Friday, February 24, 2012

Circumcision in Africa to reduce HIV transmission

I think I blogged about this before. Anyhow there seems to be evidence, that those studies, used to justify the circumcision of men to reduce HIV transmission is not that great:

new research has cast doubt on the supposed efficacy of the procedure with an article in the December Australian Journal of Law and Medicine citing numerous flaws in the Kenya, South Africa and Uganda studies.

Researchers Gregory J. Boyle and Gregory Hill claimed the 60 percent reduction in transmission was only relative with the absolute reduction rate actually no more than 1.3 percent.
Boyle and Hill said: “What does the frequently claimed ‘60 percent relative reduction’ in HIV infections actually mean?

“Across all the three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18 percent) became HIV positive while among the 5,497 controls 137 (2.49 percent) became HIV positive.
“So the absolute decrease in HIV infection was only 1.31 percent, which is statistically not significant.”

The authors of the article insisted that the WHO/UNAIDS recommendation “uncritically accepted” the findings of the Kenya, South Africa and Uganda trials, in the process ignoring a vast body of contradictory evidence.

“Examination of epidemiological data shows that male circumcision does not provide protection against HIV transmission in several sub-Saharan African countries including Cameroon, Ghana, Lesotho, Malawi, Rwanda and Tanzania all of which have higher prevalence of HIV infection among circumcised men,” they said.

“In Malawi, the HIV prevalence rate is 13.2 percent among circumcised men and 9.5 percent among those who are intact. (Again) in Cameroon prevalence among those circumcised is 5.1 percent compare to 1.5 percent for those who are intact.

“If male circumcision reduces HIV transmission as the trials claim then why is HIV prevalence much higher in the United States (where most men are circumcised) than in developed countries where most men are intact (such as Europe, the United Kingdom and Scandinavia)?”

The article warns that relying on male circumcision in the fight against HIV/AIDS is especially dangerous for sub-Saharan Africa women because circumcised men could still acquire and transmit the virus to their sexual partners.

“Evidence suggests that mass circumcision programs may exacerbate the HIV epidemic among women (and) under these circumstances it would be irresponsible and unethical to advocate mass circumcision programmes in southern Africa,” the article concludes.

“Male circumcision is a dangerous distraction and a waste of scarce resources that should be used for known preventive measures (such as condoms which are 80 percent effective.” - Source

An article in the December Journal of Law and Medicine cites numerous flaws in three African studies that claim male circumcision reduces transmission of HIV. (see: the article here)

According to the article, the studies, which are being used to promote the circumcision of up to 38 million men in Africa, had selection bias, inadequate blinding, problematic randomization, experimenter bias, lead time bias, supportive bias, participant expectation bias, time-out discrepancy, and lack of investigating of non-sexual HIV transmission among other confounding factors and problems.

The absolute reduction in HIV transmission associated with male circumcision for the three studies was only about 1.3%. The African studies had cited the relative reduction in HIV transmission, a misleading figure. Reports in the popular press have been even more misleading. Furthermore, there are at least 17 observational studies that have not found any benefit from male circumcision in reducing HIV transmission. Since condom use after male circumcision is essential to prevent sexual transmission of HIV, circumcision does not have any additional value. - Source

From the linked Article in the above:
Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission:
Methodological, ethical and legal concerns - Gregory J Boyle and George Hill
In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventivemeasure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compro-mised by inadequate equipoise; selection bias; inadequate blinding; problem-atic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.

The over-emphasis on sexual transmission modes of HIV infection has fostered the implementation of unsafe and unethical mass circumcision programmes in Africa in order to "prevent" HIV. Tens of thousands of men have already lined up to get circumcised, after three studies purportedly showed a 60% protection benefit.

These mass circumcision campaigns continue to receive millions in funding from leading organisations, including WHO and UNICEF. These health aid organisations have received strong criticism from human rights organisations and experts who question the ethics and the purported health benefits of male circumcision.

Organisations such as Attorneys for the Rights of the Child, Doctors Opposing Circumcision, and Jews for the Rights of the Child have worked tirelessly to stop the practice of child circumcision in the US and around the world. These organisations have repeatedly called upon the UN to recognise the practice of male circumcision as a form of genital mutilation.

While these organisations are not opposed to adult circumcision, there are at least three grounds for opposition to the current mass circumcision campaigns in Africa. First, mass circumcision campaigns are based on misinformation, as men are not being informed of the functions of the foreskin.

Second, many countries are being pressured to draft plans for routine infant circumcision. Earlier this year, the South African Medical Association called these plans to circumcise infants for HIV prevention “unethical” and “illegal”. In addition to the dangers of circumcision, cells from "donated" foreskins are used to manufacture a wide range of biomedical products, ranging from skin grafts to facial beauty creams. (Oprah featured SkinMedica's TNS Recovery Complex on her show, a product which contains foreskin fibroblasts.)

Third, the three studies which purportedly show that male circumcision protects against HIV by up to 60% have several flaws. According to a UNAIDS demographic survey, 10 out 18 countries have higher HIV prevalence amongst circumcised males. Furthermore, the reported 60% protection benefit is for male acquisition only: studies show that male circumcision increases female acquisition of HIV by up to 50%. - Source

Not many Rwandan men are circumcised, but in the latest figures available for HIV prevalence among circumcised men (2005, later figures are yet to be released), the operation would appear to increase transmission. This is nothing unusual; in many countries HIV prevalence is higher among circumcised men; prevalence for circumcised Rwandan men is 3.8%, compared to 2.1% for uncircumcised men. So what evidence is the country using to persuade men to undergo this operation when they will still have to use condoms, which could protect them from HIV, unplanned pregnancy and a whole host of sexually transmitted infections in one go?

Indeed, national HIV prevalence in Rwanda is relatively low, at 3%. But female prevalence is 3.6%, whereas male prevalence is only 2.3%. As in all medium and high prevalence countries, rates are far higher among women, especially urban dwelling women, wealthy women and women with the highest levels of education. And it is not even clear if transmission from men to women is reduced by male circumcision. There is evidence that transmission from men to women may increase as a result of a mass circumcision program.

It is often claimed that HIV prevalence among Muslim populations is lower and it is even stated or implied that this is because Muslim men tend to be circumcised. In Rwanda, HIV prevalence is indeed lower among Muslim men than any other religious group. But Muslims as a whole have by far the highest HIV prevalence because female rates stand at 11.4%, compared to less than 4% for every other religious group. (It could be argued that polygamy, said to be common among Muslims, results in higher HIV rates; but rates are often lower where polygamy is common; besides, many non-Muslim groups practice polygamy, even if they identify themselves as Christian.) - Source

The study findings also show although men may be willing to be circumcised, and women approve, there are very real dangers associated with promoting MMC as an HIV prevention approach. Responses from study participants reveal myths and wrongly held beliefs about MMC – that it protects fully against HIV when it does not, that other prevention methods are not necessary when they are, that it allows men to have more sexual partners without increased risk, and that women are protected when they are not. - Communication Challenges in HIV Prevention: Multiple Concurrent Partnerships and Medical Male Circumcision - Panos Eastern Africa - Source

THE Ministry of Public Health and Sanitation in conjunction with the National Male Circumcision taskforce have expressed concern over reports of multiple sex partners among those who recently underwent male circumcision.

Nyanza provincial director of publichealth and sanitation, who is also the task force chairman Jackson Kioko, said therehave been reports that those who have been circumcised are taking it as immunity againstHIV.

Speaking during the launch of the resultsof the third rapid results initiative on male circumcision, Kioko said the taskforce will conduct a study to ascertain post-male circumcision sexual behaviour. During the launch of the exercise, itscritics including the Luo Council of Elders said the programme will be disastrous if not well packaged and the beneficiaries sensitised on itsimplication.

The council of elders argued that marketing male circumcision on the platform of preventing HIV was going to erode the overallgoal since many men will take it as complete immunity. - Source

The University of Illinois' Chicago School of Public Health study of 51 young women - presented in December 2011 in Addis Ababa, Ethiopia, at the 16th International Conference on AIDS and Sexually transmitted infections in Africa - found that most women were happy with the appearance of their partner's penis and enjoyed sex more after circumcision.

However, the study also revealed that more women than men were likely to perceive HIV as a less serious threat - 51 percent of men compared with 76 percent of female participants, and to feel that condoms were less necessary following circumcision - 4 percent of men compared with 51 percent of female participants.

A greater number of women than men said after circumcision, they were more likely to have more than one sexual partner - 22 percent compared with 2 percent of men, and to have sex without a condom - 28 percent against 2 percent of men.

The study was conducted in Nyanza Province, home to the Luo, Kenya's largest non-circumcising ethnic community and the focus of the country's male circumcision programme. Since 2008, more than 350,000 men have been circumcised in Nyanza alone; the government aims to circumcise 1.1 million men by 2013. - Source

The most obvious smoking gun: The United States of America
Circumcision hasn't stopped HIV in our own country.
http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf

And, it hasn't stopped other STDs either.
http://www.reuters.com/article/2009/01/13/us-infections-usa-idUSTRE50C5XV20090113?pageNumber=1&virtualBrandChannel=0

In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.
http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=419&Itemid=177

In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they're actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.
http://www.nejm.org/doi/full/10.1056/NEJMp1000069

The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009.


"[Washington D.C.'s] rates are higher than West Africa... they're on par with Uganda and some parts of Kenya."

Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009.
She once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe.

http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html

One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we're supposed to believe that what didn't worked in our own country, or anywhere else, is going to start working miracles in Africa.

Studies With Contrary Conclusions


According to USAID, "there appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."
http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431

Results: ...No consistent relationship between male circumcision and HIV risk was observed in most countries.
http://apha.confex.com/apha/134am/techprogram/paper_136814.htm

"Conclusions: ...[M]ale circumcision... is not associated with HIV or STI prevention in this U. S. military population."
http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102282676.html

One study which aimed at measuring male to female HIV transmission was ended early, because the results were not looking favorable. The Wawer study showed a 54% higher rate of male-to-female transmission in the group where the men had been circumcised. The figures were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women. Somehow that's considered unethical, yet it's considered ethical to promote male circumcision while not knowing if the risk to women is increased (by 54%?, 25%?, 80%? - who knows?)
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960998-3/fulltext

The latest study in Kenya finds no association between male circumcision and lowered HIV rates:
'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 that circumcised men are less likely to become infected with HIV.'
http://www.plosone.org/article/info%3Adoi/10.1371/journal.pone.0015552?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+plosone/PLoSONE+%28PLoS+ONE+Alerts:+New+Articles%29

Conclusion
A few select studies show a prevalence of HIV transmission in uncircumcised men, but real world empirical data shows that circumcision hasn't stopped HIV in countries where there is already a prevalence of the practice of circumcision, nevermind the United States. Yet, for whatever reason, leaders at the WHO continue to endorse it as HIV prevention policy and millions are being spent on so-called "mass circumcision campaigns," even in countries where HIV transmission was shown to be prevalent among the circumcised. - Source

And this huge source.

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