Male Circumcision and HIV

We've seen the cart, now here comes the horse.

Aidsmap has recently reported on an emerging realization among HIV prevention researchers that asking about anal intercourse is important to rule out this confounding factor in prevention studies based in Africa.

Studies into sexual behaviour in Africa have often neglected to enquire about anal sex, and sex between men. There has either been an assumption that such behaviour was not prevalent, or a sensitivity to cultural taboos and prejudices means that investigators are reluctant to enquire about such behaviour. But studies are now suggesting that anal intercourse is common in Africa in both heterosexual and homosexual contexts and is an important mode of HIV transmission.

Excuse me, but could we get a do-over on those African circumcision trials?? This problem has been suggested before, but I think saying it out loud in the literature ought to get some attention. In studies where the numbers are small, but the difference in infection rate is great (precisely because the numbers are small), the problem of failing to account for all the confounding factors is greatly magnified. The African circumcision trials fall squarely into this trap. Now, will we hear calls to re-examine the studies? Unlikely, and as usual the responsibility to call them out on it will fall to the lay person. That would be most of you who read this blog.

In related news, Aidsmap is also reporting that HIV+ gay men with HPV, or ano-genital warts, have presented in Australia with abnormal cells in the anus that could indicate greater rates of cancer and/or HIV infectiousness. Combine this with the recent survey that demonstrated almost twice the rate of HPV among circumcised men in the USA, and we may be on to something.

Reuters repeats for emphasis(?): Circumcision Doesn't Protect Against HIV Among Men Who Have Sex With Men

Reuters is re-reporting the news that three studies have shown no protective effect among men who have sex with men. The story misreports again that black men in the United States are less likely to be circumcised, in a probable attempt to give context to one of the studies that looked exclusively at African-American and Latino men. Ethics of circumcision was not mentioned in the Medscape article summarizing the article published in the Journal of Acquired Immune Deficiency Syndromes.

Circumcision did not reduce the risk of HIV infection in [the] entire study group or in any subgroups, including men who were bisexual, engaged in unprotected insertive anal sex or protected receptive anal sex, or men who reported that their previous HIV test was negative.

The current results do not support circumcision as a means of reducing the risk of HIV infection among MSM in minority groups in the U.S., the researchers conclude.

Link: Circumcision Doesn't Protect Against HIV Among Men Who Have Sex With Men. (Medscape registration required)

Picking up on SFAF's Statement on Circumcision and HIV

The San Francisco AIDS Foundation, an organization for whom I have raised money, came out with a policy statement on male circumcision and HIV in March of last year. This escaped my attention even though I knew they were formulating a policy. Better addressed late than never ...

Here are the important points made.

• Being circumcised is not HIV protection. Circumcision may reduce, but does not eliminate risk of HIV infection. Sexually active men, whether or not they are circumcised, should use condoms to protect against acquiring and transmitting HIV and other sexually transmitted infections.

• There is a potential for men who have been circumcised to believe they are fully protected and to lapse in condom use and other modes of risk reduction, which could have the effect of increasing HIV transmission rather than decreasing it.

• The studies in sub-Saharan Africa took place in highly controlled medical settings and were conducted by medical experts on previously uncircumcised men who have vaginal sex with women. These men were given counseling about sexual risk and were provided with condoms. Their health was regularly monitored for any adverse outcomes from the circumcision, which were treated upon detection. [Statements that would seem to validate the lack of similar real world outcomes.]

• There  is no comparable evidence about the effect of male circumcision for gay and other men who have sex with men. [In fact, the evidence is in, and it is that circumcision provides NO protection for gay men.]

• There is no comparable evidence about the effect of male circumcision for anal intercourse.

• There is insufficient evidence about whether circumcision in HIV-positive men protects their male or female sexual partners. [In fact, there is some evidence that male and female partners of circumcised men are at greater risk.]

• There is no evidence about the effect of male circumcision on reducing acquisition of HIV among women. Another study in Rakai, Uganda is currently looking at this, but it is not yet completed. [Preliminary data from this last trial suggested women were at greater risk; see last bullet point above.]

• The evidence from the trials in sub-Saharan Africa applies to adult men. It cannot tell us specifically about the potential HIV risk reduction benefits of circumcision conducted on newborns or children. [Good as far as it goes. However, any reference to informed consent and voluntariness must recognize that these principles extend to all human life. Decision-making shifting due to age on care not intended to address an immediate health need, like say a polio vaccine shot, leads to lack of consent and involunatary procedures.]

• Male circumcision has cultural and religious significance in many settings, which may affect its acceptability among different communities.

With the foregoing in mind, the Foundation goes on to state:

• Circumcision is an invasive medical procedure that must be conducted by trained individuals under sterile conditions with appropriate monitoring and an adequate healing period to eliminate the risk of bacterial infection. Community and health care provider education will be essential for the implementation of male circumcision as an HIV prevention strategy.

• Payment for the procedure should not be an obstacle to any man who chooses to undergo it; public and private health care programs and insurers should cover male circumcision as part of preventive medicine.

• Adult male circumcision should always be voluntary, with appropriate informed consent. ["Should" is too weak. It must always be voluntary and with complete informed consent. No overreaching or undue persuasion should be permitted. The loss of sexual function must also be addressed.]

• The public health community should understand and respect religious and cultural meanings of male circumcision in formulating implementation strategies. [Statements like these require clarification. What about cultural aversion to the procedure? Wouldn't such aversion require the same level or a greater level of respect? The Luo seem to have lost out on this particular principle.]

• Circumcision is a personal decision that should be made in consultation with providers, pediatricians and others. The Foundation does not make recommendations about individual health choices. [Reference to pediatricians is telling as to where the Foundation lies in its conventionality viz. infant circumcision.]

The SF AIDS Foundation is a non-governmental political body trying to maximize its fundraising potential. It has some obligation to kowtow to have its greatest success. And so in this particular case, it has gone along to a certain extent while trying to make obviously valid points. It fails in the end by pointing to sources, such as the AIDS Vaccine Clearinghouse, which is an egregious choice for information on this issue. Which brings me to a point that needs to be made.

I think it is a stunning success for the proponents of circumcision that they have sold the lie that circumcision prevents HIV with such alacrity. Today whole nations are purportly willing to force their populations under the knife with scant proof that it will do anything in their fight against HIV/AIDS. This is just stunning.

I think anyone with an interest in public health policy would do well to learn from this development. One important message to be drawn (I write here somewhat sarcastically) is that one should start with a plausible proposition that is essentially unverifiable, do your experimenting in and make your weightiest pitches to the most desperate nations far, far away, and publish, publish, publish. It also helps to have an acquiescent media and be employed by prestigious medical and educational institutions who are familiar with and favorable to circumcision as a cultural artifact.

I would recommend everyone who wishes to weigh in on SFAF's policy to write to them. Put the "public" back in health policy.

Contact SFAF:

policy@sfaf.org
415/487-3080

Public Policy Dept.
San Francisco AIDS Foundation
995 Market St, Ste 200
San Francisco CA 94103

Results and Result-oriented Studies: Drugs Edition

You can hear their refrain echo in your head now. Not our research. Not this research. Yet, how much attention have the three studies demonstrating no protective effect in gay men from circumcision gotten? A few mentions here and there. Mostly glossed over, minimized, ignored. Yet no distinction is made in the message that is out there now: circumcision is a prevention. How about the research showing no protective effect in real world settings? Or the research that looks at the social constraints that have kept HIV in check in Muslim countries? Has there even been any research on that issue?

"It tells you where they placed their bets before they saw the data."

...

"Not only were positive results more likely to be published, but studies that were not positive, in our opinion, were often published in a way that conveyed a positive outcome."

And so we have a parallel situation in drug research. The following article describes a study that looked at drug studies, published, unpublished, rewritten, and buried. The researchers discuss how drug companies, who have counterparts in universities and international aid agencies, seek to advance their agendas, in this case, drugs. Every time they mention drugs think of circumcision. When they mention a drug company, think of Halperin, Klausner, and Bailey.

Link: Unfavorable drug studies don't get into print: report - Yahoo! News or fair use article after the jump.

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.

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.

Gay men's HIV prevention 'falter[s]', JAMA misleads and ignores evidence viz male circumcision

A JAMA article highlighting the newly rising rates of HIV seroconversion in gay men ignored studies that rule out circumcision as an effective intervention, claiming the effectiveness is unknown. Aidsmap has caught it and pointed out Jaffe et al.'s ignorance. Inevitable conclusion: American researchers and commentators simply can't be trusted anymore require heightened vigilance to determine biases on issues of prevention, particularly the weight given to the relative value of new prevention technologies.

Link: Aidsmap | Gay men's HIV prevention in the US and Europe is 'faltering'.

Edit: And this just in, a cross sectional survey of black and Latino men in three US cities presented "no evidence that being circumcised was protective against HIV infection among black MSM* or Latino MSM. ... Further, circumcision was not associated with a reduced likelihood of HIV infection among men who had engaged in unprotected insertive and not unprotected receptive anal sex." Link is to the abstract. If anyone has a pdf copy for the pdf library, please forward it to me. Thanks.

Hat tip to Hugh on the Intactivist Pages for the heads up.

*Men who have sex with men.

Study finds no protective effect in gay men from circumcision, so why are the authors still promoting it?

The stock response in the last two decades to the realization that circumcision has little to no value in public health and can be demonstrated to harm newborn males as well as adult sexuality has been to repeat old saws that it's cleaner, all the kids are circumcised, and that it's "healthier" in some as yet undiscovered way. And so Zohar Mor, Charlotte K. Kent, Robert P. Kohn, and Jeffrey D. Klausner have dressed up nothing to look like something to reinforce the point in the misleadingly entitled article Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit. The only thing to recommend their nothing-new-to-report [pdf] article is that they conclude:

Our findings, showing no significant differences between circumcision status and the risk of HIV or syphilis infection, are consistent with the importance of non-penile, rectal acquisition of those infections (or oral infection in syphilis) among gay men in the U.S. [22], rather than penile acquisition as in heterosexual intercourse, during which the foreskin may be exposed to HIV infection. Because large proportions of gay men practice both insertive and receptive anal intercourse [23], the ability to differentiate between different risks for HIV infection associated with sexual practices versus circumcision status is limited.

So there you have the real take home point: penile acquisition of HIV is but one method of acquisition among the highest risk group in the United States that cannot be separated out from other methods of acquisition. And hence, no value is realized from circumcision due to the diversity of sexual behaviors among men who have sex with men. This is wholly consistent with the study presented in Sydney, Australia at the International AIDS Society conference earlier this year. Due to the low prevalence of HIV among American heterosexuals this conclusion effectively pulls the rug out from under the prime justification remaining for routine circumcision in the United States, i.e. disease control.

So why do these authors dress up truths as lies by continuing to advocate circumcision? Only they know for sure. But the public needs to be aware of these junk scientists' intentions, which may be neatly summarized in their own words:

In conclusion, while a majority of men attending the San Francisco STD clinic were circumcised, there were large and steady declines in circumcision across all racial/ethnic groups since 1960. There were significant differences by racial/ethnic groups suggesting important socio-cultural factors related to decisions to circumcise newborn males. Given the recent evidence demonstrating the substantial potential public health benefit of male circumcision [refuted a few short paragraphs before] and our observed declines in circumcision rates, national organizations that promote circumcision policy should review current practice guidelines in responding to those trends.

Direct your comments to: Jeff.Klausner@sfdph.org; zmor@sph.emory.edu

Notebook: Dallas Edition

Once again, getting out of town has provided me with the chance to jot down some ideas on recent news. This time, we're in Dallas, Texas.

The Numbers

In the early days of the AIDS epidemic in the United States gay men were emerging from not years or decades, but centuries of discrimination and persecution. AIDS was often cited by scary religious types  as devine retribution, or in the secular understanding, as a "natural" outcome of "unnatural" sexual behavior. In this environment, it's not hard to understand the urge to exaggerate the numbers. The argument that this isn't just us (gay men), but could in short order be you (heterosexuals) has a certain power.

Today, however, this tactic has resulted in the long established and accepted belief, largely supported by the obvious truth it carries in Africa, that the disease is biding its time before it races through the general population. But Africa is a very special case where multiple concurrent partnerships are responsible for the widespread dissimination of the virus. Yet still better data and a greater understanding of the whys and wherefores of dissimination at the population level is only now working its way into the popular understanding of HIV/AIDS.

And so once again, after first being noted in India, the numbers are being revised downward [Yahoo! link may expire] worldwide by the large AIDS organizations. What does it mean to revise downward the number of people living with this disease? First and foremost, it means a re-prioritization of health needs and the resources allocated thereto. In the pantheon of preventable diseases, cancer and heart disease kill more people than HIV. And emerging threats, such as MRSA, are proliferating in the United States and abroad, and also apparently kill more people than AIDS.

[Edit: Hugh over on the Intactivism Pages points out the very important fact that lower numbers throw the circumcision/HIV mathematical models into very grave doubt.]

"Territorial Jealousy"

In a related AFP article, a global lung health conference taking place in South Africa reports that  organizations working on different diseases compete -- and not in a good way. The astounding idea that two groups working on public health issues would exhibit "a lack of mutual trust and territorial jealousy" is really hard for me to take in. But a quick reflection on the driver of any public health campaign, i.e. resources aka money, in a place of dire poverty doesn't seem so astounding after all. Enter the circumcisers.

Within a given disease, differing approaches clearly compete for the available resources. The mad scram for money exists wherever there's ... well, money. That is to say, also in healthcare, public health policy making and implementation, wherever ... . Circumcision without regard to its appropriateness or effectiveness may be developing into just one more offering in the school cafeteria of HIV/AIDS.

Stem cell from foreskins

Yesterday, National Public Radio in the Untied States reported that stem cells can be created by introducing only four specific genes into a skin cell using a virus as a vehicle. The scientists tell us  that this is extraordinary because "from the foreskin of a newborn child" we can make limitless numbers of stem cells for actual practical applications for disease control and cures. Yes, they said that. Let it be known that another market may be developing to continue driving gratuitous circumcisions of unconsenting infants. From one speculative ethical issue, i.e. embryonic stem cells, to a well-established ethical issue, i.e. circumcisions without consent, a morally confused America meanders.

Now, the inevitable question is: Can they take a skin cell from an infant foreskin, make a stem cell, and then grow a new foreskin for restorers? And would conscientious restorers accept such a restoration in light of the ethical problems? Fortunately, the skin cell likely can come from other areas of the body.

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Notebook: Rising food costs, the tanking dollar, sexual behavior in multiples, and PrEP, like condoms, may be a true pillar of AIDS prevention

The New York Times reports that American food aid to Africa is in a pinch due to rising costs. The reasons are varied. However, the primary reasons are a higher demand for food stocks for ethanol and higher transportation and logistical costs. Food aid purchases (as opposed to total allocations) fell from $105 million to $70 million between 2002 and 2006.

Implicitly, the tanking US dollar, which hit a record low against the Euro this week at $1.41 plus, can't be helping. And the dollar's problems are in some ways related to the energy issues, tying this all up in a nice little bow.

The article makes the observation that food aid has never been as altruistic an endeavor as one would hope. A solution to higher demand for US corn crops for ethanol production could be buying these same crops elsewhere where production costs are less. However, the article quotes an American ship owner representative, Gloria Tosi,  who suggested "buying commodities abroad would erode domestic political support for the program and lead to lower food aid budgets from Congress. She said it was 'politically naïve' to think the food commodity groups and ship owners that have for decades supported food aid in Congress would favor buying commodities abroad."

Clearly, one lesson seems to be that acts of charity don't happen on their own. They happen when interests coalesce and business or careers advance. This obviously implicates the bit of luck necessary in just about everything. Still, individual efforts are valuable and necessary if anyone feels like throwing up his or her hands on the circumcision issue.

The dollar

In the last few weeks, the US dollar has hit parity with the Canadian dollar for the first time since the 1960s and reached a new low against the Euro, having lost fully 69% of its value against that currency since 2001. This is extraordinary on a number of levels. First for the issues this blog is concerned with, the dollar's buying power is clearly being eroded across all currencies, although not at the same rate. For example, the Thai baht is fetching 25% more now than it did a few years ago. Circumcisions are therefore escalating in cost, for what it's worth.

Never underestimate the power of unexpected forces to change the calculus in this game.

Gay Sex: three times more potent than straight sex

A recent study has demonstrated that heterosexuals require up to three times more unprotected sexual encounters to reach the levels of infection of gay men. Not sure of the implications here, but it seems this is not so difficult to explain. Gay men may adopt both passive and insertive roles in intercourse. Heterosexual vaginal intercourse is logically believed to be less conducive to HIV infection. As a percentage, more gay men than heterosexual pairings combine drug use and sexual encounters in the major urban centers of HIV prevalence, which has been identified as a risk factor.

Maybe the researchers that be should conduct some studies in sub-Saharan Africa to determine whether heterosexuals exhibit any extraordinary risk factors similar to that of gay men in the West, particularly the US, and that are decidedly absent in Western heterosexual pairings. That would explain super low rates of infection among the intact Europeans.

Condoms and a pill: a death blow to new HIV infection

In the last post, I talked a bit about a study that suggested that risk reduction strategies were much less effective on an individual basis than had been hoped for. Well, how about a new strategy with an effectiveness rate approaching that of condoms.

Animal studies have shown a 100% prophylactic effectiveness rate with two drugs, tenofovir and FTC (emtricitabine, Emtriva). Taken daily by HIV negative monkeys, not necessarily together, repeated exposure to HIV resulted in no new infections. That's pretty amazing. It would be the first and only female controlled method of prevention. Combined with the inevitable incomplete use of condoms and we may have a winner.