Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation”

This week the Public Health Perspectives blog team offers a total of five posts highlighting and interpreting findings in an important new PLOS research collection, Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up. This research documents the work of global health doctors and public health workers toiling in the epicenter of the global epidemic – SubSaharan Africa – where over 16 million people currently live with HIV and where new HIV infection rates are highest. It also presents some surprising and enlightening results from surveys of VMMC clients and prospective clients, men and women with the most at stake in the battle against HIV-AIDS.

Circumcision clinic

Bapong Health Centre, Bapong, North West, South Africa Credit: Gaph Phatedi, CHAPS

The following introductory post includes some background on voluntary medical male circumcision (VMMC) with reporting by Public Health Perspectives bloggers Atif Kukaswadia,  Beth Skwarecki and Lindsay Kobayashi. In the course of the week, each PHP  team member will publish a separate post, incorporating interviews with collection authors, to examine individual papers and themes in the research.

We hope you’ll get involved with our PLOS-wide discussion on the important topic of HIV-AIDS prevention by reading the collection papers, offering comments on blog posts, posting on the PLOS Facebook page, or tweeting to the collection hashtags #MaleCirc  and #PLOSVMMC2014.

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How Voluntary Medical Male Circumcision Can Get Us Closer to an AIDS-free Generation

There’s still no vaccine for HIV, but it’s not for lack of trying. Thirty-seven trials are ongoing right now, according to the International AIDS Vaccine Initiative. If one were to prove even partially effective, it would be a major boon to public health: even a halfway effective vaccine, given to a fraction of its target population, could still save millions of lives in Africa. There, 1 in every 20 adults is living with HIV, and over 17 million children have lost one or both parents to AIDS.

Rather than waiting for the long-promised vaccine, public health agencies across the African continent, with major assistance from the US and other donors, are rolling out an intervention that trials have shown is almost as effective: circumcision for men.

First things first, what is VMMC and how does it prevent HIV infection?

Circumcision is the surgical removal of the foreskin on a male’s penis. In uncircumcised men, the area under the foreskin can be more vulnerable to infection by the HIV virus (and to other STIs including gonorrhoea and syphilis), due to its microenvironment. In the first decade of this century, epidemiological studies and randomised clinical trials have provided consistent and compelling evidence that male circumcision helps to prevent HIV transmission. As a result, the WHO and UNAIDS have been recommending since 2007 that voluntary medical male circumcision as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision, where the public health benefits will be maximized.

Because the skin cells under the foreskin are particularly vulnerable to HIV infection, circumcision reduces a man’s chance of being infected by 60%. (That’s about the same success rate as last winter’s flu shot). It’s not a complete solution to the AIDS epidemic, since it does nothing for male-to-female transmission; and because it’s only partially effective, condoms are still crucial. But safe sex messages have obviously fallen short. Circumcision is promising because it’s a one-time action: a few minutes in the operating room, and you’re (partially) protected for life.

The PLOS VMMC Collection assesses ongoing efforts in 14 countries in Eastern and Southern Africa to scale up voluntary medical male circumcision (VMMC) programmes to prevent HIV transmission. These countries are Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

Containing a comprehensive PLOS Medicine review, plus 13 original PLOS ONE research articles, the collection authors recommend increasing program efficiency and by identifying and prioritizing those most at risk of acquiring HIV, matching supply with demand and focusing on quality at all levels.

Because of its proven effectiveness when studied in multiple randomized, controlled clinical trials, male circumcision could be used almost like a vaccine to help prevent HIV. Based on modelling studies published in PLOS Medicine in 2011, if 80% of men aged 15 to 49 in these countries underwent circumcision, about 3.4 million new HIV infections would be prevented and US$16.5 billion in averted HIV-related costs would be saved.

In the resource-poor countries involved in the VMMC campaign, these savings would go a long way in supporting other forms of health infrastructure, not to mention the millions of human lives saved.

Today, voluntary medical male circumcision is designed to be part of a comprehensive package for HIV/AIDS treatment — one that includes treatment and counselling, screening, condom promotion and health education.

Some countries in southern Africa show low rates of HIV testing, and enrollment in Antiretroviral Therapy (ART) treatment is even lower. In countries such as Lesotho and Zimbabwe, voluntary medical male circumcision services are seen as an effective strategy to attract men to HIV testing and counselling and link them to continuing care and treatment, since early diagnosis of HIV and treatment initiation at higher CD4 counts improves outcomes and reduces HIV transmission.

The Multiplied Benefits of VMMC for Men and Women

VMMC involves a one-time procedure and offers men life-long benefits, including greatly reducing their risk of acquiring HIV and many other sexually transmitted infections (STIs), such as herpes, syphilis and human papilloma virus (HPV). In addition, female partners of circumcised men also have benefits, including lower rates of cervical cancer (the leading cancer killer among African women) and bacterial vaginosis, a condition that has been associated with pre-term birth.

Iringa campaign vmmc

Clients line up in Iringa, Tanzania to receive circumcision services; Credit: Jhpiego/Tanzania

In some parts of Africa, men are lining up to be circumcised—over 2 million in 2013, bringing the total since 2007 to around 6 million. However, in certain countries, particularly among rural people and those over the age of 25, slow uptake of VMMC is a concern to local and international health agencies. Reflecting this on-the-ground reality, several papers in the collection probe the causes and potential solutions to the challenge of “demand creation.”

emmanuel

Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, “on the ground” during the VMMC campaign.

The importance of documenting lessons learned thus far in the VMMC program implementation was discussed by Emmanuel Njeuhmeli, Senior Biomedical Prevention Advisor at the US Agency for International Development and lead author of the collection, in an interview posted  on the PLOS Speaking of Medicine blog:

“Scale-up of VMMC is critically important to reduce the future burden of HIV, particularly in high prevalence regions, such as Eastern and Southern Africa. HIV infections are happening every day among uncircumcised men in the region and this can easily be prevented. Each day that this proven prevention method is not brought to scale represents a missed opportunity to bring us closer to reaching an AIDS-free generation.”

We invite you to stay with us throughout the week to learn more. Also posting today is an in-depth interview with Emmanuel Njeuhmeli about the program he oversees in 14 countries — and how researchers documented its progress and remaining challenges in the new PLOS VMMC Collection.

Read other posts in this series:

Male Circumcision Part 2: His Choice and Her Influence

Male Circumcision Part 3: Why Some Men are Resisting the Next Best Thing to an AIDS Vaccine 

Male Circumcision Part 4: Public Health is a Noble Profession

Male Circumcision Part 5: Measuring Health Provider Burnout 

 

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Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation” by Public Health, unless otherwise expressly stated, is licensed under a Creative Commons Attribution 3.0 Unported License.

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30 Responses to Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation”

  1. Please stop deleting my comments on this website and your facebook page. I have not been insulting or rude; I do strongly disagree with plos, but I have done so in a respectful way. Plos has proceeded to censor my comments and has not answered my scientific questions. This is not how science is supposed to work; science is a dialog.

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    • Victoria Costello says:

      It would seem we are not censoring you in that your previous comment is available, although we haven’t approved repeats of the same information in multiple comments. Apparently, there are different interpretations of the available evidence on circumcision for HIV prevention, which is part and parcel of scientific debate — which PLOS supports. I thank you for maintaining civility throughout.

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  2. Pingback: Male Circumcision Part 3: Why Some Men Resist the Next Best Thing to an AIDS Vaccine - Public Health

  3. Hope Hope and stop HIV

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  4. Adam Cornish says:

    Circumcision worked so well in the US to prevent the spread of HIV, that we’ve buried nearly a million mostly circumcised men, who died of AIDS.

    Please stop this ridiculous cheerleading, for amputation of healthy genital tissue.
    It is not helping. Condoms work, unlike circumcision.

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    • Victoria Costello says:

      You may have noticed the absence of comments on this series of posts — which began on Tues May 6– covering a new PLOS research collection reporting results of the implementation of a voluntary medical male circumcision (VMMC) program currently underway in 14 Southern and Eastern countries. Several comments submitted since May 6 have been deleted for one of three reasons: they contained gross misinformation, they were unnecessarily vitriolic and/or engaged in name calling — all violations of our PLOS BLOGS Community Guidelines. The comment above does not violate our rules for civil discourse; it includes the poster’s strong critical opinion — which is fine — and includes an implied question about the efficacy of VMMC that has been typical of many comments we’ve received. Our answer below sticks to the scientific research contained in PLOS published research as well as research published in other similarly peer-reviewed scientific journals. It does not overly interpret or speculate on the research.

      First, why some populations with high circumcision rates have high rates of HIV?

      In populations in which men’s HIV risk is primarily due to injection drug use (exposure to HIV is intravenous) or through receptive anal sex with other men (exposure to HIV is rectal), male circumcision is not expected to be protective because removing the foreskin does not change infection risks that are intravenous or rectal. However, in generalized (heterosexual) epidemics, male circumcision does biologically protect men from acquiring HIV from women through sex.

      In 2005, PLOS Medicine published the first randomized, controlled intervention demonstrating a 60 percent reduction in HIV infections over a two-year period among a trial population of 3,274 young South African men who received a voluntary medical circumcision (VMMC). This level of prevention against contracting the AIDS virus through sex with women is considered equivalent to that of an effective vaccination. Since then two further randomized controlled trials — the “gold standard” for medical or scientific research — have replicated this result. It is based on this evidence that the current VMMC campaign has been designed and implemented.

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      • First, an RCT in itself is not a “gold standard.” Rather, a double blind RCT is, and the trials were not double blind. Second, the RCTs to which you refer were conducted by biased researchers who had already professed an interest in promoting circumcision, and they did not note these as conflicts of interest, which is a violation of medical ethics. Third, these researchers intentionally chose to conduct these studies in countries for which population data suggested higher rates of HIV among intact men (Uganda, Kenya) rather than in countries where HIV rates are higher among circumcised men (as in the case in 10 out of 18 countries surveyed; see links below.) Fourth, based on the latest scientific research, we do not know how HIV infects men. It seems much more likely that HIV infects through the urethra, rather than through the foreskin. Fifth, the scientific mechanism as to how circumcision supposedly protects is not known; studies have shown that it does increase the thickness of penial skin. It is irresponsible, and a violation of medical ethics, to promote circumcision when we don’t know how or why circumcision supposedly helps.

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  5. JackieNo says:

    Cutting genital parts off of men has never been shown to prevent HIV infection in real populations. The US NAVY study shows that there was no STD or HIV advantage to the cut American men. Also, records from the US Veterans Administration shows there is no difference at all in the likelihood of HIV infection between cut and natural men.

    Africa provides similar real world data from the ongoing genital mutilation campaign. In HIV prevalence rate among circumcised males between the ages of 15 and 49 in Zimbabwe is higher than that of the uncircumcised male” after a Bill Gates funded circumcision drive. Uganda, since they started cutting men’s genitals, new infections have increased by 11.5 per cent between 2007/8 and 2010/11.

    The idea that cutting the parts off does not affect sexual pleasure is ludicrous. And yet, this has been denied, ignored or downplayed by those that so so want the next generation to also have parts of their p@nis cut off. The parts move, so natural sex is fundamentally different from partial genital sex. The outer skin and inner mucosa (with THOUSANDS of nerves) provides space for an erection. The nerves touch inside the female. This is the sensory input as acute as a fingertip, the nipples or lips.

    The nerves are real. The dynamic action of the NATURAL genitals is real. Of course the cutting of these affects sexual pleasure and function.

    Men who are circumcised are far more likely to suffer from ED.

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    • Victoria Costello says:

      On the question of whether circumcision makes sex less enjoyable for men:

      Only men who have had sex both with and without their foreskin can compare the sensation and sexual satisfaction they have felt before and after undergoing circumcision. Initial studies that evaluated sexual satisfaction among African men who had undergone VMMC indicated that VMMC does not have any effect on sexual desire or satisfaction, erectile function, or ability to achieve penetration; nor does it cause pain with intercourse. A study that compared men who had undergone VMMC to a control group showed that 98% of the men in both the intervention group and the uncircumcised control group rated their sexual satisfaction as “satisfied” or “very satisfied” six to 24 months after enrolling in the trial.

      Sources:
      6 Bailey RC et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 369(9562): 643–656.
      7 Krieger JJN. 2008. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. Journal of Sexual Medicine 5(11): 2610–2622.

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      • Heath says:

        The perception that circumcision protects against HIV likely lead to the psychological enhancement of sexual satisfaction in these men.

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      • Victoria, you state that only men who have experience sex both intact and circumcised can compare; but then, you — a female — make a comparison. This is quite hypocritical. I am an intact male and I can state from personal experience that my foreskin, especially the ridged band, is the most sensitive part of my body. You pick and choose studies that support your claims, including one from Bailey, a circumcision promoter. At the same time, you ignore the work of Sorrells, et al, who found that, “The glans of the circumcised penis is less sensitive to fine touch than the glans of the uncircumcised penis. The transitional region from the external to the internal prepuce is the most sensitive region of the uncircumcised penis and more sensitive than the most sensitive region of the circumcised penis. Circumcision ablates the most sensitive parts of the penis.” http://www.ncbi.nlm.nih.gov/pubmed/17378847

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        • Beth Skwarecki says:

          Sensitivity is one part of overall sexual satisfaction, and the study Victoria cited asked men what they thought in total, having experienced sex both ways. I’ll let their responses stand on their own.

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      • Sarah says:

        This is laughable. In both papers, men were asked a few crude questions about their sexual activity over the past months; no preparatory research was conducted to see just how forthcoming these men were likely to be in discussing their sexual problems–and in face-to-face interviews, no less. The men were being given free healthcare for years and were also paid for enrollment; were tests conducted to ensure that these factors did not induce acquiescence or social desirability biases?

        In the Ugandan paper men simply failed to disclose anything at all. If you look at comparably bad research conducted in other populations, far higher reports of ‘sexual dysfunction’ (by one measure or another) are reported; either Uganda is a sexual paradise for reasons unknown, or these men were not comfortable and/or willing to discuss their sexual issues in this context.

        To take the Kenyan paper seriously the entire field of neurology must be called in to question. One would expect the ablation of impressively innervated tissue (from the distal, business-end of the penis, no less) to diminish sensation (at the distal, business-end of the penis, at least) but these Kenyan gentlemen tell us otherwise. Indeed, in a quite novel finding, more and more men reported ‘much more sensitive’ penises on every occasion they were asked! Apparently circumcision is so amazing that your penis 18 months later is even more sensitive than it was 12 months later! If only the uncircumcised men had been asked whether THEIR penises had gotten more sensitive during the course of follow-up–they did after all report a dramatic decline in sexual ‘dysfunctions’ simply for having enrolled in the study. One would be forgiven for thinking that these biologically implausible findings are mere artifacts of the embarrassingly clumsy and incompetent study designs, but thoughts like those warrant suppressing. If only the investigators had tested themselves by employing as an internal control questions even more obviously silly, like whether sperm production had increased or eyesight improved, for example. If the circumcised men had reported continually/continuously (hard to say) improving hearing, would these findings be published? What if they said they could run faster?

        Like it or not, the impressive sensory innervation of the foreskin has been attested to, incontrovertibly, in quality histological research–most notably by Taylor (1996 and 1999) in what was then the British Journal of Urology (now the BJU International); his research is easily found online and can be read with profit by anyone. Readers might also care to read Sorrells et al. (‘Fine-touch pressure thresholds in the adult penis’) again demonstrating that the primary sensory tissue of the penis is lost to circumcision. As one gentleman colorfully put it, ‘the foreskin isn’t the wrapper–it’s the candy!’ Ignore this at your peril, especially when trying to sell vulnerable adult populations on circumcision—word will spread quickly.

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        • Sarah says:

          Oh, Victoria, I’m sorry, but this comment of yours really is a bit much:

          “Only men who have had sex both with and without their foreskin can compare the sensation and sexual satisfaction they have felt before and after undergoing circumcision”

          Really? If my husband stimulates his foreskin he induces (very powerful) orgasms; does it not stand to reason that he’d be without those orgasms were the tissue extirpated?

          Suppose, Victoria, you were to lose your legs in a road traffic accident. Do you anticipate your enjoyment of foot massages would intensify, or diminish? Another example: could the ablation of any of your vulvar tissue fail to diminish the sensation of your vulva?

          You’re all trying far too hard here.

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  6. Please end the male circumcision campaigns in Africa immediately. These campaigns will only lead to “risk compensation” in which African men will engage in riskier sexual practices, and use condoms less often. Comments verifying these claims can be found on Africans’ own facebook pages and in various news articles from Africa. What is the point in circumcision if you have to use a condom anyway? Circumcision desensitizes the penis and thus makes one less likely to want to use a condom. Male circumcision also increases male to female transmission, due to open wounds, as verified by HIV researcher Wawer (who is biased in favor of circumcision). The RCTs were fixed; a 1% reduction was extrapolated to 60%, without taking into account those who had dropped out of the trial. Circumcised men could not have sex when their wounds were healing, and the control group could. The full data sets have not been released to the public. Please stop the circumcision campaigns now before it becomes obvious that they are making the epidemic worse. When this happens, don’t say that nobody warned you.

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    • Victoria Costello says:

      On whether VMMC increases risk taking in circumcised men…

      This phenomenon is called risk compensation, and it is a valid concern with any partially protective intervention against HIV, including VMMC. The available data suggest that men do not change their behavior very much after circumcision. Risk-taking levels remain relatively fixed over time among circumcised and uncircumcised men, even among recently circumcised men.

      A study in Kenya found that men who underwent VMMC as part of a randomized controlled trial (RCT) did not increase their risk-taking behavior compared to their uncircumcised counterparts. There were no statistically significant differences in risk-taking behavior behaviors (or incidence of gonorrhea, chlamydia, or trichomoniasis) between circumcised and uncircumcised men, which further supported the self-reported evidence that risk compensation did not occur among men circumcised in the RCT.

      In slight contrast, a study in South Africa found that men enrolled in an RCT in the intervention group (circumcised men) reported an average of approximately one more sexual contact in the prior eight months compared to men in the control group (uncircumcised men). As more research and programs address the risk compensation issue, risk compensation among VMMC clients may be reduced. Follow-up studies are needed to evaluate this. All VMMC clients receive extensive safer sex counseling and are advised that VMMC is only partially protective. In print media, circumcision is often described as the “goalkeeper” on a football field, analogous to the last line of defense against HIV, if other “defenders,” such as condom use and reducing the number of sexual partners, fail. Men are counseled to take additional steps to reduce their HIV risk, such as reducing their number of partners and using condoms correctly.

      Sources:
      11 Castellsagué X et al. X et al. 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl
      J Med 346: 1105–1112.
      12 Njeuhmeli E et al. 2011. Voluntary medical male circumcision: Modeling the impact and cost of expanding male circumcision for HIV
      prevention in Eastern and Southern Africa. PLoS Medicine 8(11): e1001132.
      13 Hankins CA, Njeuhmeli E and Forsythe S. 2011. Cost, impact, and challenges of scaling up voluntary medical male circumcision. PLoS
      Med 8(11): e1001127. doi:10.1371/journal.pmed.1001127
      14 Njeuhmeli et al. 2011.
      15 Hankins, Njeuhmeli, and Forsythe, 2011.

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      • Mutilated Man says:

        You write, “All VMMC clients receive extensive safer sex counseling and are advised that VMMC is only partially protective.”

        Indeed, and the circumcised cohorts in the studies you’re citing received counseling as well, while the “control” cohorts did not, so *if* there actually was any benefit seen in the circumcised cohorts, you cannot attribute it to the circumcisions.

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  7. Madre says:

    Could you comment on this study that demonstrate that intact men may use condoms much more frequently that circumcised men? (USA)

    http://std.sagepub.com/content/24/3/175.short

    Any similar study done in Africa?

    On the other hand, I see that the VMMC randomized studies used a 72 months time scale. Are there longer studies? If the protection is partial, longer studies may demonstrate that the effort is not worthy…

    Wouldn’t be better to shift the money and effort employed for VMMC (partial protection still to be validated in the long run) to Condom awareness (full protection).

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    • Victoria Costello says:

      The issue of condom use was covered in the previous reply.

      On the question of resource allocation to fight the HIV-AIDS epidemic in Africa

      VMMC is not only cost-effective but cost saving. It is a brief, one-time medical procedure that provides a man with a lifetime of partial protection. Because repeated treatments are not necessary, services can be provided at a limited cost to health care systems. In some high prevalence settings, if scale-up is rapid, every dollar spent on VMMC has the potential to save $14 in care and treatment costs, according to mathematical models.12,13 By averting new HIV infections in men and women (as fewer men acquire HIV, fewer women will encounter HIV positive partners), VMMC will save a substantial amount of money, which can then be used to accelerate progress in researching and implementing other prevention strategies. There have been concerns that VMMC stresses scarce resources and adds to already overburdened health care systems. It is important to remember that although adult VMMC services do require short-term support from health care systems, they promise substantial longterm relief by sharply reducing the number of HIV-positive individuals needing care and treatment. The opportunity cost of not scaling up VMMC now will be the cost of providing care and treatment to an additional 3.4 million men and women in the future, individuals who likely would not have been infected had VMMC scale-up occurred.

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      • First, you are basing your argument off of the assumption that circumcision will work, even though it has not worked in the US, the Philippines, Israel, and Malaysia. You “believe” in circumcision like someone who “believes” in G-d. Why are follow-up studies not being conducted to assess the extent to which the VMMC programs are working? Why are researcher finding upticks in HIV now, after the programs have been underway for several years? Plus, a lot of people do not even having access to clean water or sanitation, the two primary causes of health problems. Yet you state that money should be spent on circumcision instead?

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  10. Jhon Murdock says:

    It has never been demonstrated that HIV is entering the male body via the foreskin. Never. All other STDs are known and proven to enter through the urethra. So why has WHO, UNAIDS, PEPFAR et al been studiously avoiding the study of the urethra? And why are they ignoring this study: http://www.news-medical.net/news/20130301/Macrophages-allow-entry-of-HIV-in-the-urethra.aspx ? Could it be that they and the good doctors in back of the three seriously flawed and fallacious African studies are now in too deep? Only a condom can protect the urethra. End of story.

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    • Victoria Costello says:

      This is a long answer, but for anyone who wants to hear how scientific evidence accrued to demonstrate the definitive link between circumcision and a lower risk of HIV infection, here is that process….

      When researchers first suspect a cause-and-effect relationship between two things (in this case male circumcision and HIV), they look to see whether there are existing correlations that support their hypothesis. Scientists looked at levels of HIV and male circumcision across different populations and found a
      strong correlation: HIV prevalence was often higher in countries where male circumcision was uncommon (and lower in countries or areas where male circumcision was common).20,21,22 This is particularly true in Africa, although not for all countries/areas. If the association had been found across all populations worldwide, then further studies and clinical trials might not have been necessary to prove the cause-and-effect relationship.

      Therefore, to further test the hypothesis that male circumcision provides biological protection against HIV acquisition, observational studies (the next higher level of scientific investigation) were performed. The observational studies followed HIV-negative men over time to see if they developed HIV infection. The infection rates among the circumcised men in the studies were then compared to the rates among the men who were not circumcised. Because men were being followed over time, they could also be asked about their sexual behaviors.

      In this way, the statistical analyses could control for any differences in sexual behaviors, and the level of protection against HIV resulting from circumcision could be separated from the level of protection resulting from differences in behaviors. The data from the observational studies also supported the hypothesis that male circumcision biologically protects men against acquiring HIV.23,24,25

      Despite the ecological and observational evidence, some skepticism remained about whether unmeasured differences between circumcised and uncircumcised men were resulting in lower HIV in circumcised men.

      To conclusively test the hypothesis that male circumcision biologically protects men against acquiring HIV, RCTs were needed. The ecological and observational studies provided the ethical justification needed to randomly assign study participants either to undergo male circumcision or to remain uncircumcised. Because the process of randomization is entirely one of chance, it ensures that men in the circumcised and uncircumcised study arms are/will be different in only one way: the presence or absence of their foreskin. Thus, if the risk of HIV is different between the two groups of men over time, the difference is attributable to circumcision. As with the observational studies, men were also asked about risk behaviors while in the study, in case men randomized to undergo circumcision behaved differently than those randomized to remain uncircumcised. The results of three RCTs revealed that the circumcised men experienced an HIV infection rate that was 60% lower than the infection rate of uncircumcised men.26 It was at this point that WHO and UNAIDS issued recommendations for male circumcision and gave priority to countries with generalized (heterosexual) epidemics, high HIV prevalence and low male circumcision prevalence.27

      Although the scientific evidence that male circumcision provides partial biological protection against HIV acquisition is irrefutable, some researchers still question whether the men who enrolled in the RCTs were similar enough to men in the general population. It stands to reason that if the men in the trials were very different from men in the general population, then scaling up VMMC in the general population might not result in the same reductions in HIV infection that were as seen in the RCTs. However, community-level studies from Uganda and South Africa have since demonstrated that the rate of HIV infection is lower among circumcisedmen compared to uncircumcised men.28,29 In these studies, men who received circumcision did so as part of routine health services and not as part of an RCT. Therefore, it is clear that when men in the general population receive circumcision as a routine service (instead of as a research intervention), their risk of HIV is reduced—a finding that is consistent with the RCT findings. WHO prioritized expansion of VMMC in 14 countries with generalized (heterosexual) epidemics, high HIV prevalence, and low male circumcision prevalence. What about areas within these countries where HIV is more prevalent among circumcised men than uncircumcised men? These data, which seem contradictory to the RCT findings, are from cross-sectional surveys, meaning that the data were collected at a single point in time. It is not possible to know whether men in these populations were circumcised before becoming infected with HIV, or after. Men may have been infected with HIV when they were uncircumcised and later decided to become circumcised for clinical or other reasons. Also, cross-sectional data about circumcision status are based on self-reporting. Studies have revealed that many men report being circumcised when actually they either are not circumcised at all or are only partially circumcised.30,31 For these reasons
      and others, cross-sectional data cannot be used to prove a causal relationship. Nevertheless, skeptics often refer to cross-sectional data to refute the gold standard scientific evidence provided by the RCTs.

      These investigations have been completed and the findings are conclusive. Using cross-sectional data now to refute the conclusive findings demonstrates a lack of understanding of the limits of cross-sectional data and the overall scientific process for testing hypotheses.

      20 Bongaarts J et al. 1989. The relationship between male circumcision and HIV infection in African populations. AIDS 3: 373–377.
      21 Moses S et al. 1990. Geographical patterns of male circumcision practices in Africa: Association with HIV seroprevalence. Int J Epidemiol
      19: 693–697.
      22 Halperin DT and Bailey RC. 1999. Male circumcision and HIV infection: Ten years and counting. Lancet 354: 1813–1815.
      23 Cameron DW et al. 1989. Female to male transmission of human immunodeficiency virus type 1: Risk factors for seroconversion in men.
      Lancet 2: 403–407.
      24 Weiss HA, Quigley MA and Hayes RJ. 2000. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and
      meta-analysis. AIDS 14: 2361–2370.
      25 Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N
      Eng J Med 342: 921–929.
      26 Gray et al., 2007; Bailey et al., 2007; Auvert et al. 2005.
      27 World Health Organization. 2007. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. WHO:
      Geneva.
      28 Kong G et al. 2012. Longer-Term Effects of Male Circumcision on HIV Incidence and Risk Behaviors during Post-Trial Surveillance in
      Rakai, Uganda. Paper #36. 18th Conference on Retroviruses and Opportunistic Infections, February 27–March 2, Boston, Mass.
      29 Auvert BH et al. 2012. Decrease of HIV Prevalence over Time among the Male Population of Orange Farm, South Africa, following a Circumcision Roll-out (ANRS-12126). Presentation at the 2012 International AIDS Conference, July 22–27. Washington, DC. Abstract TUAC0403.

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      • “Irrefutable” and “conclusive”? Far from it. Plos is engaging in pseudoscience — in which a belief is accepted and not questioned — rather than actual science. In actual science, something is not considered to be irrefutable or conclusive until a causal mechanism is known. In the case of circumcision and HIV, the causal mechanism is still unknown, despite all the research being done to find one. Additionally, plos engages in bias and “cherry picks” those studies that support their beliefs, while ignoring those that do not. When a real scientist, such as myself, asks questions that plos cannot answer, comments are censored.

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      • Mutilated Man says:

        “… Scientists looked at levels of HIV and male circumcision across different populations and found a
        strong correlation … ”

        That’s actually completely false. Quoting from your own publication at: http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030078

        “If all men are circumcised, then prevalence among women will be lower, and men will have lower risk of being exposed and infected. However, several natural experiments do not confirm this argument. For instance, Tanzania has some 110 ethnic groups, some groups using universal male circumcision, others not circumcising. After controlling for urbanization, there was no difference in male HIV prevalence between the two groups: in urban areas, HIV seroprevalence was 9.5% in circumcised groups and 9.7% in uncircumcised groups, and conversely, 4.6% and 5.2%, respectively, in rural areas—none of the differences being significant [3]. In South Africa, the KwaZulu-Natal province, where few are circumcised, has a higher HIV seroprevalence than other provinces, reaching 37% among antenatal clinic attendants in 2003. But, in the Eastern Cape, where circumcision is the rule, the dynamics of the epidemic are almost the same, simply lagging a few years behind, increasing from 4.5% in 1994 to 27% in 2003. Finally, it was argued that the large epidemic in Abidjan, Côte d’Ivoire, and surrounding areas in the late 1980s was largely due to the lack of male circumcision of the local ethnic groups. This, however, did not impede the rapid increase in HIV infection among migrant workers from Burkina Faso and Mali living in Abidjan, who were circumcised.”

        You’re right, of course, that if a positive protective association had been found in all cases, further studies would not have been needed. In fact, further studies were not needed anyway, because this evidence constitutes a *counterexample* to any hypothesis of a causal relationship, and thus demonstrates that it does not exist.

        “In this way, the statistical analyses could control for any differences in sexual behaviors, … ”

        … but it did not, as mentioned in a previous comment.

        “The data from the observational studies also supported the hypothesis … ”

        No, it does not. Even aside from your mis-representation of the statistics in your articles, that data is tortured in many ways…. Same for the (so-called) RCTs you mention.

        ” … ensures that men in the circumcised and uncircumcised study arms are/will be different in only one way: the presence or absence of their foreskin.”

        Also false, as mentioned elsewhere.

        “… circumcised men experienced an HIV infection rate that was 60% lower than the infection rate of uncircumcised men.”

        And there you go with the misrepresentation of the statistics again. As I wrote in my previously deleted post:

        This number means that (to choose example numbers in the ranges reported in most of the studies) if a control group had an infection rate of 2% over the (limited) period of the study, a test group over the same period might have had an infection rate of 1.2%. If you’ve got groups of 100 people, that means you prevent *less than one* (0.8) case of HIV, and only in that limited time period. Indeed, the “Number Needed To Treat” (NNT) to prevent an single case in these studies in between 30 and 55. (and look at those confidence intervals!)

        http://www.circumstitions.com/HIV-SA.html#rrr

        Also, referring to an earlier comment, you’re claiming that “mathematical models” show that circumcising 55 men is cheaper than treating one for HIV – which may actually be, I don’t know – but more importantly, that circumcising 55 men plus the costs of treating all the ones who still get infected is cheaper than a lifetime supply of condoms for all of them.

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      • Sarah says:

        The assumption seems to be that bias introduced by acceptance/refusal of treatment allocation (in the SA trial, approximately 10% of men allocated to the control group elected to get circumcised anyway; I think roughly 4 or 5% of those allocated to the intervention group refused to be circumcised) is going to be either non-existent or of less importance than bias found in observational and quasi-experimental designs, despite quite consistent evidence that men taking up circumcision tend to be more concerned with their sexual health than those avoiding it.

        It’s also being assumed that the high attrition rate–far exceeding the incident HIV cases–is of no importance. I’m at a loss as to just why anyone can think RCTs are a particularly robust means of examining this question, especially given the biomarker evidence from these studies of (1) unreliable self-report of sexual behavior–large numbers of men with STIs reported only abstinence or complete condom use; and (2) incomparability between groups–for example, circumcised men in SA had less HPV (of course this becomes ‘circumcision protects against HPV prevalence’…) and wives of the control group in Uganda had higher rates of bacterial vaginosis at baseline and 12 months, more trichomoniasis, more non-infectious genital ulcers of unknown aetiology, and reported significantly more sexual partners during the observation period (in the most nullifying data collection conditions imaginable).

        There are also amusing inconsistencies, like ‘VMMC’ protecting against genital herpes in Uganda (which we’ve all heard about because the results appeared in the one journal journalists appear to read – the NEJM) but not in Kenya. That’s curious, isn’t it? Apparently HSV-2 findings in Ugandan men aren’t externally valid for Kenyans, but the HIV findings apply to all boys and men everywhere–I’ve even seen editorials in medical journals arguing for the permissibility of mutilating boys in Sweden because of this HIV stuff. Astonishing.

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        • Victoria Costello says:

          In response to any suggestions that voluntary medical male circumcision is being “imposed” on non-circumcising cultures, please note….

          Male circumcision is traditionally practiced in Africa, and VMMC is an African solution to an African public health threat. An estimated two-thirds of African men are already circumcised for cultural or religious reasons. The non-circumcising communities in Southern Africa and parts of East Africa have the highest HIV prevalence.

          PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) does not define HIV prevention strategies for countries in Africa; rather, PEPFAR supports African governments in their fight against the HIV/AIDS epidemic. Most ministries of health in Africa follow international guidance from WHO and UNAIDS, and that guidance recommends VMMC as an important HIV prevention intervention in countries with high HIV prevalence, low male circumcision
          prevalence, and a generalized (heterosexual) HIV epidemic.

          All individuals have the right to know the proven benefits and potential risks of VMMC and todecide for themselves whether they wish to be circumcised (or have their newborn or adolescent son circumcised).

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          • Sarah says:

            Individuals of either/any sex/gender should be free to have their bodies modified as they see fit–assuming informed consent is given, of course. (I’ll here leave aside the problems of men providing informed consent for circumcision when their intuitive understand of their own sexual anatomy is so poor.) But why should anyone have the authority to give proxy consent to the modification of another person’s anatomy? In the absence of medical necessity (after having exhausted all conservative treatment options), this is clearly an act of abuse. HIV is not an airborne disease–it is an STI inefficiently transmitted amongst heterosexuals; there are many options available for any man who wishes to eliminate what is in almost all of the world the vanishingly small risk of contracting HIV via his penis.

            Are you really arguing that no boy anywhere has a legitimate right to his own intact genitals so long as it can be argued that any man anywhere will, for being circumcised, avoid (or delay) infection with an STI he could easily avoid by simply not behaving recklessly?

            Ethics, anyone?

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  11. Pingback: Bacterial Vaginosis Be Gone! » Male Circumcision Part 1: How It Can Get Us Closer to an “AIDS-Free Generation”

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