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Where Circumcision Doesn't Prevent HIV

By Joseph Lewis © 2012
Read original at Joseph4GI


There's currently a lot of hype surrounding circumcision and the transmission of HIV. The word on people's lips is that "circumcision reduces HIV transmission by 60%." The claim is based on the result of three major "studies" that were carried out in Africa, but there are a few confounding factors that bring the validity of these so-called "studies" into question. One of the greatest confounding factors in these studies is empirical evidence to the contrary; real world data from countries where circumcision is already a widespread practice and studies with contrary results.

Countries in Africa
Let's begin with countries in Africa, where these "studies" would be relevant. According to demographic health surveys performed in other countries in Africa, HIV transmission was prevalent in circumcised men in at least 6 different countries. I go one by one, analyzing some of the commentary in these surveys, some of which seems to be revealing of the researchers' bias.

Cameroon
In Cameroon, where 91% of the male population is circumcised, the ratio of circumcised men vs. intact men who contracted HIV was 4.1 vs. 1.1. (See p. 17)
http://www.measuredhs.com/pubs/pdf/FR163/16chapitre16.pdf

Ghana
"...the vast majority of Ghanaian men (95 percent) are circumcised... There is little difference in the HIV prevalence by circumcision status..." (1.6 vs 1.4 See p. 13)
http://www.measuredhs.com/pubs/pdf/FR152/13Chapter13.pdf

Lesotho
In Lesotho, 23% of the men are circumcised, and the ratio circumcised men vs. intact men who contracted HIV was 22.8 vs 15.2.

"The relationship between male circumcision and HIV levels in Lesotho does not conform to the expected pattern of higher rates among uncircumcised men than circumcised men. The HIV rate is in fact substantially higher among circumcised men (23 percent) than among men who are not circumcised (15 percent). Moreover, the pattern of higher infection rates among circumcised men compared with uncircumcised men is virtually uniform across the various subgroups for which results are shown in thetable. This finding could be explained by the Lesotho custom to conduct male circumcision later in life, when the individuals have already been exposed to the risk of HIV infection. (Additional analysis is necessary to better understand the unexpected pattern in Table 12.9.)" (p. 13)

What is disturbing here is that it seems researchers grope for a reason to dismiss these results because they are not what they are looking for; a positive result for circumcision. The above is an interesting defense of male circumcision, given the fact that the latest "studies," if they can even be called that, observed HIV trasmission in men circumcised as adults. Then again, this demographic health survey was conducted in 2004, BEFORE the newer "studies" in 2006. None the less, the unproven assertion that "circumcision is only effective in reducing the risk of HIV when done in infancy" persists in some circles.
http://www.measuredhs.com/pubs/pdf/FR171/12Chapter12.pdf

Malawi
In Malawi, 20% of the male population is circumcised. The ratio of circumcised vs. intact men who contracted HIV was 13.2 vs 9.5.

"The relationship between HIV prevalence and circumcision status is not in the expected direction. In Malawi, circumcised men have a slightly higher HIV infection rate than men who were not circumcised (13 percent compared with 10 percent). In Malawi, the majority of men are not circumcised (80 percent)(...where one would expect HIV to be the most rampant... note the "expected direction."(p. 10)
http://www.measuredhs.com/pubs/pdf/FR175/12Chapter12.pdf

Rwanda
According to a demographic health survey taken in 2005,  the ratio of circumcised vs. intact men who contracted HIV was 3.8 vs 2.1. (See p. 10)
 http://www.measuredhs.com/pubs/pdf/FR183/15Chapter15.pdf

Swaziland 
In a recent demographic health survey (2006-2007), the ratio of circumcised vs. intact men who contracted HIV was found to be 22 vs. 20.

As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent). (p. 256)
http://www.measuredhs.com/pubs/pdf/FR202/FR202.pdf

Here is that "expected direction" again. The majority of Swazi men are uncircumcised, and one would especially expect to see HIV prevalence here. HIV transmission was more prevalent in the circumcised men here, yet our (the US) government has decided to spend millions on a campaign to circumcise 80% of the men in Swaziland.
http://joseph4gi.blogspot.com/2011/05/soka-uncobe-our-us-tax-dollars-at-work.html

Other Countries Where HIV/Circumcision Rates Don't Correlate

Malaysia
According to Malaysian AIDS Council vice-president Datuk Zaman Khan, more than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims. In Malaysia, most, if not all Muslim men are circumcised, whereas circumcision is uncommon in the non-Muslim community. 60% of the Malaysian population is Muslim, which means that HIV is spreading in the community where most men are circumcised at an even faster rate, than in the community where most men are intact.
http://www.mmail.com.my/content/39272-72-percent-aidshiv-sufferers-malaysia-are-muslims-says-council

The Philippines
In the Philippines, the majority of the male population is circumcised, as it is seen as an important rite of passage. In the 2010 Global AIDS report released by UNAIDS in late November, the Philippines was one of seven nations in the world which reported over 25 percent in new HIV infections between 2001 and 2009, whereas other countries have either stabilized or shown significant declines in the rate of new infections. Among all countries in Asia, only the Philippines and Bangladesh are reporting increases in HIV cases, with others either stable or decreasing.
http://globalnation.inquirer.net/news/breakingnews/view/20110102-312124/Philippines-HIVAIDS-problem-worries-UN

Israel
Despite circumcision being near-universal, it hasn't stopped HIV transmission in Israel.
http://www.haaretz.com/print-edition/opinion/failing-the-aids-test-1.249088
http://www.haaretz.com/print-edition/features/israeli-gays-shun-condoms-despite-worrying-rise-in-aids-1.249372
http://www.haaretz.com/news/has-the-aids-cocktail-worked-too-well-in-israel-1.258520
http://www.haaretz.com/print-edition/news/hiv-diagnoses-in-israel-climb-new-cases-among-gays-up-sharply-1.248651

The most obvious smoking gun: The United States of America
Circumcision hasn't stopped HIV in our own country.
http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf

And, it hasn't stopped other STDs either.
http://www.reuters.com/article/2009/01/13/us-infections-usa-idUSTRE50C5XV20090113?pageNumber=1&virtualBrandChannel=0

In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.
http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=419&Itemid=177

In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they're actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda.
http://www.nejm.org/doi/full/10.1056/NEJMp1000069

The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009.


"[Washington D.C.'s] rates are higher than West Africa... they're on par with Uganda and some parts of Kenya."
Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009.
She once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe.


One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we're supposed to believe that what didn't worked in our own country, or anywhere else, is going to start working miracles in Africa.

Studies With Contrary Conclusions



According to USAID, "there appears no clear pattern of association between male circumcision and HIV prevalence—in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher."
http://www.measuredhs.com/pubs/pdf/CR22/CR22.pdf

"Conclusions: We find a protective effect of circumcision in only one of the eight countries for which there are nationally-representative HIV seroprevalence data. The results are important in considering the development of circumcision-focused interventions within AIDS prevention programs."
http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2197431

Results: ...No consistent relationship between male circumcision and HIV risk was observed in most countries.
http://apha.confex.com/apha/134am/techprogram/paper_136814.htm

"Conclusions: ...[M]ale circumcision... is not associated with HIV or STI prevention in this U. S. military population." 
http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102282676.html

One study which aimed at measuring male to female HIV transmission was ended early, because the results were not looking favorable. The Wawer study showed a 54% higher rate of male-to-female transmission in the group where the men had been circumcised. The figures were too small to show statistical significance, but there will be no larger scale study to find out if circumcising men increases the risk to women. Somehow that's considered unethical, yet it's considered ethical to promote male circumcision while not knowing if the risk to women is increased (by 54%?, 25%?, 80%? - who knows?)
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2809%2960998-3/fulltext

The latest study in Kenya finds no association between male circumcision and lowered HIV rates:
'Using a population-based survey we examined the behaviors, beliefs, and HIV/HSV-2 serostatus of men and women in the traditionally non-circumcising community of Kisumu, Kenya prior to establishment of voluntary medical male circumcision services. A total of 749 men and 906 women participated. Circumcision status was not associated with HIV/HSV-2 infection nor increased high risk sexual behaviors. In males, preference for being or becoming circumcised was associated with inconsistent condom use and increased lifetime number of sexual partners. Preference for circumcision was increased with understanding that circumcised men are less likely to become infected with HIV.'
http://www.plosone.org/article/info%3Adoi/10.1371/journal.pone.0015552?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+plosone/PLoSONE+%28PLoS+ONE+Alerts:+New+Articles%29

Conclusion
A few select studies show a prevalence of HIV transmission in uncircumcised men, but real world empirical data shows that circumcision hasn't stopped HIV in countries where there is already a prevalence of the practice of circumcision, nevermind the United States. Yet, for whatever reason, leaders at the WHO continue to endorse it as HIV prevention policy and millions are being spent on so-called "mass circumcision campaigns," even in countries where HIV transmission was shown to be prevalent among the circumcised.

As if the waste of money weren't bad enough, reports are showing that these "mass circumcision" campaigns are actually proving to be disastrous, as they are confusing African citizens, and many now believe to be fully protected by circumcision.
http://joseph4gi.blogspot.com/2011/05/male-circumcision-and-hiv-in-africa.html

Something must be done to alert our world leaders. Millions of precious funds are being used to promote a worthless surgical procedure that leaves men with permanently altered organs, and they are no better protected. The false security that the promotion of circumcision creates is actually helping to facilitate the spread of HIV. Funds are already scarce, and they could be better spent promoting cheaper, less invasive modes of prevention that have actually been proven to be conclusively effective, such as condoms and education. In light of the real-world evidence, promoting a worthless surgical procedure is an impertinent disservice in the fight against HIV/AIDS and governments need to be told to stop. Africans deserve better.

Circumcision Spreads HIV?

By Andrew Sullivan 
Read original at The Dish




Brian Earp savages the studies purporting to show that male genital mutliation would prevent the spread of HIV/AIDS in African countries:
The "randomized controlled clinical trials" upon which these recommendations are based represent bad science at its most dangerous: we are talking about poorly conducted experiments with dubious results presented in an outrageously misleading fashion, toward public health recommendations on a massive scale whose implementation would have the opposite of the claimed effect, with fatal consequences. Read that sentence again if you want to get the point.
Here's how the mutilation-beats-HIV crowd conducted the tests (pdf):
While the "gold standard" for medical trials is the randomised, double-blind, placebo-controlled trial, the African trials suffered [a number of serious problems] including problematic randomisation and selection bias, inadequate blinding, lack of placebo-control (male circumcision could not be concealed), inadequate equipoise, experimenter bias, attrition (673 drop-outs in female-to-male trials), not investigating male circumcision as a vector for HIV transmission, not investigating non-sexual HIV transmission, as well as lead-time bias, supportive bias (circumcised men received additional counselling sessions), participant expectation bias, and time-out discrepancy (restraint from sexual activity only by circumcised men).
And here's how they came up with that stunning conclusion that mutilating the penis reduces HIV transmission by a relative 60 percent:
Across all three female-to-male trials, of the 5,411 men subjected to male circumcision, 64 (1.18%) became HIV-positive. Among the 5,497 controls, 137 (2.49%) became HIV-positive, so the absolute decrease in HIV infection was only 1.31%, which is not statistically significant.
Go deeper into the studies he cites and links to and it seems quite clear to me that this massive campaign to rid Africa of foreskins is likely to accelerate HIV transmission rather than slow it.

Functions of the Foreskin: Purposes of the Prepuce

Excerpt from this article at DrMomma.org



Immunological Protection


The mucous membranes that line all body orifaces are the body’s first line of immunological defense. Glands in the foreskin produce antibacterial and antiviral proteins such as lysozyme. (5) Lysozyme is also found in tears and mother’s milk. Specialized epithelial Langerhans cells, an immune system component, aboud in the foreskin’s outer surface. (6) Plasma cells in the foreskin’s mucosal lining secrete immunoglobulin’s, antibodies that defend against infection. (7)

Rigorously controlled studies have also demonstrated that the foreskin plays a protective role in shielding the rest of the penis and thus the rest of the body from the contagion of common sexually transmitted diseases (STDs) encountered during sexual activity. (8)

In infancy, antibacterial substances, such as the complex sugars (glyconutrients) in breastmilk, the oligosaccharides, are passed from mother to child during breastfeeding and are secreted in the baby’s urine. (9) The penis retains these substances in the foreskin. Universy studies have shown that these substances protect against urinary tract infections (UTIs), as well as from infections of other parts of the body. (10) Babies excrete in their urine 300-500 mililgrams of oligosaccharides every day. These compounds prevent virulent strains of Escherichia coli (e.Coli) from adhering to the mucosal lining of the entire urinary tract, including the foreskin and glans.

Researchers conducting immunological experiments with the foreskins of bulls have found that plasma cells in the mucosal lining of the foreskin secrete immunoglobulin. (11) The researchers hypothesize that this provides immunity from bacteria and other germs. This is likely to work the same in other mammals, including humans.

Apocrine glands are important glands found in the skin. They are found in the foreskin and elsewhere on the body. (12) They secrete the important lysosomal enzymes cathepsin B, lysozyme, chymotrypsin, and neutrophil elastase. (13) All of these enzymes help protect the body from many kinds of bacteria. These enzymes are also found in tears and other bodily fluids. Human apocrine glands also produce cytokine, a nonantibody protein that generates an immune response on contact with specific antigens. (14) All these substances have immunological functions and protect the penis from viral and bacterial pathogens. This natural protective function has been destroyed in circumcised males.

The Truth About Circumcision and HIV

By Gussie Fauntleroy


Medical journals and mainstream publications caught the world's attention in recent years with headlines such as this one, from the December 24, 2007 issue of Time: "Circumcision Can Prevent HIV." The magazine honored this dramatic claim with the top spot on its annual list of "medical breakthroughs." The New York Times, the Manchester Guardian, Medical News Today, and scores of other newspapers, magazines, and online news and medical information sources echoed the news. The World Health Organization (WHO) used the phrase "compelling evidence" to describe the development.

The source of all the excitement was a pair of research studies from Africa whose results were reported in the British medical journal The Lancet in February 2007.1, 2 According to the researchers, randomized trials conducted in Kenya and Uganda, and a similar, earlier one from South Africa, indicated that circumcision of heterosexual men could reduce the risk of HIV infection by 53 to 60 percent.

This attention-getting assertion quickly resulted in action by WHO and the United Nations' AIDS advocacy organization, UNAIDS, both of which recommended expanding programs of male circumcision in sub-Saharan Africa, where HIV rates are highest. These recommendations represent a "significant step forward in HIV prevention," according to Dr. Kevin De Cock, director of WHO's HIV/AIDS Department.3


In the US, the national Centers for Disease Control and Prevention (CDC) concurred, stating that "several types of research have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex."4 (At the same time, however, the CDC's own research has yielded contradictory results among American black and Latino homosexual men.5) In addition, the President's Emergency Plan for AIDS Relief (PEPFAR), established by Congress in 2003 to fund health initiatives in developing countries, last year asked beneficiary governments to draft policies encouraging male circumcision as part of their HIV prevention plans.6

What about American babies?
What does all this mean for American parents who may wonder whether to have their infant sons circumcised? How does the claim of HIV protection relate to neonatal circumcision in the US and the developed world?

The short answer: It doesn't. Short-term trials involving heterosexual adult males in Africa cannot be applied to babies in the US because the two populations have too little in common, experts say. In addition, a number of scientists and scholars are raising serious questions about the African studies themselves, in terms of methodology, statistical results, confounding factors, ethics, and other issues.
Marilyn Milos, founder of the National Organization of Circumcision Information Resource Centers (NOCIRC), addresses the question of HIV risk protection succinctly in a pamphlet designed to clear up confusion on the issue: "Circumcision cannot prevent the spread of HIV; circumcised men contract HIV, transmit HIV, and die from AIDS. Transmission of HIV infection is caused by risky behaviors, such as multiple sex partners, failure to use condoms, and contaminated instruments or needles. Anyone who engages in high-risk behavior, whether circumcised or intact, is in danger of contracting HIV and other sexually transmitted diseases."7


Milos goes on to point out that the US has the highest rate of medically unnecessary, non-therapeutic infant circumcision in the world—about 56 percent of male babies today undergo the procedure,8 down from almost 85 percent in the 1960s9—and yet the HIV infection rate in North America is twice the rate in Europe,10 where circumcision rates are low. Even in Africa, the correlation between circumcision and HIV in various countries and regions does not support the premise that intact men are more at risk for the infection. Some geographic areas where the practice is part of the culture have higher HIV rates than areas where circumcision is rare; in other places, the situation is reversed.11, 12


Weighing in on circumcision in general for American babies, the American Academy of Pediatrics statement, reaffirmed in 2005, asserts that the data on the potential medical benefits of circumcision are "not sufficient to recommend routine neonatal circumcision."13, 14 Physicians' organizations and AIDS advocates in other countries, including Australia, have made similar statements.15, 16

What's behind all the fuss?
The two randomized trials that have aroused so much discussion were initiated in Uganda and Kenya in early 2006, and were funded by the National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health. Additional support for the Kenyan trial came from the Canadian Institutes of Health Research. Leading the Kenyan trial were Robert Bailey, PhD, of the University of Illinois, and Stephen Moses, MD, of the University of Manitoba, in Canada. The Ugandan study was headed by Ronald Gray, MD, of Johns Hopkins University. Both trials were similar in structure and outcome to one conducted the previous year in South Africa—which researchers brought to an early conclusion.17, 18


In Uganda, researchers began with a total of 4,996 men and randomly divided them into two groups, medically circumcising one group (2,474 men) and leaving the other group (2,522 men) intact. After 24 months, both groups were tested for HIV infection. Of the circumcised men, 22 tested positive, while 45 in the uncircumcised group tested positive. Researchers derived a 55 percent risk-prevention figure from the difference in results between the two groups. Similarly, the Kenyan trials began with 2,784 men and randomly divided them, with 1,391 undergoing circumcision and 1,391 left intact. Two years later, testing showed 22 new infections among the circumcised men and 47 among those left intact. In both studies, the men were given extensive counseling on the use of condoms. Significantly, researchers made no attempt to determine the HIV status of any of the men's female partners, a startling omission that effectively negates the findings, critics say.

Equally important were the findings of a major 2007 research investigation that sought to determine whether male circumcision had any effect on the risk to heterosexual African women of acquiring HIV from their male partners. Analyzing data from 4,417 Ugandan and Zimbabwean women enrolled in their study, the researchers concluded that "male circumcision status was not significantly associated with women's risk of HIV acquisition in any group . . . [and we] did not observe a significant protective effect of male circumcision overall or for any subgroup in [their] cohort."19


The results of the Ugandan and Kenyan trials were released to the media in early December 2006 in conjunction with UN World AIDS Day, two months before the studies were published in The Lancet. This unusual move produced worldwide publicity that was heavy on eye-catching headlines and light on details because—in the absence of the published studies themselves—few journalists took the time to dig beyond the press releases made available to them.

"Mutant statistics"
After the articles appeared in The Lancet, a number of scholars and scientists began questioning the studies' methodology and statistical relevance. Charles Geshekter, an African studies specialist and Emeritus Professor of History at the California State University at Chico, has served on the executive council of the American Association for the Advancement of Science/Pacific Division. Geshekter cautions that the statistically small number of new infections in each group raises major questions about extrapolating such results to larger populations. In the Ugandan trial, 0.8 percent of the circumcised men tested positive after two years, while 1.7 percent of the non- circumcised men tested positive.20, 21
"Keep in mind that of all the participants, a total of 1.3 percent tested HIV positive; the other 98.7 percent remained HIV-negative," Geshekter points out. Likewise, in Kenya, the claim of a 53 to 60 percent rate of risk reduction is based on 1.5 percent of circumcised men becoming infected, compared with 3.3 percent of those left intact. "These are microscopically small studies," Geshekter contends. An economic historian, he describes the use of such numbers as "mutant statistics" that "take on a life of their own and can have a remarkably long shelf life. The more they get repeated, the longer their shelf life." This is extremely important, critics observe, because policy decisions affecting millions of lives are based on headline-grabbing figures that may not reflect the reality on the ground.

A related issue that has raised scientific eyebrows is the African trials' short duration, with initial results presented as definitive less than two years into the studies. "Any time you have a short time span and then extrapolate, small differences become amplified," observes pediatric specialist Dr. Robert S. Van Howe, of Marquette General Hospital, Marquette, Michigan, who for many years has studied the issue of infant circumcision.22


Confounding factors
Emphasizing that HIV infection is "driven by behavior, not by biology," Van Howe suggests that behavioral factors could have influenced participants in the African studies, producing results that may not be replicated in a widespread circumcision of men, even within the same African countries. The Kenyan and Ugandan men—more than half of whom were unemployed when they signed up—were eager to join the studies, for which they were paid to take part in. The men received two years of free health care, as well as thorough and continual instruction in the importance of condom use. For these reasons, their experience was not reflective of the broader population in many parts of Africa, where a powerful stigma continues to be attached to HIV/AIDS and many are reluctant to undergo even routine testing, Van Howe and others note.

While the African studies' claim of 53 to 60 percent risk reduction is based on the assumption of infection transmission through heterosexual activity—a broadly accepted assumption among most of the AIDS community—some researchers point to other highly probable but little-acknowledged sources of infection. In an article in the October 2007 issue of the International Journal of STD and AIDS, the authors state that an exhaustive review of studies linking HIV to sexual behavior among African adults accounts for only about a third of HIV infections. The rest, they argue, is likely transmitted through unsafe medical procedures, including injections, transfusions, and other contact with infected blood.23 In fact, a March 2007 article in Annals of Epidemiology, the official journal of the American College of Epidemiology, suggests that some HIV infections may result specifically from circumcision procedures.24


Other scholars go further, positing a possible overreliance on the HIV and AIDS labels themselves. These critics, including some African leaders, question the accuracy of using HIV/AIDS terminology to define medical conditions among millions of people—especially in rural, impoverished parts of Africa considered at "high risk" for HIV infection—whose disease symptoms potentially have nothing to do with the virus. "The available medical literature cites over 60 pre-existing medical conditions, including pregnancy, influenza, tuberculosis, hepatitis, and malaria, that can trigger a false positive test result," Charles Geshekter warns.

Where should funding be going?
Adding to these concerns are questions about the testing methods themselves. Geshekter explains, for example, that there are ten proteins said to be characteristic of HIV-infected blood. Yet depending on the country of origin, the medical authority in charge, and the location of the laboratory analyzing the test results, detection of as few as two of these proteins may be considered sufficient to earn the HIV label. He adds that HIV testing kits themselves, from all manufacturers, include a packet insert with a disclaimer stating that such kits cannot be used to conclusively detect HIV infection in human blood.25 Mathematician and former HIV researcher Rebecca Culshaw calls the HIV-antibody tests "some of the worst tests ever manufactured in terms of standardization, specificity, and reproducibility."26


As a result, critics say, large numbers of Africans suffering from diseases common among impoverished populations may be tossed into the "AIDS epidemic" pot, producing overly high figures. Although many in the AIDS advocacy field are motivated by a genuine desire to relieve suffering, some critics point out that most well-established AIDS-related research careers and professional reputations—and associated funding—remain inherently dependent on claims of an ever-increasing number of AIDS cases.

Many AIDS advocates contend that, rather than encouraging widespread circumcision, international funding would be much more effectively spent on an intensive, ongoing, continent-wide, and culturally sensitive educa-tional push involving proven methods of risk reduction, especially condoms. The cost of one circumcision in Africa ($70) is enough to buy 3,500 condoms—enough condoms for one man for every day for ten years, notes Dr. Robert S. Van Howe. Concern about widespread circumcision is particularly strong when it is described as a "virtual vaccine," as it has been in some publica-tions. The fear is that, among newly circumcised African men, an unfounded belief in lifelong protection from infection could cause some to abandon any commitment to measures known to provide substantial protection, such as condoms, limiting sexual partners, and abstinence. Under-scoring this point, Thailand and Uganda have seen significantly reduced HIV/AIDS rates in recent years as a result of intensive educational programs, reduced visits to sex workers, and strong encouragement for 100 percent condom use among sex workers.27 A 2000 US Census Bureau paper also counts Senegal as a "success story," noting that "programs put into place early in the epidemic have kept HIV prevalence rates low."28

Back in the USA
Whatever the case in Africa, public health professionals emphasize that studies on African men cannot be applied to American infants. The two populations share little more than the male biology, differing substantially in areas such as culture, conditioning and behavioral patterns, health risks, and access to medical care. Another key difference is that, in the US, there is no evidence of an AIDS epidemic through heterosexual transmission. The CDC, estimating 40,000 new cases of HIV infection each year in the US, puts the rate of new AIDS cases among males in 2004 at 25.6 per 100,000, and among females at 9.0 per 100,000. "Almost all 'heterosexual female AIDS cases' in the US are actually intravenous drug users," Charles Geshekter maintains. "Heterosexual non-IV-drug users in the US almost never contract AIDS. This was pointed out by a definitive survey published in 1994.29 But the mainstream AIDS establishment ignores all of that."

For parents considering whether to have a son circumcised for purported health benefits of any kind, physicians and public health officials stress that, even under ideal medical safety conditions, the surgery comes with inherent health risks, some quite serious. Among them are pain, hemorrhage, infection, complications of anesthesia or analgesia, damage to the penile shaft or the urethra, surgical mishap, and possible death, as well as postsurgery interference with breastfeeding and normal sleep patterns. There also may be physical complications such as skin tags, skin bridges, or extensive scarring of the penis, as well as loss of penile sexual sensitivity.

Increasingly, another risk has begun looming large on the public-health radar screen: infection by Methicillin-resistant Staphylococcus aureus (MRSA), commonly known as a superbug. This staph infection frequently is spread in hospital newborn nurseries by parents and caregivers whose skin or nasal mucosa may carry the bacteria.30, 31 The risk is compounded by circumcision, which produces on an infant's penis an open wound through which the life-threatening infection may enter.32

Moreover, newborns' immune systems are immature and thus less resistant to infection. Foreskin: A barrier to HIV? On the other side of the health and circumcision equation, recent studies suggest that the presence of a certain type of cell in the foreskin of intact males may actually serve as a protective agent against HIV and other pathogens.33 Langerhans cells are known to exist in mucosa and on the skin's surface, and are especially concentrated on the inner lining of the foreskin. In laboratory studies using an amputated foreskin, the HIV virus appears to attach itself to Langerhans cells, leading researchers to believe that they serve as "target cells," providing the infection with a gateway for absorption into the body.34 Based on this research, the CDC has postulated that the "inner mucosa of the foreskin . . . is more susceptible to HIV infection."35 However, more recent studies offer another view of the role of Langerhans cells. According to a roundup of the relevant research published in March 2007 in the Journal of Cell Biology, it appears that, "rather than transmitting the virus . . .

[Langerhans cells] trap HIV-1 and thus act as a barrier to infection."36 That is why intact men also have a lower incidence of some types of sexually transmitted diseases (STDs). However, experts suggest that when the cells are overwhelmed by a heavy viral load, their ability to protect against HIV decreases. As Dr. Robert S. Van Howe puts it, Langerhans cells are "the bouncer at the door. If the crowd is too big, sometimes infection slips in." The bottom line As parents struggle to sift through the conflicting "facts" of circumcision and HIV, it is instructive to know that many research studies and published papers claiming circumcision's medical benefits have been written by physicians and others, primarily North American, known to be advocates of circumcision.37 Likewise, whole-baby advocates point out that many of the recent news releases on the issue have been actively channeled to media outlets by some of the same circumcision supporters. One thing is clear: Existing evidence worldwide does not support non-therapeutic infant circumcision. And despite the media frenzy around this issue, the African studies do not provide scientific data convincing enough to undermine or contradict this conclusion. As for protection against HIV, we know that neither circumcised nor intact men, or their partners, are free of this risk. Well beyond babyhood, responsibility rests with parents and society to instill a solid, commonsense approach in children, adolescents, and adults, and to create an environment of open discussion and reliable education about high-risk behavior.



 See original at Mothering Magazine

Male Circumcision and the HIV/AIDS Myth

By Ali A. Rizvi

http://www.huffingtonpost.com/ali-a-rizvi/male-circumcision-and-the_b_249728.html

 

This year, 1.2 million male babies in the United States will have between 35 and 50% of healthy, functioning penile skin -- containing over 20,000 nerve endings and the five most sensitive areas of the penis -- removed in a procedure that all of the major medical associations in the world, including the American Academy of Pediatrics and the Canadian Paediatric Society, have deemed medically unnecessary.


Overall, routine, non-therapeutic circumcision costs over $2 billion a year; in most states, it is still covered by Medicaid, at a cost of tens of millions of dollars to the taxpayer. Despite near-universal recommendations against performing it routinely, it is the most common surgical procedure performed in the United States.

Having started among ancient Egyptians and ancient Semitic peoples as a religious sacrificial ritual, the practice didn't take hold in Western societies until the late 1800s, when Western society was mired in masturbation-related hysteria. Dr. John Kellogg (yes, the Corn Flakes guy) was seminally (ahem) influential in the fight against what he called the "practice of solitary vice", to prevent which he ardently recommended circumcision, writing:
"The operation should be performed by a surgeon without administering an anesthetic, as the brief pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment, as it may well be in some cases. The soreness which continues for several weeks interrupts the practice, and if it had not previously become too firmly fixed, it may be forgotten and not resumed."
This recommendation was accepted and implemented widely for male children, likely buoyed by the belief that circumcision was, after all, part of Abraham's covenant with God, who doesn't really like dickheads. Because the application of phenol to a girl's clitoris wasn't part of this covenant, this second recommendation from Dr. Kellogg to prevent female masturbation -- an "excellent means of allaying the abnormal excitement" as he wrote in his book Plain Facts for Old and Young -- wasn't embraced as enthusiastically.

I personally debunked Dr. Kellogg's myth as a young, foreskinless pre-adolescent, sometimes several times a day. Science can be fun. But since Dr. Kellogg, many more myths have come and gone.
One had to do with a 1932 study by Abraham Wolbarst claiming that infant circumcision virtually eradicates the risk of penile cancer, an exceedingly rare condition that affects approximately 1 in 100,000 males in the United States. His research was later discredited on several grounds, including the fact that Wolbarst happened to an avid circumcisionist who also believed, like Dr. Kellogg, that circumcision prevented not only masturbation, but also epilepsy and infant death.

We now know that penile cancer is only slightly more prevalent in the uncircumcised, and routine circumcision is not the best way to go about preventing it, just as routine double mastectomy in women who are done with breastfeeding (and thus have no remaining physiological need for their breasts) is not a good approach to preventing breast cancer -- which is much more common than penile cancer. We also know that the human papilloma virus (HPV), which also causes genital warts, is the most important risk factor for cancer of the penis -- and genital warts are more easily contracted by circumcised men. Moreover, penile cancer is much less prevalent in countries like Denmark, where circumcision is uncommon, compared to the United States, where between 50-60% of males are circumcised.

Advocates of circumcision found more ammunition recently when it was reported that uncircumcised heterosexual males were more likely to contract HIV/AIDS than their circumcised counterparts. The finding, based on studies in Africa, specifically Kenya, Uganda, and South Africa, seemed to show that circumcision reduces the chances of heterosexual men contracting HIV/AIDS from women by up to 60%.

The World Health Organization got behind this immediately, and the WHO's HIV/AIDS Department director, Dr. Kevin De Cock (yes, that's his real name) stated unequivocally that circumcision would give a significant "additional benefit" to men trying to avoid HIV infection.

So how do you go about conducting a randomized, controlled intervention trial looking at HIV infection in circumcised adult men? Probably not the way that these researchers did.

First, to be included in the study, men had to be HIV-negative and uncircumcised. The men also had to consent to "avoid sexual contact (except with condom protection) during the 6 weeks following the medicalized circumcision."

The experimental group which underwent the circumcisions was given the following instructions:
"When you are circumcised you will be asked to have no sexual contact in the 6 weeks after surgery. To have sexual contact before your skin of your penis is completely healed, could lead to infection if your partner is infected with a sexually transmitted disease... If you desire to have sexual contact in the 6 weeks after surgery, despite our recommendation, it is absolutely essential that you use a condom."
So the males in the study that underwent circumcision were not only told to abstain from sex for a significant time period after the operation -- reducing their exposure time by six weeks compared to the uncircumcised (control) group -- but told to use condoms, taught how to use them, and educated about their benefits. During this six week period, the men in the uncircumcised group did not have the same restrictions. There also doesn't seem to be any mention of the researchers calling up the circumcised men after six weeks to say, "Okay, time's up. Ease up on the condom use from here on." The possibility that many of these men might have become accustomed to using condoms, armed with knowledge about their benefits, didn't seem to be much of a concern.

Also, other routes of HIV transmission like blood transfusion, IV needle sharing, or a dentist with dirty instruments (not unimaginable in Africa) don't seem to have been taken into account. Individual variables like hygiene were also poorly controlled for.

Casting further doubt on the theory that circumcision prevents HIV transmission is a simple look at the prevalence of circumcision and the prevalence of HIV/AIDS in different parts of the world.

As a continent, Africa has the highest percentage of circumcised men, over 60%. Africa also has -- as most people know -- the highest prevalence of HIV/AIDS, with South Africa housing the world's largest HIV-infected population. In countries like Nigeria and Kenya, (the latter being one of the countries where the study was conducted) over 80% of males are circumcised, yet they contain the second and fourth largest HIV-infected populations in the world respectively.

Among industrialized nations, the highest prevalence of HIV/AIDS is in the United States, which has the 10th largest HIV-positive population in the world. And yes, the USA also ranks number one among all industrialized nations in its number and percentage of circumcised men: 56% as of 2003, compared to countries in Europe, where circumcision is markedly less common -- as is the prevalence of HIV/AIDS.

Finally, let's address a question that seems to have been largely overlooked: what about the women?
Well, last month, The Lancet -- which refused to publish the male circumcision trials due to certain ethical concerns -- published a study led by Dr. Maria Wawer at the Bloomberg School of Public Health in Baltimore, concluding that circumcising men did not reduce HIV transmission to their female partners.

Actually, it's quite possible that circumcised men are more likely to give their female partners HIV/AIDS than uncircumcised men. Dr. Wawer found that 18% of the women in her study contracted HIV/AIDS from circumcised men, compared to 12% of women who contracted it from uncircumcised men.

The result was not statistically significant, but the Findings section states, "The trial was stopped early because of futility." Futility? The study may not have been "futile" if, with a larger sample size and properly completed, it had showed that circumcised men were more likely to transmit HIV/AIDS to their female partners, would it? An unanticipated result is still a result, specially if there is pre-existing data supporting it, like this Johns Hopkins study suggesting that women are indeed more likely to get HIV/AIDS from a circumcised male partner.

In an interview with VoA, Dr. Wawer appeared to have had a preference regarding her results. "Yes, of course we are disappointed," she said. "But the data are what the data are."

At the end of the day, we're close to busting another myth, and back to where we started with this whole circumcision-HIV thing. Even if the researchers in the Africa trials were right, it would take over 70 circumcisions in Africa to prevent 1 case of HIV. If the data were applied to the United States, it would take over 300 circumcisions to prevent one case of HIV. The bottom line remains the same: the best way to prevent HIV and other sexually transmitted infections -- whether you're circumcised, uncircumcised, gay, straight, male or female -- is through education and condom use. Where these two conflict -- as they did with the Pope's fatwa on condoms this year -- please go with the condom use.
A recent study looking at sensitivity of the penis in the circumcised and uncircumcised male found that the five most sensitive areas on the penis are removed at circumcision, and that the keratinized glans on the circumcised penis is less sensitive than the foreskin-protected, mucosa-lined glans on the uncircumcised penis. The skin removed from the penis at circumcision makes up close to 50% of the total penile skin, amounting to 15 square inches in an adult.

Even the mildest form of female circumcision is illegal, and very rightly termed female genital mutilation. Male circumcision on the other hand, is demonstrably more severe than some of the milder forms of FGM, but still performed widely. It is still covered by many insurance providers, and Medicaid in most states, despite being completely unnecessary.

Suppose for a moment that females who have been circumcised are shown to have a lower risk of acquiring HIV/AIDS. Kind of like it says in this abstract here.

How appropriate would it be for a group of researchers to carry out a massive study like the African male circumcision trials for women?

How long would it take for Dr. Kevin De Cock at the WHO to recommend female genital mutilation -- even in its mildest form -- as a form of HIV/AIDS prevention?

I wouldn't hold my breath.







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