Male circumcision procedure to reduce risk of HIV

93re2 · 2018-05-06T03:38:53+00:00

The manager for this program is blatantly discouraging and stigmatizing condom usage, painting circumcision as a viable alternative to condoms, and then throwing in a token "of course you should wear a condom anyway" line. I get that his job depends on pushing MGM, but it's still unconscionable.

The 60% Reduction claim is the supposed relative, not absolute reduction, which would in fact only be about 2%. But even then the studies that figure is based on suffered from considerable methodological flaws.

The results of three randomized clinical trials (RCTs) are often presented as proof beyond a reasonable doubt that male circumcision prevents HIV infection.2 After all, RCTs are the gold standard of medical experimentation. However, such accolades only apply to well-designed, well-executed trials. The three RCTs were neither.

The trials were nearly identical in their methodology and in the number of men in each arm of the trial who became infected. The trials shared the same biases, which led to nearly identical results. All had expectation bias (both researcher and participant), selection bias, lead-time bias, attrition bias, duration bias, and early termination that favored the treatment effect the investigators were hoping for.3 All three studies were overpowered such that the biases alone could have provided a statistically significant difference.

The common hypothesis for these trials was that male circumcision would decrease the rate of heterosexually transmitted HIV infections. A basic assumption adopted by the investigators was that all HIV infections resulted from heterosexual transmission, so no effort was made to determine the source of the infections discovered during the trial. There is strong evidence that this assumption was not valid.

In the South African trial, men who reported at least one episode of unprotected sex accounted for 2498 person-years and 46 HIV infections during the trial. Among the remaining men, who accounted for 2076 person-years, 23 become infected although they either had no sexual contact or always used a condom. These men, who had infection rate of 1.11/100 person-years (95%CI=0.74–1.67), presumably became infected through non-sexual means. The men at sexual risk of infection had an infection rate of 1.84/100 person-years (95%CI=1.38–2.46). It would be expected that all men in the trial shared the same baseline risk of non-sexual transmission and any additional risk could be attributed to sexual transmission. The infections attributed to sexual contact would be the difference between the total rate and the non-sexually transmitted rate (0.73/100 person-years). Consequently, only 18 (0.0073 infections per person-year * 2498 person-years) of the 69 infections in the South African trial can be attributed to sexual transmission.4

Similarly, in the Ugandan trial, men who consistently used condoms had the same rate of infection as those who never used condoms (Consistent condom use: 1.03/100 person-years; No condom use 0.91/100 person-years; RR=1.13, 95%CI=0.54–2.38, P=0.74). Men who reported no sexual partners for the duration of the trial accounted for 1252.1 patient-years and 6 infections (0.48/100 persons-years, 95%CI=0.22–1.07). If this rate is subtracted from the rate in sexually active men, at most 35 of the 67 infections in the Ugandan trial can be attributed to sexual transmission.5

Finally, in the first three months of the Kenyan trial, five men became HIV-positive who reported no sexual activity in the period before the seroconversion (0.73/100 person-years, 95%CI=0.30–1.76). If this rate is subtracted from the overall rate of infection in the trial, at most 36 of the 69 infections in the Ugandan trial can be attributed to sexual transmission.6 Conservatively for the three trials, 89 of the 205 infections (43.1%) were sexually transmitted. Without knowing which infections were sexually transmitted, it is impossible to test the hypothesis of whether circumcision reduces the rate of sexually transmitted HIV. Basing policy on studies that were unable to answer their own research question is unwarranted.

Lack of biologic plausibility

How does cutting off the foreskin prevent the transmission of HIV? This question remains unanswered. Proponents of the circumcision solution have speculated that the interior mucosa of the prepuce is thinner and more prone to tearing, but mucosa of the inner and outer prepuce have been shown to be of the same thickness.7 Proponents also speculate that HIV is more likely to be transmitted through the foreskin because it has a high concentration of Langerhans cells, which they believe are the entry point for HIV. Research has shown that Langerhans cells are quite efficient in repelling HIV and explains why the transmission rate of HIV is one per 1000 unprotected coital acts.8 The inner foreskin secretes langerin, which kills viruses.9 Langerhans cells also protect against other sexually transmitted infections (STIs), which may explain why circumcised men are at greater risk for getting an STI (unpublished data). In general, mucosal immunity provides a stronger barrier to infection than the skin. Finally, to support their plausibility argument, circumcision proponents have identified the sub-preputial space as a harbor for sexually transmitted viruses. Meta-analyses assessing the susceptibility to genital infections with herpes simplex virus and human papilloma virus have not shown an association with circumcision status.10–12 Unfortunately, these speculations have been repeated so often in the medical literature that many physicians and public health officials consider them factual. There is, however, no direct scientific evidence to support the hypothesis that the foreskin is a predisposing factor for infection.

Van Howe, RS and Storms, MR. How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa. Volume 2, Issue 1. Article e4. March 2011

thrway_1000 · 2018-05-06T02:57:14+00:00

Utter BS.

Archive -- https://archive.is/lg616

intactisnormal · 2018-05-06T15:36:34+00:00

Data from the CDC: “The number needed to [circumcise] to prevent one HIV infection varied, from 1231 in white males to 65 in black males, with an average in all males of 298.” Terrible stats. Also circumcision is not effective prevention. Condoms must be used regardless.

Dr. Guest discusses the methodological flaws with the African studies including that the circumcised were unable to have sex for 6-8 weeks, the prevalence and impact of sex workers in those areas, how malaria helped spread HIV in the study area, and problems with early closure of the study.

Title	Male circumcision procedure to reduce risk of HIV
Author	maluminse
Upvotes	0
Comments	24
Date	May 6, 2018 12:47 AM UTC (8 years ago)
Subreddit	Posted in /r/MensRights
Original Link	https://old.reddit.com/r/MensRights/comments/8hbq8u/male_circumcision_procedure_to_reduce_risk_of_hiv/
Archive Link	https://theredarchive.com/r/MensRights/male-circumcision-procedure-to-reduce-risk-of-hiv.901732 https://theredarchive.com/post/901732

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