Male Circumcision and HIV

Sociodemographic and behavior/risk characteristics explain "effectiveness" of circumcision

In a long description of a recent study investigating the (real world) effectiveness of circumcision, Aidsmap has highlighted important data that reveals an association with sociodemographic (aka cultural and value-based) characteristics and HIV infection risk. The money quotes are as follows.

... Circumcision was significantly associated with tribal affiliation [hence, the common practice among a single group], high school education [perhaps indicating greater knowledge of the perils of unprotected sex], fewer marriages [a likely lower incidence of concurrent partnerships or greater emphasis on serial monogamy?], and a smaller age difference between spouses [indicating a greater power balance within marriage].

...

Since the majority of uncircumcised men belonged to the Luo tribe, sociodemographic and behavioural/HIV risk characteristics and HIV incidence rates between Luo and non-Luo males were investigated. Luo males were significantly older [indicating a longer sexual history], more likely to practice traditional African religions, were significantly older than their spouses by more than 10 years, and reported sex with a commercial sex worker. Regardless of the circumcision status, Luo men were 4.6 times more likely to become HIV-infected.

The largely American researchers, possibly exhibiting their pro-circumcision bias, came to the perplexing conclusion, "The findings provide additional evidence that circumcision by traditional circumcisers offers protection from HIV infection in adult men in rural Kenya where circumcision is common."

A more logical conclusion would be that differences in the ages of spouses, a history of using the services of commercial sex workers, generally more permissive behavioral patterns in sexual relations, and greater power differences between spouses are indicative of greater HIV infection risk. And this we already knew.

Fair use Aidsmap story below the fold.

Circumcision study proves reporters are stupid

[Ed. note: I half-ass rewrote this to reflect that some reporters are stupid. I'm going back to the original. Let the reporters plead their case in the comments.]

A recent study out of Canada has proven once and for all that reporters are only slightly more stupid than some medical journal editors.

What they did

They took intact penises and circumcised ones. They compared two discreet points on the remains of the circumcised penis with the anatomical equivalent points on the intact penis. They discovered that in the remaining tissue of the circumcised penis and the equivalent points in the intact penis, the two are more or less capable of reacting to stimulation at the same level to the same degree.

What they didn't show

They failed to show that circumcised penises are capable of equivalent sensitivity to stimuli as intact penises, the circumcised penises having lacked the necessary parts to compare. They merely succeeded in showing that as for the remaining tissue, stimuli can be said to be more or less equally felt.

Why this study

This study appears to be calculated to pave the way to greater acceptability of circumcision, particularly in light of the current push to circumcise the world in the name of AIDS. It further appears to be an exercise in over-simplification to appeal to lazy, uncritical medical reporters with a quota of stories to file on deadline.

Conclusions

Reporters are stupid, gullible, or both.

Male circumcision gives women the shaft one more time

Women are dying of AIDS while some researcher bends over his penis, smiles at it fondly, and imagines what little alteration would make it an all-purpose tool safe to use again.

Kelly Jean Cogswell reminds us that women need protection from HIV more than men -- and sometimes from men.

Women aren't factored in at all except as a vector of disease. While millions of dollars are already pouring into circumcision programs even if only men have foreskins to whack off, women are struggling for equivalent funds for female condoms and microbicides - never mind programs with as vague a goal as girl power, the real key to HIV prevention.

I could go on quoting from her article, but I won't. Why don't you go on and read it yourself.

Article after the jump.

THANK YOU to Adrienne Soti for forwarding this article.

San Francisco's AIDS Epidemic Becomes Endemic

If talk of disease stability makes it look as if we've averted the kind of crisis that would throw the world into total chaos, perhaps we should be thankful. But since HIV transmission is 100 percent preventable, we've earned very few bragging rights. - Mark Cloutier, Director, San Francisco AIDS Foundation

This may be a little San Francisco, California, USA -centric. However, I think it is important news for large, progressive metropolitan cities around the world.

Mark Cloutier (pictured third from the left) announced in May of this year that the AIDS epidemic in San Francisco was over. The disease has entered a period of neither increasing nor decreasing incidences of infection. That officially makes it an endemic condition. Persistently present, but not out of control.

Along with the finding that gay men needn't give up their foreskins for a safer time, this is good news indeed. The time has arrived to realize that HIV is becoming more like other chronic diseases. And responses in communities like San Francisco should be level-headed and measured instead of hysterical and in constant emergency mode.

What does a calm, measured approach to an endemic mean? I would suggest it means we can be more thoughtful about prevention campaigns. Outreach can be more targeted without fear of missing important , unidentified at-risk populations. The goal should be on lessening  message fatigue, so that at-risk populations can receive support and encouragement in avoiding risky behaviors.

Fair use article after the fold ...

Method and timing of washing after intercourse matters in HIV prevention

In a headline that misplaces the emphasis in a recent study, Aidsmap appears to slowly be slipping into the circumcision hysteria. Aidsmap reports under the headline, Penile washing after sex not a substitute for circumcision, that the method of washing matters in preventing HIV after coitus.

Washing only, reported in 46.9% of interviews, was associated with an incidence of 2.20 per 100 patient years. Using a cloth and washing was used in 40.6% of cases and was associated with an incidence of 1.04 per 100 patient years. And using only a dry cloth, 12.4% of cases, was associated with the lowest incidence, 0.55 per 100 patient years (p = 0.0442).

Waiting to wash 10 minutes post-coitus was associated with an even lower rate of serconversion. "[Washing within three minutes of intercourse caused seroconversion to be] significantly higher than the incidence of 0.39 per 100 patient years among men who waited at least 10 minutes after sex before cleaning."

The article stated that washing is being explored in situations and places where circumcision is not acceptable.

Session on Ethics in Biomedical Prevention fails to address male circumcision

The International AIDS Society can hardly be blamed for the failure to address male circumcision in their Ethics in Biomedical Prevention session. The 4th IAS Conference is dependent on the submission of abstracts to cover whatever issues are covered. Yet it is quite amazing that at least some researcher somewhere hasn't taken up this issue. So far it's all been lay organizations and the grass roots, with a few exceptions such as Aggleton's paper [pdf].

Still, there is one abstract with lessons that apply to the male circumcision context. How Informed is consent? Using a continuous consent process ... acknowledges that a few, short cursory questions and answers hardly addresses all the issues in any intervention.  The problem of course is that in the microbicide trials under study the ongoing nature of the intervention makes any breakdown in consent easy to correct either by stopping the trial or refreshing the knowledge necessary for consent to remain informed. Obviously, male circumcision is not amenable to this process.

Another concern is that male circumcision is typically researched and promoted by advocates, not scientists seeking purely scientific answers. Therefore, it is highly likely that the information imparted to participants will likely omit certain information and overstate other information. The reason researchers such as Bailey et al can make overbroad statements that "this is as good as evidence gets" is because so far researchers have not followed up on their study participants. A follow up is likely to  change the conclusions.

Bailey has recently said that the slow adoption of male circumcision is because money is not to be made from the procedure. Of course, this is a lie. But more importantly, money isn't the only motivator. Reputation and career ambition motivate, too. And Bailey is a prime exhibit of this.

Welcome to The Projects, a safer place than you think ...

Public policy activism is a grassroots affair. If you don't like what a United States public figure is doing, you have all the power of the First Amendment to fight back.

Concurrent with this post, we are debuting a new campaign we affectionately like to call The Projects. Each Project is named after an individual who is abusing his position to inappropriately promote circumcision or any policy that harms the fight against HIV.

Who decides what is harmful? Why, you do, of course. You decide and you write the letters. Don't agree? Don't write a letter. Do agree? Hopefully, you will find enough information on the The Project page to help influence the debate.

This weblog gets approximately 60 unique visitors per day, and is growing. That's a lot of letter writers. Let's harness that power to send a message to the individuals and their supervisors that we feel the actions of these people harm society.

We begin with The Robert Bailey Project. Click on the preceding link and go to work.

Real Evidence? Forget about it! We have mathematical models.

What do you do when the real world fails to cooperate and instead gives you evidence contrary to expectations? Well, naturally you ignore the evidence and use complex speculation instead.

The only sustained objection in litigation worse than relevance is speculation. A sustained relevance objection often means the cross examiner has nowhere to go with his questioning. Speculation on the other hand often points to a witness's underhanded attempt to distract or mislead the jury. And speculation is what a gratuitous mathematical model is.

Experts get to speculate sometimes, but not when there is perfectly good evidence available -- in this case epidemiological evidence. Why turn to modeling when you can turn to real data, such as was done by Talbott? Because the real data in this case won't help you sell the goods.

And so, here we go again with not social scientists but mathematics professors! That's right. Now the mathematicians have been recruited to show how magical [abstract] all this talk about circumcision is.

This study concludes with not so famous last words,

... an intervention will fail if steps are not taken to prevent the majority of men increasing their sexual activity due to overestimation of circumcision's benefits.*

There you have it, the great unknown variable. And as has been seen, circumcised men begin to approximate behavior of their uncircumcised brethren in a more permissive environment, thereby raising their infection levels to the average of their communities.

*Edit: I just noticed that the authors' conclusion is in fact contradicted overstated in the abstract by this observation: 

These benefits are lessened with increasing sexual activity in men who have been circumcised, with complete negation of the intervention occuring once a lower bound of 40% of men increase their activity.

Yeah, so forget a "majority of men increasing their sexual activity." You need a mere 40% to negate the benefit. But again, we already knew circumcision fails as an HIV public health measure from the epidemiological evidence.

Apologies for the heavy linkage.

Male Circumcision and HIV (and the controversy)

Finally, we have an acknowledgment of the controversy. Aside from the occasional comments on these pages from Daniel Halperin, acknowledgment of, much less confrontation with, the strong dissent in the HIV/circumcision discussion has been absent. (And if I am wrong, send me the links.)

So why is it that male circumcision has gotten so much boosterish attention from the HIV/AIDS community when "there does not seem to be a significant difference in prevalence between communities that circumcise, and those that do not" ? It's a good question about which we can hazard a few guesses.

For example, it isn't a secret that the primary researchers come from circumcising (or formerly circumcising) countries, primarily the United States and Australia. It also is no secret that there is money to be made and reputations to be built, egos to assuage and desperation to stoke by the sudden appearance of a silver bullet. At this late stage, of course, no one would take claims of a silver bullet at face value. So, the requisite warnings with a wink are trotted out: men still must use condoms, it must be part of a comprehensive approach, men want it anyway, etc.

Northern Zambia, where circumcision is the norm, has the lowest HIV prevalence in the country. But, according to Mutamba Simapuka of the Maina Soko Military Hospital in the capital, Lusaka, the protective benefits are more than biomedical; young men also receive lessons on fidelity in sexual relationships imparted to initiates.

Hasn't this been obvious from the beginning? Actually no, not to the researchers who are not social scientists. They would rather skip over this bit of social science data because it makes their scientific conclusions shaky at best, and positively harmful at worst.

When northern men migrate to Lusaka, with its looser sexual mores, "their prevalence rates equate with the local population", Simapuka told IRIN/PlusNews.

Clearly, a disaster is brewing as the social forces are ignored and hungry pro-circumcision researchers spread their message. What do these researchers do when real world epidemiological data don't square with their randomized trials? They create speculative mathematical models, of course. More on that later.

First article in PlusNews's series after the break.

AIDS researchers, conditioned to embrace negativity, poo poo good news ...

AIDS from a scientific point of view is no longer a death sentence. But researchers, confusing the political with the scientific, cynically poo poo the good news -- news that is in fact a reality today. The overlooked news is that it is now a disease almost exclusively of the poor.

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Blogged earlier from Digg ... follow link above for full story.