More evidence that condom use a primary source of stable HIV incidence

HIV negative men who engage in high risk sexual behavior but who also engage in sero-sorting, or the practice of choosing partners of the same HIV status, sero-convert at much greater rates than men who use condoms as their primary method of prevention, so reports a new study from The Netherlands.

When I read this article, it occurred to me that both sero-sorting and condom use would provide much greater protection than either alone. But then I realized that if you are using condoms, at an effectiveness rate of around 99%, sero-sorting would yield a negligible gain. So ultimately, condoms are the answer and everything else is a distant second.

An echo of this phenomenon can easily be imagined in the case of circumcision. HIV negative men who depend on circumcision as a method of prevention will sero-convert at much greater rates than condom users. Obviously. Give them condoms and circumcision simply has no effect at all on sero-conversion rates. Wasn't this the problem with the circumcision/HIV studies?

At any rate, the point here is, given condoms or discussing and choosing partners based on HIV status or in many cases perceived status, condoms win the effectiveness race every time. Given condoms or circumcision, the choice is equally obvious. Circumcision posits a hopelessly confused and confusing message that will not work and sets the stage for "prevention" based on wishful thinking and denial, and ultimately a worse epidemic.

Aidsmap fair use article after the jump.

Condoms, not serosorting explain stable HIV incidence in 'lower risk' Amsterdan gay men

Adam Legge, Thursday, September 13, 2007

Condom use – not serosorting – is the most likely reason why HIV incidence is stable among lower-risk men who have sex with men (MSM) in Amsterdam but rising among higher risk men.

Serosorting - where MSM discuss their HIV status and have sex with men of the same status – is thought to be the reason why HIV incidence in cities such as San Francisco has stopped rising despite increases in risky behaviour and STIs.

But the behaviour relies on a high level of HIV testing among the MSM population, for example in cities like San Francisco and Sydney where testing rates are over 90%.

Serosorting as a risk reduction behaviour has also been studied in London where testing rates are around 75% and now Dutch researchers have studied the behaviour in Amsterdam where HIV testing rates are even lower at 70%.

Contrary to the stable HIV incidence seen in some US cities, the Amsterdam STI outpatient clinic has seen a continued rise in HIV among MSMs above the age of 35. But HIV incidence in the general MSM Amsterdam population has remained roughly stable since 1991.

The researchers compared behaviour and HIV infection rates in two groups of MSM - 281 men classed as “lower risk” and 232 men classed as “high risk”. Behaviour was assessed by surveying the two groups of men during 2004 and 2006.

The men classed as lower risk were from the Amsterdam Cohort Study- an ongoing study of mainly gay men – which is estimated to have had a relatively stable HIV incidence at 1.24 per 100 person-years (PY) from 1999 to 2005.

Men classed as higher risk were recruited from the Amsterdam STI Outpatient Clinic population, in which HIV incidence is estimated to have risen in the same period to 3.75 per 100 PYs. In the high risk group 46% were HIV-positive compared to seven per cent in the lower risk group.

In both groups, men who discussed their HIV status with their partners were more likely to have unprotected anal sex (p < 0.001).

Fifty per cent of the lower risk and 72% of the high risk MSM who were HIV-negative reported having unprotected anal sex with partners of the same HIV status (concordant partners). HIV-positive men in both groups were more likely to have unprotected anal sex with concordant partners - 72% concordant and 22% discordant in the lower risk group (p = 0.07) and 82% concordant and 36% discordant in the high risk group (p < 0.001).

These findings suggest there is some degree of serosorting practised in both groups.

But men in the high-risk group were still more likely to have unprotected anal sex with partners who were either traceable but of a different HIV status or non-traceable anonymous partners of unknown HIV status.

The researchers say this suggests the stability in HIV incidence seen in the general population - compared to those attending the STI clinic - is due to condom use rather than differences in serosorting behaviour.

They conclude that - despite a lower rate of HIV testing - serosorting is practised in Amsterdam in both high and low risk groups but that the former are still more likely to have unsafe sex with HIV discordant or anonymous partners.

Reference

Van de Bij AK et al. Condom use rather than serosorting explains differences in HIV incidence among men who have sex with men. J Acquir Immune Defic Syndr 45: 574-580, 2007.

http://www.nam.co.uk/en/news/5E3EABAE-DF2F-4221-88B3-5C144E79A974.asp

Comments

[Ralph]

Condoms are only effective for 99% of times that condoms are used.

[Hugh]

That must be conceded. So circumcision (if - and it's a big if - the African studies are accurate) is a like a permanent, leaky condom. Coupled with the fact that once the glans has keratinised, men will be less willing to use real, non-leaky condoms as well.

[J]

It goes without saying that condom don't work if they aren't used but it also goes without saying that if one relies on circumcision to protect themselves from HIV I can promise them that they will contract HIV, eventually.

Which is what makes a statement like this,
... "It's now the most proven, effective HIV prevention strategy we have for male heterosexuals, so it's really important that we make this widely available," said Robert C. Bailey, so dangerous. To even suggest such a absurd notion, and seeing it regularly repeated in major papers, stuns me almost beyond the capacity for rational thought. As nonsense like this circulates through the population, we may lose what little control we have over this epidemic especially in the countries being targeted.

The WHO and UNAIDS support of such ideas appears to demonstrate the same abandonment of critical reasoning of a group or individual who believes defeat imminent. They'll be lucky if this policy doesn't create a surge in prevalence.

As I said before there are really two options you either:

A. Don't need a circumcision but you need to always wear a condom and you ought to be choosy about your sex partners.

B. You can get a circumcision but you need to always wear a condom and you ought to be choosy about your sex partners.

The dominant factor in these options is a condom followed distantly by being choosy about your sex partners. Along side condoms and selectivity, circumcision is irrelevant which is why the former must be unswervingly emphasized.

To concider circumcision is the best and only means, or even a reasonable option, for a man to protect himself from HIV means that man is not thinking too hard. But that is what Bailey et al are suggesting for Africa. Spin the barrel, pull the trigger you only have to be wrong once.

[Joe in CA]

Surely, as someone who is concerned with the spread of HIV, circumcision is but a myriad of possible "solutions" Bailey has up his sleeve, and isn't putting all of his eggs in this one (leaky?) basket...

[J]

Is Bailey et. al. trying to promote circumcision exclusively? Truthfully, I find it hard to tell; but, it sure sounds like it most times. I am sure when discussing the matter with the powers that be, or when a critical thinker in the media puts the screws to him, he cast circumcision in the light of a supplemental. But when you read in the mass media, like the Post, a statement like,
... "It's now the most proven, effective HIV prevention strategy we have for male heterosexuals, so it's really important that we make this widely available," said Robert C. Bailey.”, you really have to wonder. Unless he is talking about the condom, this is an astonishing, brazen, and dangerous lie.
Of course this is certainly not the first such assertion along these lines made by Bailey et. al. only the most recent that I am aware of. It has been nearly a non stop parade of exaggeration and and half truths for months. Do statements like those made in the Post send the wrong message? Just ask the French SIDA Info Service. In their recent statement, “Report on Male Circumcision, an Arguable Method of Reducing the Risk the Risk of HIV Transmission”, they are quoted as saying on Page 9, “...In France, SIDA Info Service has begun receiving calls from peopled wanting to find out whether, if the man is circumcised, it is still necessary to wear a condom...”. Similar misconceptions have been reported across Africa.
The response to these questions must be Yes, of course you still need to use a condom and be picky about your partners. When a South African walks into some clinic and asks, “What do I need to do to protect myself from HIV/AIDS”, you hand him a box of condoms. Then when he says, “If I get circumcised do I still need the condoms?” the answer is still Yes.
The whole issue really boils down to this, contrary to Bailey's assertion, correct and consistent condoms use is your best protection, circumcision is irrelevant. Circumcision is a proposed quick fix to a seemingly insurmountable problem. The problem with quick fixes though are they almost never work and usually make things worse but they appeal to those who want to shirk responsibility or not do the real hard work. To consider circumcision is to consider a situation where you might try and forgo the condom for whatever reason. In a low HIV prevalence population this is a bad idea, in a pandemic zone this is suicidal.

[Ralph]

An individual who is promiscuous will become infected regardless of his circumcision status. The point that people like Bailey make is that across a given male population as a whole circumcision (as he says) works like immunization in reducing the general incidence of female to male HIV infection in that population. Societies where circumcision is normally practiced have some inherent protection as a result we need to accept that and acknowledge it. The hard sell is where Bailey and other want to introduce mass male circumcision at all ages into hitherto non male circumcising societies.

[David]

Ralph:

Your point is a good one. However, the inherent protection has been demonstrated to be only valid in unlikely situations, such as where the circumcised men receive condoms and counseling to a degree the intact population doesn't. Reverse the situation and, as has been acknowledged by other researchers, there would no protective effect. Indeed, the danger is that the infectivity rate could be higher. The false comparison with Muslim communities is what got this ball rolling. More realistic assessments among circumcising and intact populations of the same cultural background have demonstrated little difference in infection rates.

- David

[Joe in CA]

"An individual who is promiscuous will become infected regardless of his circumcision status. The point that people like Bailey make is that across a given male population as a whole circumcision (as he says) works like immunization in reducing the general incidence of female to male HIV infection in that population."

Actually, given the fact that the circumcised group was instructed and councelled on the use of condoms and the uncircumcised group was not, not to mention the fact that the studies were intentionally ended prematurely, the results from the shoddy studies that Bailey uses to concede his "point" are questionable at best. Furthermore, Bailey over-states the examples in which "results" showed female to male HIV contractions to be less in circumcising populations, while conveniently choosing to leave out the examples where this was clearly not the case.

"... a population where male circumcision is widespread can also exhibit a high HIV prevalence. In Cameroon, where 93% of the population is circumcised, HIV prevalence among circumcised men is 4.1% compared to 1.1% among uncircumcised men. In Lesotho, where half of the population is circumcised, the prevalence among circumcised men is 22.8% compared to 15.2% among uncircumcised men6. There are numerous other contradictory examples. ..."

http://www.cns.sante.fr/htm/avis/rapports_pdf/07_05_24_rapport_circoncisions_eng.pdf

"Societies where circumcision is normally practiced have some inherent protection as a result we need to accept that and acknowledge it."

No, the under-stated examples above show that what we need to "acknowledge" is that this is most definitely NOT the case. The hard reality that circumcision advocates are faced with is the fact that an HIV epidemic afflicts the US itself, which is a country where circumcision is still very much routinely practiced. This is trebled by the fact that the circumcision rate in the US was at an all-time high during the late 70s and early 80s, when the HIV epidemic began. Circumcision has not served to prevent anything then, and it's not serving to prevent anything now.

Faced with this reality, one must wonder how it is study conductors like Auvert and Bailey managed to come up with results that defy reality. Could it possibly have something to do with the fact that these people have been long-time advocates of routine infant circumcision with an axe to grind?

A look back at history: the idea that "circumcision prevents HIV" was first introduced by one Aaron J. Fink back in 1986. Now, 20 years later, scientists finally manage to come up with "studies" that back this claim. The difference between other REAL studies and the recent Auvert/Bailey studies? In these cases, the solution to the problem came first.

But let's just say for the sake of argument, that Auvert and Bailey are honest chaps, and that their "findings" are correct, and that they would never do ANYTHING to manipulate their studies so as to get desired results for the agenda of male-circumcision propagation.

The implication in circumcising children and men as a means of female to male HIV prevention is that all males grow up to be straight, promiscuous, and ONLY have sex in the conventional penile/vaginal way.

The fact of the matter is that vaginal sex is not the only venue for HIV contraction. Men grow up to be homosexual. And even when they are straight, they still engage in sexual behavior outside conventional monogomous penis/vagina means (IE, straight anal intercourse, oral sex, menage a trois, etc.). Needle-sharing transcends sexuality, and even if circumcision DID prevent HIV like proponents claim, how would that prevent parent to child contraction?

The fact of the matter is that condoms, being 99% effective at preventing HIV, ANY DAY OF THE YEAR, would be clearly more effective than circumcision, which would only be 60% or so, effective for the period of one year (or less. WHEN were these studies terminated?).

"The hard sell is where Bailey and other want to introduce mass male circumcision at all ages into hitherto non male circumcising societies."

Given the fact that the results from the latest "studies" conflict with reality, the "hard sell" is that circumcision prevents anything, PERIOD. (Though it is quite an easy sell with countries and cultures that already circumcise...)

If, this statement is true: "An individual who is promiscuous will become infected regardless of his circumcision status."

Then what is this "protection" that must be "accepted" and "acknowledged?"

Can this "protection" truly be attributed with the fact that a population is circumcised? Or would it be attributed to safer sex practices? Because as already shown in examples above, one of the most crucial being that of the US itself, the statement that "Societies where circumcision is normally practiced have some inherent protection as a result..." cannot hold any water.

[Joe in CA]

One more tidbit I thought would be worth noting:

The claim often used to attack the foreskin as a "prime port of entry for HIV" are the Langerhans cells found within the mucosal lining. The intentional drying up and callousing of the mucosal mebrane is what is supposed to help prevent HIV infection.

However, just recently...

http://www.cirp.org/news/healthday2007-03-05/

Meaning, circumcising would actually be a form of protection DEPRAVATION.

Take the latest discoveries of the Langerhans cells as you will.

[J]

“Societies where circumcision is normally practiced have some inherent protection as a result we need to accept that and acknowledge it.”

Actually, I don't think this is necessarily the case. There are only a handful of societies where circumcision is routinely practiced: Muslim countries and communities, certain small tribal communities, Israel, and the United States; it is not common anywhere else in the world. Now the problem is that when we look at how western first world countries stack up in HIV prevalence, the United States is the clear winner. Most European countries, where circumcision is unheard of, have an HIV prevalence of between 1/3rd and 1/6th the US rate. The US rate is about 0.6% whereas countries such as the UK, the Netherlands, and Greece have a prevalence of approximately 0.2%, Nordic countries including Norway, Sweden, and Finland have a prevalence of approximately 0.1%, and Pacific countries including Australia, Japan, New Zealand have a prevalence of 0.1%. So the US, with perhaps 80% - 85% of the sexually active adult population circumcised has a significantly higher prevalence than countries such as the Netherlands where circumcision is unheard of. This is not just a comparison I noticed, in a recent statement published by the Australian Federation of AIDS Organizations, “Male Circumcision has no role in the Australian HIV Epidemic”, the AFAO said in part “African data on circumcision is context-specific and cannot be extrapolated to the Australian epidemic in any way.” followed by “...The USA has a growing heterosexual epidemic and very high rates of circumcision – in high prevalence areas it reduced the risk of female-to-male transmission. HIV rates were nevertheless high in both the circumcised and the non-circumcised groups...” (see http://www.circumcisionandhiv.com/files/CircumcisionIAS07.pdf)

Now the thing is that these estimates include all modes of transmission but I think it is also fair to say that life in general, the standards of living, and all other relative categories are far more comparable between Europe, Japan, Australia, New Zealand and the US than between the US and Africa. The prevalence rate differs so much between the US and Europe, one would have to find a transmission vector, such as IV drug users, that the US maintains a significant lead in to bring us in line with these other countries; I am not sure it can be done. Consider the Netherlands, even with their liberal drug policies, liberal sex attitudes, a generally unobstructed gay community, and substantial legitimized prostitution they've managed an HIV prevalence 1/3 of ours. Even South American countries, who also rarely circumcise and where many people live in the same impoverished conditions as in Africa, rates are similar or in some cases lower than ours.

Couple this with the recent research from the Dutch regarding Langerhans cells which, among other places, line the inner surface of the foreskin. It had been theorized that this was the HIV port of entry but the new research now says in part “...Researchers have discovered that cells in the mucosal lining of human genitalia produce a protein that "eats up" invading HIV -- possibly keeping the spread of the AIDS more contained than it might otherwise be....” (see Joe in CA's post for the link). Now the Langerhans cells produce Langerin and Langerin scavenges HIV. Considering that Langerhans and Langerin are components of the immune system and the immune system can be depressed in people who are weak due harsh living conditions, sickness, or undernourishment perhaps what is really going on is that weakened immune systems in African subjects increase viral loads in those already infected while at the same time increasing susceptibility, by reduced Langerin production. Perhaps in healthy populations, such as found in the first world, these mechanisms function better resulting in lower incident of infection in Europe, Japan, and New Zealand. Of the remaining two groups who circumcise I will point out they maintain relatively lower rates too, Israel is similar to Norway, Sweden and Finland for instance at 0.1% as are many of the Arab/Muslim countries. In the case of the Muslim countries, I think much of this is attributed to strictness of religion with Israel I am not so sure; they are certainly less strict in sexual matters than Muslim countries but I am not sure if they are as promiscuous as Europeans or Americans.

So what does all of this tell us? Obviously behavior is a large component but looking at first world countries it is certainly not apparent that circumcision is terribly relevant, that is what the AFAO statement referenced earlier is saying; it may even be possible that it has the opposite effect. Perhaps Africa is simply a product of their environment, I thing that is almost certainly true.

And this is where the rub starts to come, how do we handle it? Considering the large degree of the problem and the relatively small amount of available resources I think we need to focus on interventions that make the most efficient use of these resources. If a condom is 0.03 cents and is 99% effective this needs to be the primary focus. Is this effort being maximized? In a recent post on this board discussing:
Hallett TB et al. Behaviour change in generalised HIV epidemics: impact of reducing cross-generational sex and delaying age at sexual debut. Sex Transm Infect 83 (suppl 1): i50-i54, 2007, the article said in part “...(for example, condom use at the last sexual act was reported by 17% of males and 8% of women)" which makes me wonder with an epidemic so wide spread why is condom use SO low? Are people unwilling to use condoms or is it a case of not enough availability? Whatever it is, this problem needs to be addressed first. Perhaps there is not enough money to provide a sufficient supply of condoms country wide; by offering circumcision, more of that money could be shifted away. Each circumcision would likely cost 1000x the cost of a condom and you still need them anyway. Taken another way each circumcision means somewhere around 1000 fewer condoms could potentially be available. Since circumcised men need condoms anyway we should focus on ensuring assured availability and regular usage, certainly higher than 17%. Then after that, and once all other needs are met (such as availability of anti-viral drugs and generally improving their lot in life), we can consider circumcision. If that is done it also must be strictly limited to consenting adults who are properly advised to all the fact including that a 50% relative risk reduction shown in the trials represented an absolute risk reduction for an individual from 3% to 1.5% and of course you still need the condom.

Finally for those who haven't read it:
http://www.news24.com/News24/South_Africa/News/0,,2-7-1442_2115519,00.html