Male Circumcision and HIV

CDC inaccurately reports data, pushes agenda

The CDC has issued its latest white paper on circumcision and HIV. The inaccuracies and implausible conclusions show heavy lobbying by pro-circumcision forces working in concert to push their agenda on a governmental public health agency.

Let's take the white paper's various problems in chronological order.

1. Langerhans cells are target cells for HIV. This is untrue and contradicted by this study [pdf]. No scientific evidence exists for this and the state of the evidence today points towards a protective effect from a protein produced by Langerhans cells called Langerin. This protein is overwhelmed by HIV rather than the cells that produce it being a targeted entryway. It has been hypothesized that bolstering the production of Langerin could have applications in new prevention technologies.
2. The foreskin is subject to "traumatic epithelial disruptions during intercourse (tears)." This is not only contrary to common sense, but has no basis in any studies conducted to date. It is rank speculation that relies on ignorance of the mechanics of sexual intercourse for its plausibilty. In fact, it is more logical to theorize that tears and skin trauma occur more often in circumcised men where the skin is largely immovable and does not produce the same level of lubrication that an intact foreskin produces. Edit: Hugh mentions in the comments that the keratinized glans and scarring (which varies a great deal between men) could be more disruptive of the vaginal walls than the rolling action of the intact foreskin. I would count this as rather intuitive in that the two sexual organs evolved in tandem. It's counterintuitive that a foreskin is prone to "tears." Sounds more like one of those stories passed around to enforce conformity than anything scientific.
3. The preputial sac is more conducive to viral survival. Pure speculation without evidence. However, the idea behind this bit of supposing is that HIV can live in closed mucosal environments, giving it more time to cross mucosal barriers or migrate to susceptible cells. But this is all just a guess.
4. Higher rates of ulcerative diseases in intact men may increase susceptibility to HIV infection. The latest research contradicts the belief that circumcised men have lower rates of STDs. Read it here. It is likely that the evidence will slowly accumulate that STDs do not increase nor decrease susceptibility, but rather go hand in hand with high risk behavior that is a marker for high risk populations. This has already seen some acceptance outside of the North American context. Moreover, it is obvious that surveys conducted in sexual health clinics where these myths got their start will naturally produce corallations not seen in the general population.
5. Of 35 observational studies on circumcision and HIV, 16 had inconsistent results. Of the remaining 19, only two had any statistical significance towards a protective effect from circumcision in the acquisition of HIV. First, these statistics are presented in the paper in a highly misleading manner, making it sound like all the observational studies prove that circumcision is preventative. But in fact, the contradictory and non-reproducible results point in one direction: Insufficient evidence to conclude circumcision is protective. Though the intent is clearly to mislead, at least they got the stats in there managed to characterize the observational studies correctly as inconsistent and contradictory.
6. Although links between circumcision, culture, religion, and risk behavior may account for some of the differences in HIV infection prevalence, the countries in Africa and Asia with prevalence of male circumcision of less than 20% have HIV infection prevalences several times higher than those in countries in these regions where more than 80% of men are circumcised. And this alone tells you nothing. It is apples to oranges. The better comparison is between circumcised and intact men within countries, and more precisely of circumcised and intact men of same or similar ethnic backgrounds. This comparison, of course, may be impossible to do due to the inseparable nature of circumcision practices and culture in regions of Africa. Moreover, the way this is presented makes it sound like circumcised Africa has lower prevalence than, say, intact Latin America or intact Asia. The opposite is true. A number of examples of circumcised populations with higher rates of HIV than that of intact men in the same societies include Rwanda, Cameroon, Lesotho, Ghana, Malawi and Tanzania.
7. Male-to-female HIV transmission rates in a Ugandan study showed a non-significant trend towards a reduction when adjusted for viral loads. A trend that is non-significant is NO trend at all. In fact, it is simply misleading and manipulation of words and data to call something "non-significant" and a "trend." These statements, of which there are more, lay bare the agenda of the "consultants" to the authorship of this paper, namely Halperin, Bailey, Kilmarx, and probably Klausner.
8. In the randomized African trials, men who had been circumcised had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared to the uncircumcised control group. But ... the studies were never finished. They were stopped midway through for so-called ethical reasons, possibly including ethical reasons not considered when they began. The circumcised groups were counseled on a regular basis regarding safe sex practices, provided routine health care during the trials, and were provided with an unlimited supply of condoms. The control group received none of these. The conclusions drawn are simply not valid under the circumstances in which the trials were conducted. Moreover, they do not comport with real world observations, such as can be seen here [pdf]. Edit: An interesting comparison between the three studies showed a higher incidence of HIV among the circumcised Kenyans than the intact Ugandans. I'm not sure you can mix and match like that in these types of studies, but the contradiction was never addressed by the authors, who btw are the consultants to the CDC. They are the same people who essentially authored this paper.
9. Complications in the United States run between 0.02% and 2.0% depending on how you measure, and include bleeding and local infection. ... Study of two outbreaks of methicillin-resistent Staphylococcus aureus (MRSA) in otherwise healthy male infants at one hospital identified circumcision as a potential risk factor. True as far as it goes. But here again the authors gloss over this as if it were not important enough to give pause. The worst case for the given stats translate into 24,000 infant victims of complications a year. That's a whole lotta injured babies. There is no trivializing that number. Moreover, the MRSA is an emerging area the authors of the white paper are clearly reluctant to address, other than the obligatory acknowledgment that it is a problem.
10. Most report either improvement or no change to sexual function after adult circumcision. Adults seeking circumcision are not a good group to base conclusions on. They have an overwhelming vested interest in reporting a happy outcome. However, one study [abstract] reports a 20% rate of dissatisfaction. A failure rate of one in five is not a success, from many people's perspective. Still, the best studies involve those between intact and circumcised men. The most comprehensive and largest study to date has shown that the five most sensitive areas [pdf] on the penis are on the foreskin. Several other studies have sought to measure the number and type of nerve receptors on the foreskin. These number in the tens of thousands. Still sexual function is a highly personal affair prone to misreporting. Therefore, the uncertainty alone should be enough to recommend alternatives, such as condoms, responsible behavior, and frequent testing.
11. Circumcision is not associated with a reduced risk of HIV infection in men who have sex with men. The authors get this part correct, but you wouldn't necessarily realize it after reading the stats they provide. Statements like "a 3.5 fold higher risk for HIV infection ... [that still] was not statistically significant" do nothing for the lay reader but befuddle. If it isn't statistically significant, why mention the insignificant difference at all? In reality, two recent, very large studies have shown that men who have sex with men get NO protection, even for those who report an exclusively insertive role. See them here [pdf] and here [Aidsmap summary].
12. The authors acknowledge the ethical concerns "some persons" have raised to elective sexual surgery in infants, but wipe away worries by claiming others see no problem with it. Those "some persons" are frequent visitors to these pages. The "others" who see no problem with it typically are Wiswell, Schoen, Halperin, Bailey, Kilmarx, Waskett, Klausner, Weiss, and Morris, people who subscribe to The Gilgal Society, an organization that has as its main purpose the promotion of circumcision on social or sexual grounds (sometimes referred to as a fetish). And btw, it's only elective when the patient makes the decision. Parents don't make elective decisions for their children.
13. While the CDC formulates a policy of encouraging circumcision, individual men may wish to proceed with it. And that's the bottom line. The CDC, infiltrated with pro-circumcision (mostly) men with an agenda, really just want to encourage circumcision despite all the ethical issues and scientific uncertainty.

You can download the full report here [pdf]. See The AAP/CDC Project page for who to contact.

The AAP/CDC policy makers speak

The LA Times has published an article in the usual circumcision news story style. You have quotes from the parents who will and the ones who won't and the fence-sitters. Inevitably, the fence-sitters always do by the end of the story. And this piece is no different. However, there were some choice quotes in there that are perhaps revealing of what the American people can expect to see soon from policy makers on circumcision.

Peter Kilmarx, chief of epidemiology in the CDC's division of HIV/AIDS prevention, is quoted as basically advocating two things. That the United States shouldn't look to the rest of the world for a consensus on this issue and that universal health care should be extended, if only for this one procedure. Rather than question why the rest of the developed world finds routine circumcision on medical grounds a little absurd, he simply says we have the science and not the cultural handicaps to prevent us from engaging in circumcision. His major emphasis is, of course, on HIV.

Interestingly, he states that "The early opinion from the consultants -- and not the position of the CDC, which involves a peer review process and public comment -- is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted."

In other words, the consultants are that cabal of close-knit individuals to include Halperin, Bailey, Auvert, Morris (maybe, not sure on this one), Wiswell, Schoen, and a few others who have been well-known long prior to  the HIV/circumcision studies to advocate (and even write poems on) circumcision. They are all members of The Gilgal Society, a UK-based organization dedicated to the romanticization and sexualization of the act of circumcision.

Dr. Doug Diekema, on the other hand, is not entirely in agreement with Kilmarx. He also sits on the AAP Task Force on Circumcision and will take part in the revision of that organization's policy statement, due out this year. "The fact that circumcision is an even split these days is not a bad thing," he says. "If there are not religious beliefs, then parents really are left with the primary question of whether circumcision offers another benefit. The data are not compelling in either direction.

"The social pressure parents faced before to circumcise their sons was not the best reason to do it," Diekema continued.

Dr. Andrew Freedman is another member of the AAP Task Force. He seems less critical of the position Kilmarx takes on the data. Yet he states, "While [the circumcision studies are] important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant."

It's hard to know whether Kilmarx is simply close-minded on the issue of circumcision for reasons all his own, or whether he just doesn't respect the opinions of doctors and medical public policy makers in Europe and much of Asia, when he says, "The procedure is so ancient, and steeped in cultures, I'm not surprised that the rate of adult circumcision in civilized countries doesn't track with medical evidence. But as scientists, we don't solely rely on what other countries do as a guideline."

As a scientist, he would should be more open-minded. As an American policy advocate, he's staking out territory.

Edit: And you have to love the occasional slip that spotlights the prejudices and bias of people like Kilmarx. If by "civilized countries" he means rich, developed countries, you can imagine his regressive views on poor, developing countries that have managed to hold onto their foreskins. And this guy is making policy. Lord, help us!

Full fair use LA Times article below the fold with a few of my comments interlineated in red.

It's the routine, regular health care, stupid. Not the STI.

HIV/AIDS is becoming more like the circumcision debate of old by the month. Remember when circumcision was discussed in terms of lower incidence of urinary tract infections in infants and fewer cases of penile cancer in very old men? Back then, the brain dead press would chirp that parents are just trying to protect their babies dot, dot, dot "just in case." Never mind that blood and erogenous tissue of another, and not of the decision maker's own, and some $108,600 in health care spending (181 NNT x $600) were wasted to prevent one UTI, treatable at a cost of $30. Never mind that penile cancer is so rare, it really is statistically absent.

Now, we have this study [Aidsmap] that proclaims that "managing" sexually transmitted infections is "cost-effective" in "HIV control." Has it occurred to these blinkered researchers that perhaps attention to health generally is the antidote to behaving irresponsibly? If you're treating STIs, you're also educating the patient. You're also providing the kind of routine health care that can catch a new HIV infection early, which incidentally is when the newly infected is most infectious. You could say that treating drug addiction would have the same effect because paying attention to the welfare of the individual is the preventative. It's why single payer health care countries are healthier countries: they pay attention to the patient and leave the bottom line to bureaucrats (not a dirty word, btw).

The researchers got on this bandwagon while trying to figure out why circumcision correlates with lower incidents of HIV in West Africa compared to East Africa (but not when comparing intact vs. circumcised within the individual countries). Their theory however has been debunked already in the several trials to check whether treating herpes would reduce the rate of infection in those affected. It didn't. So what we really have here is a case of regular health care, not managing STIs, as the protective practice. Doesn't this sound suspiciously applicable in the case of circumcision and the control groups of the African studies?

So how is this like that old debate between the circumcision junkies and intactivists? Well you see, the bigger picture just isn't important to those who want to make a point justifying something they've been doing for so long. Doctors treat symptoms, not people. And if a hammer has been used to swat flies for several generations, it's hard to abandon the sturdy, heavy feel of a hammer for the light, flimsier feeling, but more efficient and less damaging fly swatter.

Reference

White RG et al. Treating curable sexually transmitted infections to prevent HIV in Africa: still an effective control strategy?. J Acquir Immune Defic Syndr 47: 346 – 353, 2008.

Notebook: Apologies, faithful readers

This month has kicked my ass. As soon as I think I have it under control, I'm hit again with another wave, including a trial. The good news is that we (co-counsel and I) won that one, too.

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And now a few missed stories ...

The Alexander Sanger commentary on the Planned Parenthood site was interesting [also available here.]. The way I understand Sanger, he questions the allocation of resources to a very imperfect and contradictory claim for circumcision in HIV prevention. He calls for a level-headed approach to prevention that promotes the most highly effective means of prevention, i.e. condoms, testing, empowerment of women, and education. With circumcision being highly contested, expensive to administer, and likely to become a poor substitute for condoms in the minds of those who undergo the procedure, it's likely to cause harm. Plus, he seems to say that it's just bad policy to allocate money down the list of least effective measures when the most highly effective measures have yet to be fully implemented.

Other stories deserved attention earlier in the month. There was the story from Belgium regarding the jail sentences for parents who refuse to vaccinate their children against polio. That one has implications in the HIV/circumcision controversy, although important distinctions exist. Perhaps more on that later. Perhaps readers could help out on that one in the comments.

There was the news out of Ghana where circumcision will now be promoted despite the fact that circumcised men tend to be infected at higher rates than intact men in that country. Same old story, except out of Ghana instead of Rwanda this time.

Finally, Reuters is reporting this morning on that old story from last month, that circumcised men are no more protected from STDs than intact men. Actually, the data slightly favors intact men. We knew this already as study after study over the years has swung from protective to not protective. Do we need any more studies on STDs and circumcision at this point? I doubt it.

The importance of the STD story is that researchers have seen a correlation between levels of STDs and likelihood of infection with HIV. The developed theory was that STDs increase the likelihood of contracting HIV due to inflammation and lesions symptomatic of so many STDs. However, we saw that treating a prime suspect in this regard, herpes, did no good in reducing HIV rates. Therefore, it would seem the theory doesn't hold. Of course, we don't know for sure. But clearly, the theory needs more study.

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Apologies, dear readers, for the intermittent nature of this month's posts. I'll do better next month. Thanks for reading.

Notebook: This Week In HPV/HSV/HIV

Nothing focuses the mind like waking up to stacks of files with looming deadlines and an expectant client sitting in your office asking questions about the trial that, by the way, starts tomorrow. A couple of concentrated weeks of longer than usual days cleared my desk if only for the next wave and we won the trial. So all's good and I'm back.

Meanwhile, the press churned out more blogger fodder in the week that was.

Treating HSV Does Not Significantly Reduce Risk of HIV

As has been reported here in an earlier post viz. men, treating HSV (herpes) apparently doesn't reduce the risk of HIV infection in women either, according to a study conducted in Tanzania [Medscape, reg. req.'d]. As the rationale behind circumcision has been that it also may reduce some ulcerative STDs, it therefore should reduce the risk of HIV. If circumcision does reduce risk of HIV, it isn't apparently due to a reduced level of ulcerative genital conditions in men from treating HSV as the earlier study so urgently hoped. Now, we know that the women being treated also get no benefit.

Bottomline: Early detection is probably the best defense against the spread of both HIV and HSV, which we have known of course for decades.

Secondary lesson: We still have no idea why circumcision may reduce the risk of HIV. Researchers are just guessing when they offer a rationale.

1 in 4 Teenage Girls

Sounds like the title of a horror movie, but instead it was the latest hysteria (Yahoo! News, link will expire) from the media. A bunch of researchers at the Centers for Disease Control and Prevention looked at data broken down into age groups. It isn't clear from media reports where they collected the data, but accordingly nearly half of African American girls have a sexually transmitted disease compared with 20 percent of white girls.

Apart from the smear of young black girls and the obvious appeal to hysteria, appropriately enough during STD Awareness Week, more, much more needs to be known about the sample and where it was taken. Moreover, the most common STD was HPV, a disease for which we have two vaccines for the most common types and which can also be completely cleared by the body. Either the researchers were highlighting the lack of screening or commenting on the sorry state of healthcare in the United States.

Despite Vaccines, Bored Researchers Study Circumcision to Determine Prevalence of HPV Among Men

Nothing like a hysterical headline to grab attention. UNCIRCUMCISED MEN RUN TWICE HIGHER RISK (sic) OF CANCER-CAUSING HPV blares the International AIDS Society. Of course, many other studies have shown only a slightly increased risk and other developed intact countries have much lower rates over all. Therefore, uncircumcised men probably do not run twice the risk unless they are in a country with a feudal healthcare system or lack early detection. Perhaps the title should have been AMERICAN MEN RUN TWICE THE RISK OF HPV INFECTION or AFRICAN MEN RUN TWICE THE RISK ... or whatever.

Besides, aren't they about to approve the two HPV vaccines for use in men? Oh yeah, yeah they are!