Male Circumcision and HIV

Notebook: Idaho Edition

Idaho Falls in the great state of Idaho didn't inspire any great insights into the problem of prophylactic circumcision. But whiling away the hours at my grandmother's house did provide me with the opportunity to catch a little C-SPAN. One program in particular caught my rapt attention for about an hour and a half.

I caught only a part of the program and at that, only Part II of the three part series. In the section I saw, George Lakoff, Frank Luntz, and Andrew Westen gave a panel talk at the New York Public Library on the science of communication in the political discourse of the United States. (I'm posting all three parts below.) This fascinating program, entitled THERE YOU GO AGAIN: Orwell Comes to America, goes straight to the core of how some ideas take off and others don't. Clearly, you don't have to be in politics to see this is a very important area of study.

Before we begin the show, I would like to share not exactly an insight, but a little insightful family history that I experienced anew while I was in situ, Idaho Falls.

My grandfather passed away some six years ago. In the basement of the house he occupied for half his life, he kept a small office. It was walled off from the rest of the basement by a small enclosure that he paneled in deep mahogany tones. There on the shelves he also built, books could be found on his many intellectual indulgences, including amateur radio, the classics, history, literature, alternative theories on just about everything and of course on the topic of his training and chosen profession, physics.

It was he who had not once but several times asked me in our occasional phone conversations between his office and my home in Texas whether I knew what the most common surgical procedure in the United States was. I of course did know, and with my grandmother on the upstairs phone, would proceed to tell my opinion on the matter. Eventually, my grandmother, who delivered my Uncle at age seven to the surgeon, would try to end my rant with, "Ok, we get it, ... moving on, moving on ... ."

I have no idea and did not ask, nor frankly was ever tempted to ask, whether my grandfather was intact ... although I wondered. He was born in 1910 in Michigan to a Dutch mother and a German father. So it is likely he made it through life just fine. He made it clear by the insertion of the word unnecessary in the question how he felt about it. But he was a patient man in a house run by a stern disciplinarian who raised her three children according to the dictates of her own upbringing that left no room for the tolerant easy-going acceptance of my grandfather.

So, standing in his small office, I looked around at the cleared shelf space once occupied by books and amateur radio equipment. The desk was a mess. The floor was scattered with records of long ago radio communications between amateur radio operators from around the world and my grandfather. Boxes of personal effects and records from nearly 30 years of retirement were scattered around haphazardly. A faded picture hung on the wall of the bell tower at my grandfather's alma mater, the University of Michigan. This was the inner sanctum, walled off from the rigid religious world of my grandmother, but which now was reduced to salvage by his surviving children and grandchildren.

This life is short. We all know that. Once we die, the book is finished. The story is set in stone. The pages will begin to fade. And there will be no more creating, legacy-making, or changing the world in the deceased person's unique way. And so, my grandfather leaves behind not the seed, but the encouragement that he provided by asking the question, and giving me the courage to challenge circumcision. It's a gift I cherish.

Outside, the sky dumped a foot of snow while I was there. And my grandmother, who I love very much, told me that she often thinks of my grandfather out there in the ground where he is buried and it is very cold. I told her that she shouldn't worry. He's not feeling it. I was thinking that, even as I was feeling his presence downstairs in that cold basement. And I felt very warm inside.

For your viewing pleasure, please click below to go directly to the program's page for a synopsis and the audio and video podcasts.

Live from the NYPL
THERE YOU GO AGAIN: Orwell Comes to America

Part I Propaganda Then and Now: What Orwell Did and Didn't Know

Part II Deceiving Images: The Science of Manipulation

Part III Soluitions: The Future Political Landscape

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TIME Magazine's Top 10 Medical Breakthroughs: #1 - circumcision prevents HIV

Time magazine claims that circumcision "can prevent HIV" infection. Apart from naming the lie that such an assertion is, what else can you do about it? I suppose you can write them a letter, go to their talk back page.

Let me share a little insight I have finally begun to rediscover recently. People in the United States are just not equipped to deal with issues requiring critical thinking skills. In this way, Americans are more tribal than our counterparts in the developed world. As such, people in this country by and large simply see nothing wrong with performing medical procedures of marginal value on patients of whatever age. If the parents or some perceived authority figure says it's ok, then it's ok. This is our reality in the United States.

Diseases, such as HIV/AIDS, will come and go as justification and the circumcision rate will rise and fall, but it is a practice that has integrated itself like some annoying viral infection into our DNA. Not until some major disruption comes along will the people of the United States in the masses learn to assess what is or is not good for them.

Link: Top 10 Medical Breakthroughs - 50 Top 10 Lists of 2007 - TIME.

Notebook: Happiness and Development

Human rights may be the luxury of a rich and secure society. Only in such societies can one contemplate happiness. Perhaps where the happiness is not defined by freedom from hunger and fear, the abstraction can be debated. Yet many a philosopher has postulated that wealth and security are the results of human rights in the sense that the fruits of a full stomach and security in one's person are the realization of one's maximum contribution to society. And a society where every member is contributing maximally to the best of his or her ability is one that is rich and secure. Kind of circular.

So on the upside of this circle, we debate the violation of one's physical integrity. Maybe this explains why Ugandans and Zimbabweans are said to be rushing to get circumcised, absent any real security and in the midst of plenty of hunger. And so it all comes back to development. The citizens of those countries and others will accept anything on the downside of the circle because they frankly don't have that much to lose. With low life expectancies, loss of sexual tissue for the off chance that life may be extended is an easy choice easily exploited by the likes of Halperin, Klausner, and Bailey.

But we in the West have plenty to lose. And so many of us will not accept circumcision. And so Richard Duncker, trustee of NORM-UK, gives us his take on happiness once violated by infant circumcision.

Link: Are you happy? Richard Duncker, yoga teacher & trustee, Norm-UK | Weekend | Guardian Unlimited.

LA Times: AIDS displaces the basics thanks to the billions of the Gates Foundation

Balance. Or is it prioritization?

How does one criticize a lack of balance in priorities without appearing to take a cheap shot at the very generous donors to HIV/AIDS causes? The first step is to accept that very pointed interests are at stake: those of the program directors, managers, and allocators (among many sometimes unapparent others). And the second step is to understand that ranking of relative need is in no one's interest except, of course, the patient, although ostensibly there are rules to deal with this problem, i.e. rules of professionalism and ethical canons, etc. Thirdly, the patients' needs nominally have first priority as noted, but in a competitive system of allocation, the better financed, organized and pitched program, disease or organization wins the day.

The Los Angeles Times reports on the Gates Foundation and the unintended consequences of large donors to the fight against HIV/AIDS, a very high profile disease. The obvious import of this issue viz male circumcision and the almost glamorous presentation of it by the media and some AIDS organizations, including most puzzlingly those concerned with vaccine research, should be obvious to readers of this weblog.

" Dr. Peter Poore, a pediatrician who has worked in Africa for three decades, is a former Global Fund board member and consultant to GAVI (formerly the Global Alliance for Vaccines and Immunization). He says they and other donors provide crucial help but overstate the impact of their programs. 'They can also do dangerous things,' he said. 'They can be very disruptive to health systems -- the very things they claim they are trying to improve.' "

...

"Who chose the human right of universal treatment of AIDS over other human rights?" asked economist William Easterly, co-director of the New York University Development Research Institute, in his book "The White Man's Burden." He added: "A nonutopian approach would make the tough choices to spend foreign aid resources in a way that reached the most people with their most urgent needs."

However, to be explicit AIDS prevention and research efforts span many areas of concern. Male circumcision, despite its complex and uncertain real world impact, is one more offering competing for funding, attention, and the spotlight. The likes of its promoters are simply filling the natural but often harmful role of the careerists, such as those discussed in Helen Epstein's book, The Invisible Cure.

This is why a grassroots effort such as that which this weblog is concerned with eventually requires formal institutions and networks. And for that, one typically needs first and foremost funds. Funds then buy paid staff, professionalization, and well, more funds frankly. To counter careerists who have adopted male circumcision and HIV as a vehicle, you gotta pay to play (or rather to effectively organize and advocate).

Fair use LA Times story below the fold. Note: Follow the link at the end of the article for a richer read with photos, boxes, and links.

German researchers make major discovery in infectious potential of HIV

A German research laboratory has made a key finding in the infectious potential of HIV. A key protein component in semen apparently makes HIV 100,000 times more infectious than it otherwise would be. Rather than the speculation (trapped germs, etc.) that is rife in the popular press and among epidemiologists such as Halperin, Bailey, and Klausner, the German research community has dug deeper to find out why sexual contact combined with a fragile virus has lead to such an explosive spread of HIV/AIDS. Follow the link for the full story.

Link: Protein in semen found to boost infectious potential of HIV.

Aidsmap | US study suggests circumcision does not protect black or Latino MSM from HIV

Follow the link for a more detailed summary of the recent study that found no protective effect from circumcision in gay men.

One confounding statement the study authors make, paraphrased here:

Although two previous US studies examining the relationship between circumcision and HIV status suggested that circumcision conferred a protective effect from HIV infection these previous studies had primarily enrolled white MSM. The investigators think this study came to different conclusions “because HIV infection is disproportionately higher among black and Latino MSM than among white MSM in the United States” and it is possible that “the greater background prevalence of HIV infection in black and Latino MSM communities diminishes any protective effect afforded by circumcision.”

If a "greater background prevalence of HIV infection" diminishes the protective effect, how did the African studies conducted in very high prevalence areas manage to show a protective effect? Do the researchers conclude that circumcision is protective only in lower prevalence areas? Isn't this contradictory? It sounds like they're trying to say that circumcision is good in the US context only before or while prevalence is low. I can't think of a more perfect example of trying to have one's cake and eating it, too.

Link: Aidsmap | US study suggests circumcision does not protect black or Latino MSM from HIV.

Observations on Sansom cost-effectiveness analysis of circumcision against HIV infection in males

The following is a revised [12/11/2007] rebuttal analysis prepared by several observers of the recent presentation to the CDC viz recommendations on circumcision and HIV and STDs. It is extraordinarily distressing that the US government is contemplating promotion of genital surgeries not just on the poor evidence viz. public health benefit, but also given that the US pretends to be a leader on human rights issues. A country gaining a reputation for torture and blatant disregard for the well-being of the rest of the world can ill-afford to now have non-consensual genital surgery added to the list of American questionable practices.

Samson et al. analyzed whether circumcision is cost-effective in preventing HIV infection in males in:

EFFECT OF CIRCUMCISION ON U.S. MALES' EXPECTED LIFETIME COST OF HIV, Stephanie Sansom, PhD, Angela Hutchinson, PhD, MPH, Q An, I Hall, A Lasry, and A Taylor. Centers for Disease Control and Prevention, Atlanta, GA

Their results are summarized in Table 1.

Tablle 1. Expected lifetime cost of HIV for uncircumcised v. circumcised US males by race/ethnicity, 2003-2004 ($US 2006)

	Uncircumcised	Circumcised	Difference
All males	$2381	$2041	-$340 (14.3%)
Black	$8050	$6916	-$1134 (14.1%)
Hispanic	$3515	$3175	-$340(9.7%)
White	$1168	$1066	-$102 (8.7%)

Costs used in calculations:

Circumcision cost $678;
HIV treatment cost $113,381.

It is anomalous for the relative benefit for all males (14.3%) to be higher than the highest relative benefit for any of the ethnic groups. This suggests that the difference for all males ($340) is incorrect. If the differences for each group are correct, the difference for all males, based on the distribution of births by race/ethnicity in 2004, is approximately $310, and the relative benefit is 11.5%.

Although Table 1 makes it appear that circumcision has the greatest relative benefit among Blacks, it is, in fact, among Whites that the greatest proportional reduction in the incidence of HIV due to circumcision would take place to produce the figures in the table. The table implies that circumcision would reduce the number of infections among Whites by 66%, among Hispanics by 29% and among Blacks by 23%.

According to Sansom, "We assumed lifetime HIV risk from heterosexual behavior only reflected a 50% reduced risk among circumcised males." Does that imply that the assumption was made of no reduction in risk from MSM behavior and IDU, which, between them, were responsible for 85% of all infections? That would be a reasonable assumption because, recent studies have shown no protection by circumcision in MSM while, clearly, being circumcised offers no protection from infection by IDU. If the analysis makes the assumption that circumcision reduces risk of heterosexual transmission, which currently accounts for only 15% of all transmissions, by 50%, and has no effect on the risk of transmission by other modes, it is hard to see how circumcision could reduce the number of infections among Whites by 66%.

" An analysis which does not take into account all costs and benefits of a measure is useless and even if a measure has a net financial benefit it does not necessarily follow that it should be adopted."

The benefit for all males according to Table 1 implies that that circumcising all of the approximately 2.12 million boys born annually in the US would result in a reduction in the number of boys in an annual cohort from being infected during their lifetimes of about 19,000. Even using the lower benefit of $310, the implied reduction would be about 18,500.

These figures seem extraordinarily high compared with the current number of annual infections in the US. According to the 2005 HIV/AIDS Surveillance Report published by the CDC, 4,255 males were infected by heterosexual mode in 33 states which it is estimated account for 63% of nationwide infections. Taking into account the different distributions of mode of transmission by race/ethnicity and the different prevalences of circumcision by race/ethnicity, if circumcision reduces a man’s risk of infection by 50% then approximately 10,400 males would have been infected nationally if none was circumcised and approximately 5,200 if all were circumcised. In other words, if circumcision reduces a man’s risk of infection by 50% then if 100% of the males in the US were circumcised, there would have been about 5,200 fewer infections than if zero were circumcised.

It is difficult to reconcile this relatively low number with the almost four times higher number in Sansom's analysis. Could this mean that Sansom is assuming a much higher prevalence of HIV or risk of infection in the future, which would cause a rise in the incidence (and boost the cost-effectiveness of circumcision if circumcision is assumed to halve the risk)?

In Sansom's analysis, if the reduction in the number of lifetime infections in an annual cohort was less than about 12,500, the net financial value of circumcision to prevent HIV would be negative, i.e., the immediate cost of circumcision would exceed the expected future savings in HIV treatment costs. Again, comparing the required reduction in the number of infections with the current annual number of infections by heterosexual mode, it is difficult to see how circumcision could prevent a large enough number of infections in the future for the net financial value to be positive.

Apart from these arithmetical issues, there are other more serious and less easily remedied problems in Sansom's attempt to establish whether circumcision is justifiable.

The analysis appears to consider only the financial benefits of circumcision in preventing HIV infection against the cost of circumcision.

A true financial analysis must include all costs and benefits, and even that would be inadequate. A comprehensive financial analysis might provide "compelling" evidence that radical female mastectomy at birth or adolescence or after child-bearing is financially advantageous, yet it would not persuade the CDC to assert that the "benefits of prophylactic mastectomy outweigh the risks." It does not follow that something should be done simply because it is financially advantageous. Life is more than financial advantage.

Ignoring other financial costs and benefits renders Sansom's analysis useless because the net present cost of all other financially calculable costs and benefits might exceed the net benefit in respect of HIV and, even if a comprehensive financial analysis showed a net financial benefit of circumcision, it would not necessarily follow that boys should be circumcised.

Another major weakness, perhaps a fatal flaw, is that the analysis makes predictions about highly uncertain events in the future. Computer projections are too often treated as if they were crystal balls enabling people to see the future clearly and with certainty, when the future they reveal is dependent on assumptions that may be way off the mark. The future course of HIV is wildly uncertain. The average age of infection in the Sansom model is 36, i.e., for boys born in 2008, that would be the year 2044. Does Sansom's model assume that the incidence of HIV infection will be the same in 2044 as now?

That no progress will have been made in preventing or curbing the disease in the next 36 years? It's possible, but it's just one possibility in a range of possibilities that includes the possibility that a vaccine will have been developed well before then. Any analysis that relies on the assumption that HIV incidences will not change in the next 75 years or, more broadly, relies on any assumptions whatsoever about the incidence of HIV in the distant future, is inherently unreliable.

To sum up:

1. There appear to be flaws in the conduct of the analysis.
2. An analysis which does not take into account all costs and benefits of a measure is useless and even if a measure has a net financial benefit it does not necessarily follow that it should be adopted. It is difficult to incorporate all advantages and disadvantages of a measure into a financial analysis because many are not reducible to or expressible in dollar values. Beyond that, moral and ethical considerations can easily outweigh financial considerations.
3. No reliance can be placed on an analysis based on assumptions about such uncertain values as the future incidence of HIV.

Sansom's analysis is a paltry one upon which to base a recommendation concerning the circumcision of 20 million US-born boys in the next decade.

Download sansomobservationrevised.pdf

Editor's note: Yet another variable is relative cost of the two controls. Circumcision surely won't be getting any cheaper given the longstanding practice in the United States at government expense. But HIV treatment may in fact get substantially cheaper, for example, if the US turned to universal healthcare.

PLoS ONE : Publishing [schlock] science, accelerating research[er bias]

Dr. Robert Van Howe of the Department of Pediatrics at Michigan State University College of Human Medicine in Marquette, Michigan responds to the recent study disproving a correlation between circumcision and greater risk of HIV infection.

" What is most troubling is that the [article] submission made it through the review process without it being noticed that the results of the study contradict the conclusion in the abstract and the title of the article."

What should people make of this blatantly dishonest mischaracterization of the evidence? Follow the link for Dr. Van Howe's full critique.

THANKS to the Intactivist Pages for cluing me in to Dr. Van Howe's rebuttal and critique.

Link: PLoS ONE : Publishing science, accelerating research.

Reuters: Circumcision does not affect HIV in U.S. men

Reuters is reporting that circumcision does not protect against HIV in black and Latino men, consistent with the Sydney study, in the first media-wide reports on this new survey.

Unfortunately, the reporter can't resist repeating unproven speculation as to why an intact penis has been cited to be dangerous, citing unlikely methods of entry through "tears" during intercourse.

Link: Circumcision does not affect HIV in U.S. men: study | Health | Reuters.

CDC Expected To Raise Estimates Of New HIV Infections In US

One wonders if this rather complex maelstrom of information and reports is also making the decision makers nervous, since they touch on politically sensitive issues, and any suggestion that the big organizations don't know what they are doing will shake confidence and perhaps make until now generous aid donors tighten their purse strings.

Large international and national monitoring organizations frequently raise and lower estimates of all sorts of incidence in many different fields. Why are the CDC, UNAIDS, and other organizations is the media making such a fuss out of this process? They say that the "real" figures are the same, but their methodology has improved. Yet, one gets the distinct feeling that something more is happening under the surface. It's a kind of frenzy that is reminiscent of economic shocks.

I don't know what to make of this. But I think it bears mentioning ... and watching.

Link: CDC Expected To Raise Estimates Of New HIV Infections In US.