[Yoshua]

theres that proof i was talking about

[Daisyuk]

There is also this:

http://www.aidsvaccineclearinghouse....EST.Dec.14.pdf

"After theDSMB reviewed thedatatheydecided to end randomization in both trials and offer circumcision to the control arms. Both trials showed statistically significant results:Kisumu showed 53% efficacy and Rakai showed 48% efficacy. The Orange Farm study showed 60% efficacy."

Well isn't that a surprise, the efficacy goes down the longer you leave it....

And they want to circumcise HIV infected men too, just goes to show, it isn't HIV protection they're trying to spread, now is it?

"Researchers are blinded to women’s data but presumablyincidence hasn’t risen as trials are still ongoing(andhave notbeenstoppeddueto safetyissues)." LOL, it's clearly not going their way yet, so the trial can keep going.

I think they're condemning Africa to a slow and painful death

[Blumbosa]

What does it even mean?

Why would circumcision prevent the spread of HIV? Can someone explain the mechanics of what they are trying to say? Does the foreskin damage the woman's skin inside of her vagina? Or what? I am confused by the whole premise.

[stacyann21]

No. Actually there is more damage done with a dry, exposed glans due to circumcision. The premise is that the foreskin has Langerhan's cells which seem on the surface to be more susceptible to picking up HIV. The study was full of crap though and yes, unfortunately, it's the new "mainstream thing".

[Daisyuk]

Of course, just like circumcision cures or prevents TB, epilepsy, paralysis, all kinds of STDs, mental sickness, blindness....just add this century's bogey-disease HIV to the list.

I'm beginning to think that this might at last make the circumcrazies self limiting though. This is a fatal disease, and they're telling their sons they are protected if they're circumcised. Do you suppose they will get to reproduce before they contract and die of it?

Darwin Award Status By Proxy for Daniel Halperin, Robert Bailey, Alan Brody et al anyone? For promotion of the most idiotic "health intervention" in history.

[star2589]

I did the math. methodological errors aside, in a country with a low HIV rate, a 60% reduction means about nothing.

In the US, a 60% reduction would add up to about 2 one hundredths of a percent. or, 5000 circumcisions to prevent one case of HIV.

[G8P4]

Another problem with one of the studies I read about, is that, while the circumsiced men were healing, they were told either to avoid having sex or, if they did have sex, use a condom. Therefore, condom use increased in the circumcised group, as they "learned" how to use a condom, and may have been more motivated to do so (with a potential site of entry of HIV). The African studies are not talking about infant circumcision as far as I know (feel free to correct me, anyone who is more up to speed on this)...it is adult circumcision.

[Daisyuk]

Unfortunately, yes, they're after babies.

This has nothing to do with HIV prevention, they're after baby foreskins otherwise why would the people in charge be saying things like this:


""These (African) countries should now prepare how to introduce circumcision on a large scale," UNAIDS executive director Peter Piot told Reuters. "The science is clear."

"The focus should be on baby boys first, then adolescent boys and adult men, said Piot, who is in New Delhi to meet Indian officials to discuss how they plan to tackle the world's largest HIV/AIDS caseload of 5.7 million people."
http://www.alertnet.org/thenews/newsdesk/DEL116236.htm

UNICEF is also promoting child circ in Swaziland, at least, that's Alan Brody's domain. I shall never donate another penny to them, it's outrageous. He's been pushing since LONG before there were any studies, he's promoting it for 10 year olds up at the moment, but it won't be long before the kids get younger.

"But two prominent Americans based in the capital have aggressively pushed news of the circumcision research into the public consciousness here. Daniel Halperin, a researcher and AIDS technical adviser for the U.S. Agency for International Development, has convened meetings among Swazi doctors to discuss the research.

Alan Brody, the top official in Swaziland for UNICEF, began incorporating messages about the protective effects of circumcision in public education campaigns in 2002. With the results from South Africa, Brody has become increasingly vocal"
http://www.washingtonpost.com/wp-dyn...500749_pf.html

[buckeyedoc]

I've also read comments from AIDS experts criticizing the circumcision approach because its widespread implementation is more expensive than making antivirals available to HIV-infected pregnant women before and during delivery (which has a good chance of preventing infection of the newborn). It makes me suspect there is a real gender bias going on.

[dynamohumm6]

don't know how relevent this is, but a friend of mine told me this in response to a link. She worked in PR for years. The link in question had "advertorial" right there in the url...something to keep an eye out for whenever you run across one of these links.

Did you notice that the link is listed as an advertorial? Did you know that advertorials are put together by PR firms and ad agencies on their client's behalf. News programs run them all the time, hyping them as real news, when actually it's a paid broadcast arranged by the PR or ad agency.

Even if they're not hyping a particular product, it's product/service driven. And PR firms do it all the time.

[baybee]

This just in:



Please see:
http://zimdaily.com/news/129/ARTICLE...007-01-29.html

Male Circumcision and HIV Prevention - The Great Controversy
Mon, 29 Jan 2007 00:12:00
Dr Joseph Matare - HIV/AIDS Medical Officer - Namibia

In the quest to reverse the unabating HIV epidemic, various strategies are
being experimented with and researched to complement existing methods.

Already promising results indicate microbicides, to be used by women, may
have a definite impact in preventing heterosexual HIV transmission.

Women will have an opportunity to take total control of the prevention effort
in the frequent circumstances where men may decide not to use the condom.

Some of you may have heard of male circumcision being touted as a possible
method to prevent HIV transmission, especially for regions and countries of
sub-Saharan Africa hardest hit by the HIV epidemic.

The suggestion has been widely accepted in some quarters of the scientific
community as a potential effective public health approach to help tame the
epidemic in the AIDS belt that spans from East Africa through central Africa
and gets pretty huge in southern Africa (Malawi, Zimbabwe, Zambia, South
Africa, Namibia, Botswana, Lesotho and Swaziland).

On the contrary, other sections of the scientific community have been
outraged by the sudden interest in the absence of a skin on the men’s
privates as a “revolutionary” intervention.

And studies have been conducted in what other commentators have described as
somewhat “dubious” circumstances to support the hypothesis that circumcision
works. Other studies, on the contrary, have concluded that circumcision
confers no benefit as an HIV prevention strategy.

One may want to ask why suddenly people now think circumcision could be the
answer. This is because people looked at the epidemiology of HIV in terms of
the distribution of the HIV epidemic in the world and began to hypothesize
the possible confounding with local/regional social cultural practices.

Therefore, there could be something different about North Africa and most of
West Africa where the HIV prevalence is very low compared to the AIDS belt.

What they found prominently different about these regions is not only
religious persuasions but the practice of circumcision (which is also present
in some non-Moslem communities) of sub-Saharan Africa.

Immediately someone had the eureka experience that this then meant
circumcision had a preventative effect on HIV transmission, which infers that
if men were wantonly circumcised without any change in their sexual behaviour
(that had hitherto put them at risk) they would have this risk markedly
reduced.

Then studies (called randomized controlled trials) were conducted to
investigate the truthfulness of this hypothesis (assumption).

As expected, the studies were beset with ethical dilemmas. For the
circumcision to be proven whether it works or not, sexually active men who
were HIV negative at that time would have to agree to be randomly selected
(to reduce bias) into two groups. One group would be circumcised, and the
other would not.

One would want to ask the following question: How would they know
circumcision does work or not if the men were NOT exposed to HIV? That would
mean the men had to be “encouraged” to expose themselves to an HIV risk for
researchers to be able to compare the HIV incidence (new HIV cases) in the
two groups.

If circumcision really works, that is, it is protective, it is expected that
the HIV incidence rate in the circumcised group would have to be much lower
than the incidence rate in the uncircumcised group after a certain period of
the follow-up.

A study that was done suddenly showed that the group that was circumcised had
reduced HIV incidence compared to the uncircumcised group meaning
circumcision had an effect. In fact, the study had to be suspended because
the evidence was overwhelming!!!!

The researchers stated that they had advised both groups to consistently use
condoms (a proven HIV prevention method!).

Suppose the circumcised group, because they had undergone a surgical
procedure, which may take time to heal, prolonged their delay to return to
active sex.

This group may also have used condoms more consistently for fear of HIV
transmission because they still had potential unhealed wounds.

The HIV status of the women each of the individuals who had or did not have
the circumcision had “unprotected” sex with was not known. Therefore, suppose
by chance the uncircumcised man were unfortunate to have been in contact with
more HIV positive women, and the circumcised group having less infected
women, that would skew the results.

Also we do not know which of the two groups used more of the available known
method of HIV prevention: the male condom.

These are some of the many questions that were or could be asked in reviewing
this study. There is so much controversy about that and the jury is still out
(there is no conclusion yet) on the effectiveness of circumcision as an HIV
prevention method.

My opinion is that we should stick to proven methods of preventing HIV for
now. Mutual fidelity and abstinence are the gold standards.

Stay clear of persons whose status you do not know (assuming you know your
own!). If you have to have any sexual relations with the person (s), the
condom used correctly will reduce your risk significantly.

In conclusion, it is still premature to have male circumcision adopted as a
public health approach to prevent sexual HIV transmission.

If you should seriously consider circumcision for the sake of HIV prevention,
I strongly suggest one should circumcise his wayward and known risky sexual
behaviors, and one would not need to go “under a knife” to make this
possible.

[buckeyedoc]

Originally Posted by baybee

This just in:


If you should seriously consider circumcision for the sake of HIV prevention,
I strongly suggest one should circumcise his wayward and known risky sexual
behaviors, and one would not need to go “under a knife” to make this
possible.

Loving the last sentence! :

[Daisyuk]

Quite.

I so wish they'd looked at the effect on pregnancy at the same time...I bet they'd find that according to their "trial" circumcision has the effect of preventing pregnancy as well. ie. either the men weren't getting so much, especially at the beginning, or that they were more consistently using condoms.

Oh wait. They didn't allow the "study" to run long enough for that did they. I still can't get over the stupidity of all this.

A man has genital surgery, and over the following year he doesn't get a sexually transmitted disease at the same rate as a man who has been whole all the time. WELL DUH.

The only way of measuring it for certain is to take a population of HIV negative men and a population of HIV positive women, make the men wait for 6 months without sex (to throw out all the men who were infected but not seroconverted yet) circumcise half the men and ban them from wearing condoms, while you ensure (presumably by making them do it in some kind of lab facility, like they do with animals) that they all have sex exactly the same number of times. Then keep the men all isolated and test them up until 6 months to see who seroconverts.

Totally unethical and no-one would do it. That's how they get away with this crappy pseudo-science, with a million different variables you can't control for, no matter how much they cry "randomisation", not least of which is the likelihood of men from a patriarchal macho society lying about how many times they've had sex in the last week/month/year. I would also ask, exactly how random is a group of men who are willing/want to be circumcised?

[Yoshua]

I have another spin on that study.


Cut the men into fourths.

Circumcize half of them.

Make half of the circumcized men wear condoms, half not

Make half of the intact men wear condoms, half not.



Then you have a REAL control zone to see the truth about condom use as well.

[Ruthla]

The main problem is, how do you "make" a man wear a condom every time he has sexual intercourse? Or how do you prevent him from wearing one at least some of the time?

I'm still chuckling over "they ended the study early because the results were overwhelming." I thought they ended the study early so that the post-op celibacy time would skew the results?

[jessjgh1]

I thought they ended the study early so that the post-op celibacy time would skew the results?

Oh, Ruth, now you're talking conspiracy theories..... and I completly agree with you! (-;

Jessica