Male Circumcision and HIV

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.

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.

Circumcision is not predictive of HIV infection (seroconversion) in gay men.

But not content with these results, the authors conclude, "More studies, please."

Edit: Aidsmap has an excellent summary of the study and one other study showing Peruvian gay men would be willing to be test subjects for a future circumcision study in that country. Obviously, the first study would seem to preclude any need for making guinea pigs out of South American men.

Abstract after the break.