Comments on: Ethics, subjects, and proof

By: Nancy Reyes

Nancy Reyes — Tue, 28 Jul 2009 23:46:10 +0000

The headline and study was absurd.

The reason HIV spreads is via thin mucus membranes and small cracks in the skin.

Circumcision (or even a dorsal slit) allows men to clean, so that dirt and debris don’t accumulate under the foreskin and cause irritation that would allow HIV to enter tiny abrasions. It also leads to the skin of the gland being thicker, and less prone to being abraded.

Ergo, circumcision leads to less HIV spread to the man.

But there is no physiological reason it should protect women.

Indeed, since the men might think they are now “protected”, the spread may increase to women via more illicit sex (the same reason that stressing condoms increases HIV spread, because it increases the number of sexual contacts).

In contrast, traditional Muslims are both circumcized and avoid promiscuity.

To decrease HIV spread to women, we need to encourage women to get medical treatment for their vaginal irritations, and also to encourage them to stop using herbs that make them “dry” (so that men will find sex more pleasurable)…

By: Jack

Jack — Wed, 22 Jul 2009 19:55:49 +0000

I agree with some of the feelings expressed, but I feel that circumcision is surrounded by such myth and misinformation that either it should not be performed at all, or science must be involved. I am shocked by how Africans have accepted the studies as proving anything. The studies that say risk is lowered by 60% only had 50 -55% risk reduction and I think this is from about 3.2% risk to 1.79% risk. Would anyone say 3.2b bullets in a 100 shot gun to ones head is much different from 1.79 bullets in the same gun? Why are there many other studies that did not find the risk change and why are they not mentioned much? Could it be the pro circumcision agenda being pursued? If female circ involves the same type of cells and same chance for body parts to hold the virus, why is that not pursued? (American bias for MGM?) Why is it not noted that the Africa studies saying male risk reduction could be ooff by large % due to cut having less sex (to heal), condom advice and being humans trying to avoid HIV, after having the main male plasure zones removed (20,000 fine touch and stretch nerve endings).

The latest study may understate the NEGATIVE impact of circumcision
Certainly good science regarding the medical value of circumcision is hard to find because it is largely driven by pro circ fanatics. This study was undertaken by the pro-circumcision camp, funded by the Gates foundation.

There is good reason to believe that the study, if it had continued, would have shown that circumcision actually increases the likelihood of female transmission significantly, if not by twofold.

The data indicates that nearly 75% (6) of the women in the uncircumcised group, who became infected, were infected within six months. Only 2 (25%) of the remaining 62 women became infected over the subsequent 18 months.
11 of the 94 women in the circumcised group became infected in the first six months, 5 of whom may have contracted HIV through pre-healed intercourse. Nevertheless, 6 additional women from this group became infected over the next 18 months.
Excluding those in both groups who were infected in the first six months as aberrations, whether it be because of abnormal susceptibility or dangerous sex practices, the fact remains more than double the women in the circumcised group became infected over the next 18 months. When this is considered, in addition to the fact they also had the benefit of a 6 to 8 week abstinence window, which the uncircumcised group did not, there is every reason to believe that circumcision may greatly increases the chances of transmission in women.

No one can question the fact that more than twice the women (17) in the circumcised group became infected than in the uncircumcised group (8), despite most having engaged in a significant abstinence period of nearly 2 months, as well. To say that these numbers are insignificant statistically is dubious. It is highly unlikely that the public health experts who undertook the study would have reached the same conclusion if the numbers had been reversed.
Sources:
http://www.medpagetoday.com/MeetingCoverage/CROI/8221
http://www.medpagetoday.com/HIVAIDS/HIVAIDS/15120

By: Susan Pietrzyk

Susan Pietrzyk — Wed, 22 Jul 2009 15:49:01 +0000

I did note that male circumcision can increase HIV risk for women. Went as far as to suggest that the Rakai District trial itself facilitated that risk because the male participants were unable to abstain from sex for six weeks after being circumcised. More broadly, I think you missed my point. I am not opposed to trials. Just that it’s important to recognize when the trials which have been conducted are sufficient. To date, trials around male circumcision have yielded some important findings. And part of these findings have been recognition that male circumcision does not provide a singular answer to a complex problem. Male circumcision reduces risk for some, to some degree. And increases risk for some, to some degree. Important then to ask: What is another trial going bring, and what’s motivating that additional trial? At some point it’s a matter of putting into context that no amount of trials around male circumcision will change the underlying human rights element. Male circumcision is not a procedure that can be imposed. If the plan for more trials is being motivated by the desire to build more quantitative evidence to argue for imposing male circumcision, this, in my view, would be a poor use of resources.

By: Don Cox

Don Cox — Wed, 22 Jul 2009 11:56:34 +0000

You missed number 4: Male circumcision can increase the risk of HIV transmission to women.

The point about doing trials, provided they are properly conducted, is to get away from mere guesswork and “general impressions”. In this case the trial revealed a danger that was not previously known. I think that is important.

How will the consenting adults become “informed” if there are no properly conducted trials to provide evidence for or against a treatment?

One major problem is that very few people leave school with any understanding of statistics.