Male Circumcision and HIV

Swiss recommendations now state that HIV positives on effective anti-retroviral treatment not infectious

This post is coming a little late to the fore. Nevertheless, I still wanted to mention it briefly.

Swiss public health officials have issued new guidelines (original in French and German [pdf warning]) regarding the infectiousness of HIV+ individuals on effective anti-retroviral therapy. Basically, the new guidelines state that condoms are unnecessary in serodiscordant (one positive, the other not) couples under a narrow but widely applicable set of circumstances. These circumstances are:

• The HIV+ individual must consistently adhere to the anti-retroviral therapy regimen and the effectiveness of the therapy must be monitored at regular intervals by his or her treating physician according to officially accepted guidelines;
• The viral load must be below the limit of detection (<40>)
• The HIV+ person must not be suffering from any other sexually transmitted infections.

Again, under these very narrow circumstances, serodiscordant couples needn't use condoms during sexual intercourse. Read the English translation here [pdf warning].

This is in accord with a study presented at the Fifteenth Conference on Retroviral and Opportunistic Infections. That study concluded that provision of ARV therapy to African nations could reduce HIV infection over all by 90%.

[This post was picked up by Reuters through Blogburst.]

Failed Merck vaccine may have made intact men more vulnerable; rethink is in order, researchers say [updated]

[Dr. Susan Buchbinder] reported at the [15th CROI] conference today that further analysis of the Merck study results found that uncircumcised volunteers who received the vaccine ran nearly 4 times the risk of infection than those who were given a placebo.

Buchbinder said one possible explanation is that the vaccine somehow activated white blood cells near the surface of the foreskin - known HIV targets - making them more vulnerable to infection. She told reporters that she would not recommend at this time that study participants who are uncircumcised and received the vaccine, rather than a placebo, be circumcised as a precaution.

Follow-up research has also shown that the slight trend toward higher infection rates among all those who took the vaccine has not yet abated. But the number of infections involved is so low that there remains a possibility that the higher infection rates among uncircumcised men was purely the result of chance.

A vaccine trial that made volunteers more vulnerable to HIV that then would encourage circumcision is insult to injury for the unfortunates who received the ill-fated vaccine candidate.

A rethinking is in order, no doubt about it. But the rethink, at least in the developed world, is that HIV/AIDS is 100% avoidable. This virus may be beyond us, but it is infinitely containable. We know more than enough to shift some of the burden that researchers are feeling onto the shoulders of the community. We all have to take responsibility for avoiding this virus.

If some ADULTS want circumcision as part of this process, they should have it. The challenge then is how to maintain the responsibility on the adult individual, the only place where it can work. The danger is that the temptation will be to shift the decision from the individual to someone else, such as doctors and parents. Ethically, that is the wrong path to take, and ultimately another ill-effect of the virus, but which is within the power of humans to avoid.

Link: Failure to find AIDS vaccine has researchers seeking new directions.

Aidsmap, the best source of information on HIV/AIDS in the English language, has a better analysis of the Merck vaccine failure. Their article includes details of a discussion that the failed vaccine may have deactivated the protective mechanism in the mucosal tissue of the foreskin.

I think it is important to realize what the difference between the intact and circumcised seroconverters was in real numbers: 49 versus 33, respectively, out of 930 male volunteers. That's a tiny group, conclusions from which would seem ill-advised.

UPDATE: Forty-nine people in the vaccine trial group seroconverted. Thirty-three in the control group also seroconverted. Therefore, the difference between the circumcised and intact group who seroconverted is even smaller than the difference between the trial and control group. The numbers here are miniscule with no statistical significance. That wasn't made clear in the earlier reports. And it was glossed over by the largely circumcision positive press.

Link: Aidsmap | CROI: AIDS vaccine: additional [increased] infection risk restricted to uncircumcised men.

Aciclovir treatment for genital herpes as proxy for circumcision?

If circumcision reduces ulcerative genital diseases in men and ulcerative diseases such as HCV infections are a co-factor for HIV infection, then the effect should be lower HIV infection rates over all. That's one of the theories anyway behind prophylactic circumcision. Yet a large study presented at the 15th Conference on Retroviruses and Opportunistic Infections using Aciclovir to suppress HCV in infected individuals should in theory also have reduced HIV infection in the HCV infected group and their partners. That didn't happen.

This failure of theory to deliver in practice raises numerous questions about the alleged benefit of circumcision to reduce HIV infection. If suppression of HCV doesn't reduce HIV infection, maybe HCV infection isn't the cause of the higher HIV rates. Could it be that HCV infected individuals are also behaving in ways that expose them to HIV rather than the HCV infection being a vector for the infection?

The head spins, thinking about how confused the research is in the area of understanding correlation and cause and effect in HIV transmission. Aciclovir may have made a good proxy for circumcision if it indeed had had the effect of reducing HIV infection. Because it didn't, it calls into question whether the mechanism for reduction in risk in circumcised men has anything to do at all with alleged lower HCV rates in these men.

Link: Aidsmap | Aciclovir treatment for genital herpes does not reduce HIV acquisition in men or women, major trial shows.

"Surprising" research results at AIDS conference

Despite the disappointment that male circumcision seemed to offer no protection to female partners of HIV-infected men, Wawer stressed that the procedure will probably still benefit women because if fewer men are infected, they are less likely to pass that infection on to their partners. "We are sure there will be a population benefit," she said.

What does it mean when a researcher who finds an intervention is not effective still claims she is "sure there will be a population benefit"? Seriously, is there any clearer indication that these people started with a belief and will go to any lengths to "fix the evidence around the proposition?" Where have we heard and seen that happen before? Hint: It involved a certain country invading another.

Link: Surprising research results at AIDS conference.

Aidsmap | CROI: Circumcising HIV positive men increases HIV infections in women, barely decreases STIs (revised post)

Aidsmap is reporting this morning that HIV infection was higher in female partners of HIV+ men who were circumcised than in men who remained intact as observed over a two year period. The study was presented at the Fifteenth Conference on Retroviruses and Opportunistic Infections that opened in Boston, Massachusetts on Sunday.

Fascinating was the study's author's response that the result was disappointing and unexpected. Researcher bias clearly was not an issue for considered problematic by the authors of this study despite their stated preconceived expectations. Commendable is that the data wasn't massaged -- at least not to the point of changing the results.

However, it occurred to me that whenever Western, particularly American researchers, don't get their preferred result, they tend to resort to blaming the research subjects (usually Africans). Here the authors stated that the study subjects didn't wait long enough to heal before resuming sexual activity (poor impulse control) or that they didn't heal fast enough (an inferior biological response?).

Equally valid conclusions to be drawn are that the hypothesis was wrong or that the study design was flawed. Neither possibility was addressed.

Clearly, the devil's in the details and the impact of circumcision in HIV transmission long term, even assuming the African circumcision studies were meritorious and could be repeated, is simply unknown.

Link: Aidsmap | CROI: Circumcising HIV positive men may increase HIV infections in female partners, but fewer STIs seen.