HIV/AIDS and Circumcision

[Kyrisch]

Recent studies have shown that circumcision is correlated with a lower incidence of HIV infection. In addition, follow-up experiments were done in the years 2007 and 2008 which showed that circumcision "reduced the risk of infection of HIV" by 51-60%. However, in all of my research (which I confess is nominal, at best), I cannot find a proposed mechanism.

 

Many circumcision advocates have cited these recent studies as evidence that the health benefits of the surgery outweigh the risks. However, it occurred to me that this might be a case of correlation, not causation, especially if no direct mechanistic cause can be identified. Perhaps those cultures which have a higher incidence of circumcisions also have a greater genetic resistance to infection? The confounding variables can be many. Thus, my question is, do studies like this have the right to phrase it as "reduced risk"? It implies that circumcision itself reduced the risk, not that circumcised individuals were at a reduced risk.

 

In addition, is there any proposed mechanism that I missed in my research?

[ml66uk]

They have proposed a mechanism, but there's very little evidence to back it up, and there are real problems with the studies themselves. Not one of them was finished, despite the protective effect appearing to decline well below the oft-reported 65%, and several of the subjects disappearing. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.

 

Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex".

 

The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, Swaziland, and Tanzania. That's seven countries where men are more likely to be HIV+ if they've been circumcised. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Cameroon, the HIV rate is 4.1% among circumcised men, but only 1.1% among intact men.

 

Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them. ABC (Abstinence, Being faithful, Condoms) is the way forward. I believe that promoting genital surgery will cost African lives, not save them.

 

It's not like we've actually tried the things that do work. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

[Psycho]

They have proposed a mechanism, but there's very little evidence to back it up, and there are real problems with the studies themselves. Not one of them was finished, despite the protective effect appearing to decline well below the oft-reported 65%, and several of the subjects disappearing. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.

 

Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex".

 

The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, Swaziland, and Tanzania. That's seven countries where men are more likely to be HIV+ if they've been circumcised. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Cameroon, the HIV rate is 4.1% among circumcised men, but only 1.1% among intact men.

 

Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them. ABC (Abstinence, Being faithful, Condoms) is the way forward. I believe that promoting genital surgery will cost African lives, not save them.

 

It's not like we've actually tried the things that do work. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

 

Do you have any references for any of that?

 

I personally can't see how circumcision would effect contraction in a drastic way myself, it probably does make a difference to contraction rates in some way but I wouldn't think it would be large enough to be easily measurable.

 

However if this is the case it could be indirectly related to circumcision.

[Kyrisch]

They have proposed a mechanism, but there's very little evidence to back it up, and there are real problems with the studies themselves. Not one of them was finished, despite the protective effect appearing to decline well below the oft-reported 65%, and several of the subjects disappearing. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.

 

Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex".

 

The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, Swaziland, and Tanzania. That's seven countries where men are more likely to be HIV+ if they've been circumcised. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Cameroon, the HIV rate is 4.1% among circumcised men, but only 1.1% among intact men.

 

Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them. ABC (Abstinence, Being faithful, Condoms) is the way forward. I believe that promoting genital surgery will cost African lives, not save them.

 

It's not like we've actually tried the things that do work. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

 

So what was the proposed mechanism? And it's very suspicious when you make such a lengthy, seemingly informative post as your first post but sans references. It usually leads someone to believe that your post itself would be affected by what's known as volunteer bias in the world of statistics. So, references would be nice.

[ml66uk]

The figures for HIV and circumcision come from the Demographic and Health Surveys

http://www.measuredhs.com/

http://www.measuredhs.com/aboutdhs/whoweare.cfm

 

Cameroon http://www.measuredhs.com/pubs/pdf/FR163/16chapitre16.pdf table 16.9, p17 (4.1% v 1.1%)

Ghana http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf table 13.9 (1.6% v 1.4%)

Lesotho http://www.measuredhs.com/pubs/pdf/FR171/12Chapter12.pdf table 12.9 (22.8% v 15.2%)

Malawi http://www.measuredhs.com/pubs/pdf/FR175/FR-175-MW04.pdf table 12.6, p257 (13.2% v 9.5%)

Rwanda http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf , table 15.11 (3.5% v 2.1%, but they've just launched a national circumcision program)

Tanzania http://www.measuredhs.com/pubs/pdf/FR173/13Chapter13.pdf not comparable

Swaziland http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf table 14.10 (21.8% v 19.5%, but they're about to start a nationwide circumcision program)

 

"In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms."

 

This is in table 11.2 of the Malawi report. Note that I incorrectly copied the figures for women only. The corresponding figures for men are 75.5% and 80%.

 

The usual proposed mechanism for a protective effect is that the foreskin contains many Langerhans cells, and these may provide an entry point: http://www.bmj.com/cgi/content/extract/320/7249/1592?view=full&pmid=10845974

This seems to be speculative, and I've also seen it suggested that Langerhans cells protect against HIV ( http://jcb.rupress.org/cgi/content/full/177/1/5a ). A 1993 paper in the Israeli Journal of Medical Sciences suggested that uncircumcised men might be more prone to HIV because they didn't have enough Langerhans cells: http://www.ncbi.nlm.nih.gov/pubmed/8454447?dopt=Abstract

It's also been proposed that uncircumcised men have a moist environment for the HIV virus to survive, but this would also apply to women.

 

Circumcised men who are HIV+ appear to be more likely to infect women than intact men who are HIV+ btw: http://www.medpagetoday.com/MeetingCoverage/CROI/8221

 

An extra eight additional women appear to have been infected during that study solely because their partners had been circumcised for the study, but more importantly, it suggests that men who are HIV+ should not be circumcised, as it will make them more infective.

 

This is not the first time that HIV in women has been linked to partner circumcision:

History of multiple sexual partners, history of STD, high household income, partner circumcision, and past oral contraceptive use remained strongly associated with HIV-1 infection even when simultaneously controlling for other covariates.

http://ije.oxfordjournals.org/cgi/content/abstract/23/2/371

 

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

( http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138 )

 

Rwanda has not far off double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign: http://www.plusnews.org/Report.aspx?ReportId=79085

Rwanda has more than nine million people, but only one doctor for every 50,000 people and one nurse for every 3,900 people, so why would they want to waste their medical resources operating on intact Rwandan men who are less likely to be HIV+ than circumcised Rwandan men?

 

Something is very wrong here. I believe there are people promoting male circumcision in Africa whose primary interest is not in fighting HIV, but rather in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives.

[Mr Skeptic]

Might not men who are less likely to get infected more likely to choose to get circumcised (religious reasons --> more abstinence/faithfulness, or health reasons --> more careful about risks)?

[iNow]

Provide some evidence which shows religious believers to be more faithful or more abstinent relative to non-believers and I'll think about considering it.

[Kyrisch]

Might not men who are less likely to get infected more likely to choose to get circumcised (religious reasons --> more abstinence/faithfulness, or health reasons --> more careful about risks)?

 

Provide some evidence which shows religious believers to be more faithful or more abstinent relative to non-believers and I'll think about considering it.

 

It doesn't have to even be that. Any such confounding variable could easily result in such a strong correlation that has nothing to do with decreasing risk, and more to do with simple statistical correlation.

[Mr Skeptic]

Provide some evidence which shows religious believers to be more faithful or more abstinent relative to non-believers and I'll think about considering it.

 

You want evidence that people who think that premarital and extramarital sex are immoral, are less likely to do it? Who'd have thought, its actually true!

 

http://www.ncbi.nlm.nih.gov/pubmed/19387889?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/19227698?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

Sure, it may be a small effect compared to other factors, but it's there nonetheless.

[Mokele]

The studies quoted have serious problems with sample size, and no statistics.

 

Sure, the numbers *look* different, but are those differences statistically significant? To what p value? And what about statistical power?

 

Tables of means and percentages are nice, but without statistical tests, they're meaningless.

[Mr Skeptic]

How about this one:

“Religiosity and Sexual Behavior among Heterosexual College Students.”

Across a wide range of sexual behaviors and dimensions of sexuality, religiosity is found to be negatively related to sexual experience. This relationship does not differ by gender.

I see p values less than .001 in there, is that good enough?

 

Let's not get too carried away. I simply suggested that there may be a bias in that people who are more likely to get circumcised might be less likely to get HIV for the same reasons they chose to get circumcised, even if circumcision has no effect. Since some people get circumcised for medical reasons, perhaps you could focus on that aspect that I mentioned.

[iNow]

I simply suggested that there may be a bias in that people who are more likely to get circumcised might be less likely to get HIV for the same reasons they chose to get circumcised, even if circumcision has no effect. Since some people get circumcised for medical reasons, perhaps you could focus on that aspect that I mentioned.

 

One of the faults I find with your premise here is that you suggest people "choose" to get circumcised. AFAIK, the VAST majority of men who are circumcised have that choice made for them shortly after their birth.

[Mr Skeptic]

Good point. That correlation will be weakened by whatever factor correlates parental belief with belief of the individual in individuals who were circumcised as babies. This would also provide a good test of my suggestion: if true, you might expect the "protective effect" of circumcision to be greater in those who themselves chose to be circumcised, compared to those who were circumcised while babies.

[Kyrisch]

I'm not sure any one of you is on topic anymore. The data referenced by wikipedia and in the (rather ambiguous) pdf file I linked, there were alleged controlled trials that provided statistically significant results. I'm not sure how they conducted said trials without there being actual risk of infection with the virus, which is what makes the study so shady, but it seems to be claiming that it is not merely correlation, but causation with unknown mechanism. Is the implication simple intellectual dishonesty? Do you think the only studies that were done were the "observational" studies referenced in the first page of the pdf?

[CharonY]

The pdf in the OP is unfortunately appears to be only supplementary to the main (meta) study. One of the studies they are refering to is: RC Bailey, S Moses and C Parker et al., Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial, Lancet 369 (2007), pp. 643–656

 

In the same paper some nice references about proposed mechanisms are given:

 

Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodefi ciency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002; 161: 867–73.

Donoval BA, Landay AL, Moses S, et al. HIV-1 target cells in foreskins of African men with varying histories of sexually transmitted infections. Am J Clin Pathol 2006; 125: 386–91.

McCoombe SG, Short RV. Potential HIV-1 target cells in the human penis. AIDS 2006; 20: 1491–95.

O’Farrell N, Morison L, Moodley P, et al. Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa. J Acquir Immune Defi c Syndr 2006; 43: 69–77.

Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006; 82: 101–09.

[Mokele]

Mr Skeptic - my quote tag didn't work - I was referring to the OP's studies.

[Mr Skeptic]

Mr Skeptic - my quote tag didn't work - I was referring to the OP's studies.

 

Oops :doh: