Circumcision and HIV/AIDS Prevention

 

Introduction

That medical circumcision is a vital weapon in the war on HIV is now consensus in the medical scientific community. From the first suggestions in 1986, to multiple epidemiological studies through the 1990s and early 2000s, and culminating in a series of three randomized controlled trials published in 2005 and 2007 (Auvert, et al., 2005; Gray et al., 2007; Bailey et al., 2007), a wealth of compelling evidence has convinced every medical body dealing with the epidemic. Circumcision reduces the risk of female to male HIV transmission by up to 70 % (Lei et al., 2015). Safe medical circumcision is now being rolled out in 14 high priority African countries where the epidemic is at its worst. (See: http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/).

It is also being considered for countries outside Africa, such as in the Caribbean, where HIV prevalence can reach 3 %. Debate continues about whether it is worthwhile in low-HIV settings but, in principle, even there it should be protective. The effect is a biological one, related to the presence or absence of a foreskin (a major route of entry for the virus), and viruses do not care which continent they are on.

Initially targeting adults, the circumcision program is now being extended to children and infants, much to the consternation of intactivists who continue to rail against the evidence, churning out pseudoscientific articles, spreading misinformation to Africans through social media, websites and comments threads, and doing all they can to undermine this life-saving initiative. The irresponsibility, and immorality, of this is disgusting. It is already well documented how similar behaviour by anti-vaccinationists (many of whom are also intactivists) has led to outbreaks of preventable disease. Circumcision is no different.

The scope for disaster is terrifying. When former South African president Thabo Mbeki fell for HIV/AIDS denial pseudoscience on the internet he halted his country’s implementation of another effective anti-HIV strategy: antiretroviral therapy (ART). The result was 330,000 dead (Chigwedere et al., 2008). As circumcision is the third most successful intervention, after ART and condoms (WHO, 2016), undermining it could be catastrophic.

In this section we bring you rebuttals of common intactivist arguments relating to circumcision and HIV. Many relate to Africa, others are more general. But the Internet is global, and intactivist arguments can reach everywhere. Intactivists would rejoice if they dissuaded Africans from participating in the WHO-sponsored circumcision program. Africans would die in droves if they did. We at circfacts.org believe that African lives matter.

 

Table: Summary of the principal published attacks on the African RCTs, or the circumcision program following them, and the debunkings of these.

Intactivist article Debunked by
Green, et al., (2010) Banerjee et al., (2011); Wawer et al., (2011)
Van Howe & Storms (2011) Morris et al. (2011)
Boyle & Hill (2011) Wamai et al. (2012)
Ncayiyana (2011) Kessinger & Millard (2012); Venter et al. (2012)
Earp (2012) Geffen (2012)
McQuoid-Mason (2013) Millard & Goldstuck (2013)
Adler & Svoboda (2014) Moreton (2014)
Darby (2014) Morris et al. (2015)
Van Howe (2015) Morris et al. (2016)
Van Howe (2017) Morris et al. (2017)

 

References

Adler, P., Svoboda, J.S. (2014) Open letter to the Bill & Melinda Gates Foundation. Submitted by Harry Crouch of the National Coalition for Men on 16 July 2014. On-line: http://ncfm.org/wp-content/uploads/2014/07/141617-Cover-letter-AND-the-open-letter-to-the-Gates-Foundation.pdf

Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., Puren, A. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine, 2(11), 1112-22.

Bailey, R.C., Moses, M., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., Williams, C.F.M., Campbell, R.T., Ndinya-Achola, J.O. (2007) Male circumcision prevention for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet, 369(9562), 643-56.

Banerjee, J., Klausner, J.D., Halperin, D.T., Wamai, R., Schoen, E.J., Moses, S., Morris, B.J., Bailis, S.A., Venter, F., Martinson, N., Coates, T.J., Gray, G., Bowa, K. (2011) Circumcision denialism unfounded and unscientific. Am. J. Prev. Med., 40(3), e11-e12.

Boyle, G.J., Hill, G. (2011) Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J. Law Med., 19(2), 316-34.

Chigwedere, P. Seage, G.R., Gruskin, S., Lee, T.H., Essex, M. (2008) Estimating the lost benefits of antiretroviral drug use in South Africa, J. Acquir. Immune Defic. Syndr., 49(4), 410-5.

Darby, R. (2014) Syphilis 1855 and HIV-AIDS 2007: Historical reflections on the tendency to blame human anatomy for the action of micro-organisms. Global Public Health, 10(5-6), 573-88.

Earp, B.D. (2012) When bad science kills, or how to spread AIDS. Originally on the Oxford University “Practical Ethics” blog, it has since been reproduced here: http://www.creativitypost.com/activism/when_bad_science_kills_or_how_to_spread_aids

Geffen, N. (2012) Getting circumcision science right in the media. Posted on the Quackdown blog: http://www.quackdown.info/article/getting-circumcision-science-right-media/

Gray, R.H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., Kiwanuka, N., Moulton, L.H., Chaudhary, M.A., Chen, M.Z., Sewankambo, N.K., Wabwire-Mangen, F., Bacon, M.C, Williams, C.F.M., Opendi, P., Reynolds, S.J., Laeyendecker, O., Quinn, T.C., Wawer, M.J. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet, 369(9562), 657-66.

Green, L.W., Travis, J.W., McAllister, R.G., Peterson, K.W., Vardanyan, A.N., Craig, A. (2010) Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am. J. Prev. Med., 39(5), 479–82.

Kessinger, M., Millard, P.S. (2012) Voluntary male medical circumcision. S. Afr. Med. J., 102(3), 123-4.  (A brief reply by Ncayiyana followed on p. 125-6).

Lei, J.H., Liu, L.R., Wei, Q., Yan, S.B., Yang, L., Song, T.R., Yuan, H.C., Xiao, L.V., Han, P. (2015) Circumcision status and risk of HIV acquisition during heterosexual intercourse for

both males and females: A meta-analysis. PLoS ONE, 10(5): e0125436. doi:10.1371/journal. pone.0125436

McQuoid-Mason, D.J. (2013) Is the mass circumcision drive in KwaZulu-Natal involving neonates and children less than 16 years of age legal? What should doctors do? S. Afr. Med. J. 103(5), 283-4.

Millard, P.S., Goldstuck, N. (2013) Legality of circumcision in South Africa. S. Afr., Med. J., 103(7), 436.

Moreton, S. (2014) An annotated version of the National Coalition for Men’s letter to the Bill and Melinda Gates Foundation. On-line: http://www.quackdown.info/article/debunking-anti-circumcision-pseudoscience/ and https://thecaseagainstintactivism.wordpress.com/2014/08/07/ncfm-refutation/

Morris, B.J., Waskett, J.H., Gray, R.H., Halperin, D.T., Wamai, R., Auvert, B., Klausner, J.D. (2011) Exposé of misleading claims that male circumcision will increase HIV infections in Africa. J. Public Health Africa, 2:e28, 117-122.

Morris, B.J., Wamai, R.G., Krieger, J.N., Banerjee, J., Klausner, J.D. (2015) Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby. Global Public Health, 13 November, 19 pages (ePub ahead of print).

Morris, B.J., Barboza, G., Wamai, R.G., Krieger, J.N. (2016) Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe. Global Public Health, 4 April, 11 pages (ePub ahead of print).

Morris, B.J., Barboza, G., Wamai, R.G., Krieger, J.N. (2017) Expertise and ideology in statistical evaluation of circumcision for protection against HIV infection. World Journal of AIDS, 7(3), 179-203.  On-line: https://www.scirp.org/journal/PaperInformation.aspx?PaperID=78405

Ncayiyana, D.J. (2011) The illusive promise of circumcision to prevent female-to-male HIV infection – not the way to go for South Africa. S. Afr. Med. J., 101(11), 775-6.

Van Howe, R.S., Storms, M.R. (2011) How the circumcision solution in Africa will increase HIV infections. J. Publ. Health Africa, 2:e4, 11-15.

Van Howe, R.S. (2015) Circumcision as a primary HIV preventive: Extrapolating from the available data. Global Public Health, 10(5-6), 607-25.

Van Howe, R.S. (2017) Expertise or ideology? A response to Morris et al. 2016, ‘Circumcision is a primary preventive against HIV infection: Critique of a contrary metaregression analysis by Van Howe’. Global Public Health, 2017, 1-19, E-Pub ahead of print Jan 10, 2017.

Venter, F., Rees, H., Pillay, Y., Simelela, N., Mbengashe, T., Geffen, N., Conradie, F., Shisana, O., Rech, D., Serenata, C., Taljaard, D., Gray, G. (2012) The medical proof doesn’t get much better than VMMC. S. Afr. Med. J., 102(3), 124-5.  (A brief reply by Ncayiyana followed on p. 125-6).

Wamai, R.G., Morris, B.J., Waskett, J.H., Green, E.C., Banerjee, J., Bailey, R.C., Klausner, J.D., Sokal, D.C. & Hankins, C.A. (2012) Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. J. Law Med., 20(1): 93-123.

Wawer, M.J., Gray, R.H., Serwadda, D., Kigozi, G., Nalugoda, F., Quinn, T.C. (2011) Male circumcision as a component of human immunodeficiency virus prevention. Am. J. Prev. Med. 40(3), e7-e8.

WHO (2016) Voluntary medical male circumcision for HIV prevention in 14 priority countries in east and southern Africa. Progress Brief, June. On-Line: www.who.int/iris/bitstream/10665/246174/1/WHO-HIV-2016.14-eng.pdf

 
 

Evidence vs. Ideology: Intactivism and the HIV Epidemic

This article, by a contributor who wishes to remain anonymous, summarizes the early history of the discovery of the HIV/foreskin connection, and the reaction of intactivists to this hugely important, and life-saving, finding. Whilst the fact that circumcision is highly protective against female to male transmission of HIV is now consensus among all reputable medical and scientific bodies, intactivists are ideologically opposed to circumcision and cannot tolerate the idea that the procedure might actually have significant benefits. The article here describes the distortions, misrepresentations and denialism the intactivists engaged in to try and discredit the growing body of evidence against them. It covers the period from the initial indications in 1986 that circumcision may protect against HIV up to just before publication of the randomized controlled trials (in 2005 & 2007) that settled the matter – at least for everyone not resident in the crankosphere. Like creationists, intactivists are still stuck in denial and continue to rail against the evidence to this day, but that’s pseudo-scientists for you.

Although the earliest suggestions that circumcision might protect against HIV were printed in 1986, (Alcena, 1986; Fink, 1986) epidemiological evidence would not emerge for another two years. By the end of 1988, two studies were published finding evidence of increased risk of HIV in uncircumcised males (Greenblatt, 1988; Simonsen, 1988). The second, by Simonsen et al., (Simonsen, 1988) received some attention from the press.

These events evidently made an impact upon the anti-circumcision lobby. In 1989, Snyder made a presentation at NOCIRC’s symposium in 1989, in which he described the “recent speculation” that circumcision might protect against HIV as “most cruel” (Snyder, 1989a). In a second presentation only days later to the California Medical Association, (Snyder, 1989b) he referred to Simonsen’s study, asked why American men had not been protected by the fact that many were circumcised, and argued that circumcision had “failed to prevent” HIV and other conditions. This suggests that he had failed or refused to understand the concept of reduction, as opposed to elimination, of risk. By the end of that year, two more studies followed showing further evidence of a protective effect (Bongaarts, 1989; Cameron, 1989).

By 1991, a NOCIRC newsletter complained, “[the United States] circumcision rate increased eight-tenths of a percent from 1988 to 1989 following suspect reports that babies left intact are at increased risk for urinary tract infection and claims that men with foreskins are more likely to acquire AIDS” (NOCIRC, 1991). The anti-circumcision lobby may have felt threatened: the 1989 review of circumcision by the American Academy of Pediatrics had, to quote the American Medical Association, “reversed a long-standing opinion that medical indications for routine circumcision were lacking”(AMA, 1999).

The volume of published work concerning circumcision and HIV continued to increase until 1995, with 28 PubMed entries for that year alone – a cumulative total of 137 since 1986. At a NOCIRC symposium in 1996, Van Howe outlined the “problem” of the persistence of circumcision in the United States. Reasons, he believed, included “censorship in american [sic] medical journals” and “exploitation of the mainstream medical journals by pro-circumcision zealots.” He outlined his strategies, which included “aggressively countering the various circumcision “myths”” (Van Howe, 1996a). Such “myths” apparently included HIV: “[one] common scare tactic seen in the literature today posits that, if a child is not circumcised at birth, he is at risk for … HIV” (Van Howe, 1996b).

A year earlier, in a letter to the American Academy of Pediatrics, Van Howe claimed that several new studies “have shown that circumcised males are at higher risk for developing … HIV infections” (Van Howe, 1995). Investigation of his chosen sources is revealing. Of the three studies that Van Howe cited, two found no significant difference – the 95% confidence interval was 0.1-1.1 in one (Guimaraes, 1991) and 0.3-2.6 in another (De Perre, 1987). The third was a partner study (Chao, 1994). Van Howe himself later commented that most studies in this class “failed to show the foreskin to be a significant factor” (Van Howe, 1996).

Selectivity and especially misrepresentation of sources, as we shall see, would soon become a staple strategy. For example, in January 1998, Van Howe claimed that “large random cross-sectional studies which have the least degree of bias have found that circumcised men are more likely to develop or transmit HIV infection” (Van Howe, 1998). As Bailis observed, however, in all but one case, Van Howe’s references found, after adjustment for confounding factors, “no statistically significant association between HIV and circumcision” (Bailis, 1998).

Yet another tactic adopted was more disturbing. Not content with rejecting the evidence of a protective effect, anti-circumcision lobbyists argued that the opposite was true: circumcision, they argued, increased the risk of HIV! In 1998, Van Howe, along with Paul Fleiss and Frederick Hodges (both of whom have also presented at NOCIRC symposia; see NOCIRC, 2002), published a paper purporting to review the immunological functions of the prepuce (Fleiss, 1998). Remarkably, they claimed that “the most common reason given is that it [circumcision] inhibits the transmission of STDs, even though rigorously controlled studies have consistently shown that circumcised males are at greater risk for all major STDs than males whose penises are intact” (Fleiss, 1998). (Five of the six references cited in support of this claim report finding no significant differences.) In their view, the association between HIV and lack of circumcision was a new claim of “circumcision advocates”, and describe epidemiological data as an “attempt to verify this theory” of “an American circumciser … who first hypothesized that circumcision prevents HIV infection” (Fleiss, 1998).

Curiously, these authors claimed that “[t]he inner prepuce contains apocrine glands, which secrete … lysozyme” (Fleiss, 1998). In making such a statement, they overlooked two histological studies that found no evidence of glandular tissue in the preputial mucosa, (Taylor, 1996; Parkash, 1973). Remarkably, they cited one of these elsewhere in the same article (Taylor, 1996). By 1999, an anti-circumcision webpage attributed to George Hill declared that preputially-secreted lysozyme protected the owner against HIV (Hill, 1999). Disturbingly, this myth was repeated as though it were factual, and without further investigation, in a 2003 Cochrane Review (Siegfried, 2003). If nothing else, this makes clear the need for rigorous checking of bibliographies as a vital part of the peer-review process.

In 1999, Van Howe published a paper, purporting to be a meta-analysis, in which he concluded “When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis” (Van Howe, 1999). Articles were soon published which described its statistical flaws and – more importantly – the results of correct analysis of his sources (Moses, 1999; O’Farrell, 2000). These were subsequently cited in some 50 or so papers, including further meta-analyses (e.g., Weiss, 2000). Indeed, as the first published meta-analysis investigating the protective effect of circumcision against HIV, Van Howe’s 1999 paper may have accelerated research into this association.

Interestingly, the paper was cited in a comprehensive 387 reference review of techniques in meta-analysis (Barker, 2005), which noted that “Although this [Simpson] paradox is usually illustrated with hypothetical examples, in one metaanalysis that used simple data pooling to test the protective effect of circumcision against AIDS infection in sub-Saharan African men, conclusions were reached that were diametrically opposed to those of a subsequent metaanalysis in which appropriate techniques were used.”

It should be noted that, although there is no clear evidence of deliberate deception on Van Howe’s part, at least one author has cited these events as an example of Van Howe’s limited credibility (Schoen, 2007), noting Van Howe’s “long history of opposition to circumcision”. Interestingly, Van Howe authored another paper in the same year, in which he reviewed the evidence concerning STIs other than HIV (Van Howe, 1999a). As with the HIV meta-analysis, his reported results were at odds with those of other reviews, (Weiss, 2006; Moses, 1999) and indeed the source material. Perhaps the term “hostile review” should be introduced for papers such as these, which seek not to summarize but to contradict their source material.

References
Alcena, V. (1986) AIDS in Third World countries. N. Y. State J. Med., 86(8), 446.

AMA (1999) Report 10 of the Council on Scientific Affairs (I-99). American Medical Association. Retrieved 08-04-2007 from: http://www.ama-assn.org/ama/pub/category/13585.html [Link now broken, but here is an archived copy:
http://web.archive.org/web/20070206053938/http://www.ama-assn.org/ama/pub/category/13585.html]

Bailis, S.A. (1998) Circumcision and infectious diseases. Pediatr. Infect. Dis. J., 17(8), 762-3.

Barker, F.G., Carter, B.S. (2005) Synthesizing medical evidence: systematic reviews and metaanalyses. Neurosurg. Focus, 19(4), E5.

Bongaarts, J., Reining, P., Way, P., Conant, F. (1989) The relationship between male circumcision and HIV infection in African populations. AIDS, 3(6), 373-377.

Cameron, D.W., Simonsen, J.N., D’Costa, L.J., Ronald, A.R., Maitha, G.M., Gakinya, M.N., et al. (1989) Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men. Lancet, 2(8660), 403-407.

Chao, A., Bulterys, M., Musanganire, F., Habimana, P., Nawrocki, P., Taylor, E., et al. (1994) Risk factors associated with prevalent HIV-1 infection among pregnant women in Rwanda. National University of Rwanda-Johns Hopkins University AIDS Research Team. Int. J. Epidemiol, 23(2), 371-380.

Dagher, R., Selzer, M.L., Lapides, J. (1973) Carcinoma of the Penis and the Anti-Circumcision Crusade. J. Urol., 110, 79-80.

Fink, A.J. (1986) A possible explanation for heterosexual male infection with AIDS. N. Engl. J. Med., 315(18), 1167.

Fleiss, P., Hodges, F., Van Howe, R.S. (1998) Immunological functions of the human prepuce. Sex. Trans. Inf., 74(5), 364-7.

Foley, J.M. (1966) The unkindest cut of all. Fact Magazine, July-August, 3(4), 2-9.

Greenblatt, R.M., Lukehart, S.A., Plummer, F.A., Quinn, T.C., Critchlow, C.W., Ashley, R.L., et al. (1988) Genital ulceration as a risk factor for human immunodeficiency virus infection. AIDS, 2(1), 47-50.

Guimaraes, M., Castilho, E., Sereno, A., Cavalcante, S., Lima, L.A., Gomes, V., et al. (1991) Heterosexual transmission of HIV-1: a multicenter study in Rio de Janeiro, Brazil. VII International Conference on AIDS. Florence, June 1991 [abstract MC3098]

Hill, G. (1999) Summary of evidence that the foreskin and lysozyme may
protect against HIV infection. Retrieved 08-04-2007 from:
http://www.foreskin.org/lysozyme.htm

Morgan, W.K.(1965) The rape of the phallus. JAMA, 193, 223.

Moses, S., Nagelkerke, N.J., Blanchard, J. (1999) Analysis of the scientific literature on male circumcision and risk for HIV infection. Int. J. STD AIDS, 10(9), 626-8.

NOCIRC/About http://www.nocirc.org/about.php

NOCIRC (1991) Newsletter. National Organization of Circumcision Information and Resource Centers, Fall 1991. Retrieved 28-12-2006 from
http://www.nocirc.org/publish/9-91.pdf.

NOCIRC 2002 http://www.nocirc.org/symposia/seventh/symposium.pdf

O’Farrell, N., Egger, M. (2000) Circumcision in men and the prevention of HIV infection: a ‘meta-analysis’ revisited. Int. J. STD AIDS, 11(3), 137-42.

Okino, B.M., Yamamoto, L.G. (2004) Survey of Internet web sites on circumcision. Clin. Pediatr. (Phila.). 43(7), 667-9.

Parkash, S., Jeyakumar, K., Subramanya, K., Chaudhuri, S. (1973) Human sub-preputial collection: its nature and formation. J. Urol., 110, 211-212.

Schoen, E.J. (2007) Meatal stenosis following neonatal circumcision. Clin. Pediatr. (Phila.) 46(1), 86.

Siegfried, N., Muller, M., Volmink, J., Deeks, J., Egger, M., Low, N., Weiss, H., Walker, S., Williamson, P. (2003) Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software

Silverman, E.K. (2004)Anthropology and circumcision. Annual Review of Anthropology, 33, 419-445.

Simonsen, J.N., Cameron, D.W., Gakinya, M.N., Ndinya-Achola, J.O., D’Costa, L.J., Karasira, P, et al. (1988) Human immunodeficiency virus infection among men with sexually transmitted diseases. Experience from a center in Africa. N. Engl. J. Med., 319(5), 274-278.

Snyder, J.L. (1989a) The circumcision problem: inertia of the scientific community. Retrieved 08-04-2007 from
http://www.nocirc.org/symposia/first/snyder1b.html.

Snyder, J.L. Testimony against circumcision. Retrieved 08-04-2007
from http://www.nocirc.org/symposia/first/snyder1a.html.

Taylor, J.R., Lockwood, A.P., Taylor, A.J. (1996) The prepuce: specialized mucosa
of the penis and its loss to circumcision. Br. J. Urol., 77, 291-295.

Van Howe, R.S. (1995) Letter to American Academy of Pediatrics. Retrieved 08-04-2007 from
http://www.cirp.org/library/statements/letters/1995-11_VanHowe/

Van Howe, R.S.(1996a) Why does circumcision persist in the United States? Retrieved 08-04-2007 from http://www.nocirc.org/symposia/fourth/vanhowe.html.

Van Howe, R.S. (1996b) Why does circumcision persist in the United States? In: Denniston GC, Milos MF, editors. Sexual Mutilations: A Human Tragedy. New York: Plenum Press; 1997. p. 111-119. (note: combine with 1996a)

Van de Perre, P., Carael, M., Nzaramba, D., Zissis, G., Kayihigi, J., Butzler, J.P. (1987) Risk factors for HIV seropositivity in selected urban-based Rwandese adults. AIDS, 1, 207-211

Van Howe, R.S. (1998) Circumcision and infectious diseases revisited. Pediatr. Infect. Dis. J., 17(1), 1-6.

Van Howe, R.S. (1999) Circumcision and HIV infection: review of the literature and meta-analysis. Int. J. STD AIDS, 10, 8-16.

Van Howe, R.S. (1999a) Does circumcision influence sexually transmitted diseases?: A literature review. BJU Int., 83, Suppl 1, 52-62.

Weiss, H.A., Quigley, M.A., Hayes, R.J. (2000) Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS, 14(15), 2361-70.

Weiss, H.A., Thomas, S.L., Munabi, S.K., Hayes, R.J. (2006) Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm. Infect., 82(2), 101-9.

WHO/UNAIDS (2007) Technical Consultation. Male Circumcision and HIV Prevention: Research Implications for Policy and Programming Montreux, 6- 8 March 2007.
http://www.who.int/entity/hiv/mediacentre/MCrecommendations_en.pdf


Risk Compensation – an Intactivist Half-Truth

By Stephen Moreton PhD.
April 2017 (updated May, 2017)

The risk compensation argument takes the form:

Circumcised men may believe they are immune to HIV and so abandon safe sex practices thereby putting themselves at risk. Consequently, implementing circumcision as an anti-HIV measure may actually increase HIV.

The example here is the gist of an argument used by husband and wife intactivists Robert S. Van Howe & Michelle Storms (2011), and uncritically copied by intactivist Brian Earp (Earp, 2012). It crops up commonly in discussions of circumcision in relation to HIV, particularly in Africa where circumcision is heavily promoted to protect against infection during heterosexual intercourse. In this context it is commonly referred to as “risk compensation”. It is also an example of a half-truth (see: http://circfacts.org/sloppy-logic/#slog20 for other examples of this common intactivist ploy).
As with so much relating to circumcision and African HIV, there exists a wealth of research on this topic, allowing us to point to what is true in the argument, and to what has been left out. Firstly, what is true? Yes, risk compensation can happen. In fact there is even evidence for it in one of the three randomized controlled trials (RCTs) that finally settled the question whether or not circumcision actually protects against HIV (it does). In the South African trial (Auvert et al., 2005) it was found that the circumcised participants tended to have more female partners, than the non-circumcised participants. A study in Uganda also found riskier behaviour (more partners, less condom use) in circumcised men (Kibira et al., 2014).
So, at first glance, it may seem as if the intactivists have a point. But wait a moment! Here is what they don’t tell you. In the Ugandan study where risk compensation was observed the circumcised men were still less likely to become infected with HIV than their non-circumcised peers. Of the three RCTs, the one in which risk compensation was observed (Auvert et al., 2005) was also the one which found the strongest protective effect. Circumcision is so effective that, despite a tendency to take more risks, the men were still better off without their foreskins!
There’s more. Even by the time Van Howe, Storms, and Earp, wrote their articles there were studies (Riess et al., 2010; Mattson et al., 2008), which they ignored, showing that when men were properly counselled about circumcision, so that they understood it provided partial protection only and they should continue to be sexually responsible (wear condoms etc.), then they did so. Reports continue to appear showing the same (e.g., Westercamp et al., 2014; L’Engle et al., 2014; Lau et al., 2015; Shi et al., 2017). In short, with proper education risk compensation does not happen, so it is really an argument to ensure that men are educated, rather than an argument against circumcision.
For their blunders Earp got a well-deserved spanking on the Quackdown blog (http://www.quackdown.info/article/getting-circumcision-science-right-media/?print=true) and Van Howe & Storms were rebutted in detail by Morris et al. (2011), but others persist in using this argument despite the now overwhelming evidence against it (e.g. in dated articles still on intactivist websites, in some of the submissions to the CDC in 2014, and in comments threads).

References
Auvert, B., Taljaard, D., Lagard, E., Sobngwi-Tambekou, J., Sitta, R., Puern, A. (2005) Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV
Infection Risk: The ANRS 1265 Trial, PLoS Medicine, 2(11), 1112-1122.

Earp, B. (2012) When bad science kills, or how to spread AIDS. Article posted on Oxford University’s Practical Ethics blog. It has since disappeared, but a copy can be accessed here: http://www.creativitypost.com/activism/when_bad_science_kills_or_how_to_spread_aids

Kibira, S.P.S., Nansubuga, E., Tumwesigye, N.M., Atuyambe, L.M., Makumbi, F. (2014) Differences in risky sexual behaviors and HIV prevalence of circumcised and uncircumcised
men in Uganda: evidence from a 2011 cross-sectional national survey. Reproductive Health, 11(25), 1-8.

Lau, F.K., Jayakumar, S., Sgaier, S.K. (2015) Understanding the socio-economic and sexual behavioural correlates of male circumcision across eleven voluntary medical male circumcision priority countries in southeastern Africa. BMC Public Health, 15(813) 1-11.

L’Engle, K., Lanham, M., Loolpapit, M., Oguma, I. (2014) Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya. Health Educ. Res., 29(1), 122-130.

Mattson, C.L., Campbell, R.T., Bailey, R.C., Agot, K., Ndinya-Achola, J.O., Moses, S. (2008) Risk compensation is not associated with male circumcision in Kisumu, Kenya: A multi-faceted assessment of men enrolled in a randomized controlled trial. PLoS One, 3(6), 1-9.

Morris, B.J., Waskett, J.H., Gray, R.H., Halperin, D.T., Wamai, R., Auvert, B., Klausner, J.D. (2011) Exposé of misleading claims that male circumcision will increase HIV infections in Africa. J. Public Health Africa, 2(e28), 117-122.

Riess, T.H., Achieng, M.M., Otieno, S., Ndinya-Achola, J.O., Bailey, R.C. (2010) “When I was circumcised I was taught certain things”: risk compensation and protective sexual behaviour among circumcisedmen in Kisumu, Kenya. PLoS One, 5(8), 1-9.

Shi, C-F., Li, M., Dushoff, J. (2017) Evidence that promotion of male circumcision did not lead to sexual risk compensation in prioritized Sub-Saharan countries. PLoS ONE, 12(4), e0175928

Van Howe, R.S., Storms, M. (2011) How the circumcision solution in Africa will increase HIV infections. J. Public Health Africa, 2(e4), 11-15.

Westercamp, N., Agot, K., Jaoko, W., Bailey, R.C. (2014) Risk compensation following male circumcision: Results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza province, Kenya. AIDS Behav., 18(9), 1764-75.

 


The USA/Europe comparison: another intactivist fail

By Stephen Moreton, PhD

March 2017

In a discussion of circumcision and HIV it will not be long before an intactivist objects with something along the lines of:

The USA has the highest rate of circumcision and the highest rate of HIV of any developed nation. Contrast with Europe, which has low rates of both. Therefore circumcision is not protective against HIV.”

This argument is common in comments threads and intactivist propaganda. It is an intactivist favourite, so merits detailed examination.

Before we proceed any further, we must do what should be done with all intactivist claims. We must fact-check it. We need to know the circumcision and HIV rates across the developed world. Such data is readily available. The Human Development Index (HDI) ranks countries by how developed they are. It may be viewed here: https://en.wikipedia.org/wiki/Human_Development_Index  Restricting ourselves to only those listed as “highly developed” we find 49 countries listed for 2014. These are in the table below, ranked by HDI (most developed first). The most up to date list of circumcision rates by country is by Morris et al., (2016), and is used in the table below. Finally, CIA data on HIV prevalence for the age group 15 to 49, in the years 2011 & 2014 is freely available here:
https://en.wikipedia.org/wiki/List_of_countries_by_HIV/AIDS_adult_prevalence_rate .

Country % Circumcised % HIV
Norway 3.0 0.15
Australia 26.6 0.17
Switzerland 5.9 0.35
Denmark 5.3 0.16
Netherlands 5.7 0.2
Germany 10.9 0.15
Ireland 0.9 0.28
USA 71.2 0.6
Canada 31.9 0.3
New Zealand 33.0 0.1
Singapore 14.9 0.1
Hong Kong 28 0.1
Liechtenstein 4.8 0.1
Sweden 5.1 0.18
UK 20.7 0.33
Iceland 0.1 0.3
South Korea 77.0 0.1
Israel 91.7 0.2
Macau 0.1 No data
Luxembourg 2.4 0.3
Japan 9 0.1
Belgium 22.6* 0.3
France 14 0.4
Austria 5.8 0.4
Finland 0.8 0.1
Thailand 23.4 1.13
Slovenia 8.5 0.08
Spain 6.6 0.42
Italy 2.6 0.28
Czech Republic 0.1 0.05
Greece 4.7 0.2
Estonia 0.25 1.30
Brunei 51.9 0.1
Cyprus 22.7 0.06
Qatar 77.5 0.1
Andorra 1.1 No data
Slovakia 0.15 0.02
Poland 0.1 0.07
Lithuania 0.2 0.1
Malta 0.3 0.1
Saudi Arabia 97.1 0.1
Argentina 2.9 0.47
UAE 76 0.2
Chile 0.2 0.29
Portugal 0.6 0.7
Hungary 0.8 0.1
Bahrain 81.2 0.3
Latvia 0.4 0.7
Croatia 1.3 0.1
Kuwait 86.4 0.1
Montenegro 18.5 No data

* actually 15% according to Bronselaer (2013).

HIV data for Andorra, Macau and Montenegro is lacking.

Straight away we can spot a few nations that do not fit the intactivists’ narrative. Highly developed nations with HIV rates higher than the USA’s 0.6 % are (HIV rate in brackets): Thailand (1.13), Estonia (1.30), Portugal (0.7) and Latvia (0.7). Likewise, South Korea, Israel, Saudi Arabia, UAE, Bahrain and Kuwait all have circumcision rates higher than in the USA, but lower HIV prevalence.

As the most common form of the argument compares USA with Europe, we shall look at that in more detail. Whilst a few European countries do have higher HIV prevalence than the USA, most are noticeably lower. By tediously adding up the total numbers infected, and the total populations of each country, one can arrive at an average prevalence of 0.3 % HIV for Europe, whether “Europe” is defined as everything between Russia and the Atlantic, or just the European Union. This is half the USA’s 0.6 %. And circumcision is, indeed, much less common in Europe than in America. So, superficially, it seems as if the intactivists may have a point.

But they don’t. In using this argument intactivists are ignoring one of the most common, and well-known, pitfalls of epidemiology: confounding factors. Circumcision is just one of a variety of factors that influence the transmission of HIV (and other STIs). If those other factors are strong enough they may hide the influence of the factor of interest, in this case circumcision. This is called confounding, and is a fundamental weakness of country to country comparisons. There may be some other factor, or factors, influencing the result. Or, to put it simply, correlation is not causation.

Many factors influence HIV transmission: condom use, availability of anti-retroviral therapy (ART), promiscuity, genetic susceptibility, unhygienic tribal circumcision rituals, migration patterns, use of prostitutes, intravenous drug use, homosexual sex and, doubtless, others, all affect HIV transmission and, therefore, prevalence. Some (e.g. tribal circumcision) are of little or no relevance here, but the others do matter to varying degrees.

So comparing one country with another is very risky. What appears to be a correlation with the factor of interest may be due to something entirely unrelated. This is why randomized controlled trials (RCTs) are so beloved of epidemiologists. Their design specifically eliminates confounding factors, allowing the researchers to focus on the factor under study, confident any effect they observe is not due to interference from something unrelated. RCTs are often referred to as the “gold standard” of epidemiology for this reason, and their results taken as authoritative.

The connection between foreskins and HIV was originally detected on the basis of regional comparisons. There was a tendency, in Africa, for HIV to be more common in regions where most men were not circumcised. But, as intactivists pointed out (and still do) there are a few places where the association is reversed. Or (as they were keen to point out) the observed association could be due to confounding factors. Maybe men in one region were circumcised, but were also prudish in their sexual habits. Men in another region were not circumcised, and also promiscuous. Or perhaps circumcised men in one country lived in isolated rural communities, with little contact with the outside world, whilst non-circumcised ones belonged to urban communities, or travelled far in search of work, so had more exposure to the virus. And so on.

To eliminate these possibilities, three large RCTs were conducted independently in three different African countries. Each one showed conclusively that circumcision does indeed protect against female to male transmission of HIV, and the observed trends across countries really were due to this effect, and not to confounding factors.

So, given that circumcision does protect against HIV, why do we fail to see this in the USA/Europe comparison? In light of the above discussion the answer is obvious: confounding factors. So what are those factors?

To begin with, we now know that HIV has been present in the USA since about 1971, possibly even earlier (Worobey et al., 2016), although not first detected there until the 1980s. It arrived in the USA via Haiti, and was already established in the gay community there by the time it began turning up in Europe. So the epidemic had a head start in the USA.

This, however, is not the main confounder. Comparing data for unwanted pregnancy rates reveals a startling disparity between the USA and the rest of the developed world. The bar chart on page 4 of UNICEF (2001) is a “must see”. The USA has almost twice as many teenage pregnancies as the next developed nation (the UK) and about four times the European Union average. When it comes to unwanted pregnancies, the USA is the capital of the developed world. One can repeat the exercise for abortion rates, and find the same. The same report noted that 40 % of sexually active US teenagers do not use contraception.

In short, there are huge differences in sexual behaviour between America and the rest of the developed world. Americans are more promiscuous, are sexually active at younger ages, and are less likely to use condoms, than many other countries. These are all hugely important confounding factors, likely to have major effects on HIV transmission. And they are completely ignored every time intactivists deploy the USA/Europe comparison.

Their argument is hypocritical too. Intactivists advocate sexual restraint, and condoms, as effective ways of controlling HIV (which they are, if used) seemingly unaware that these are likely reasons why Europe is so far ahead of the USA with respect to HIV (and other STIs). They also forget that they were quick to point to confounding factors as an explanation for the observed foreskin/HIV association prior to the RCTs, but ignore them as an explanation for the USA/Europe disparity. Do they think that confounding factors only apply to arguments that favour circumcision?

So we can dismiss the intactivists’ USA/Europe comparison as baseless, ignorant and hypocritical, but it doesn’t end there. It is superficial too. A more detailed look at the data reveals a story the intactivists would not like told.

HIV has been in the USA since about 1971, yet in all that time it has remained largely confined to high risk groups (mostly men who have sex with men, also some who share needles (CDC, 2016)). In none of these cases does circumcision make a difference. It works for female to male heterosexual transmission, and when HIV is transmitted that way, it is disproportionately so in black and Hispanic people. Now this could be down to confounding factors (socio-economic status may affect sexual behaviour, for instance) but they also happen to be the groups in which circumcision is least common (CDC, 2010)! Could it be circumcision that has kept the infection from crossing over into the heterosexual population in the USA?

It is difficult to gather good epidemiological evidence in settings where the prevalence of the infection under study is low. It requires large sample sizes, and/or long study durations. This makes Africa a good setting for HIV studies because it is so common there. But, in countries with mere fractions of a percent prevalence, it is hard to tease out the effect of one factor (e.g. circumcision) from the others. Consequently, observational studies in low-HIV settings are less likely to find an association, and there are only a handful of such studies. Some find no link, and are eagerly cited by intactivists, but some do.

A study of heterosexual African-Americans in Baltimore found that HIV was more common in those not circumcised (Warner et al., 2009), and a recent comparison between Israel, France and Netherlands (Chemtob et al., 2015) found a higher HIV incidence in the latter two, non-circumcising, cultures. Again, this might be confounding, but the comparison is better than the USA/Europe one, as sexual behaviour between these countries is more alike. Data on specifically female to male transmission in developed countries is very scarce but, given that what is known of the mechanisms of transmission indicates the foreskin is involved, there is no reason in principle why circumcision should not afford protection regardless of country.

In short, intactivists are showing their ignorance, and double standards, whenever they make the USA/Europe comparison. Looked at in more detail, the data do not support their cause.

References:

Bronselaer, G. (2013) Reply, BJU Int., 111, E270-1.

CDC (2010) Trends in circumcision among newborns. On-line: https://www.cdc.gov/nchs/data/hestat/circumcisions/circumcisions.htm

CDC (2016) HIV in the United States: At a glance. On-line: https://www.cdc.gov/hiv/statistics/overview/ataglance.html

Chemtob, D., Op de Coul, E., van Sighem, A., Mor, Z., Cazein, F., Semaille, C. (2015) Impact of male circumcision among heterosexual HIV cases: comparisons between three low HIV prevalence countries. Israel J. Health Policy Research, 4(36), 8 pages.

Morris, B.J., Wamai, R.G., Henebeng, E.B., Tobian, A.A.R., Klausner, J.D., Banerjee, J., Hankins, C.A. (2016) Estimation of country-specific and global prevalence of male circumcision. Population Health Metrics, 14(4), 13 pages.

UNICEF (2001) A league table of teenage births in rich nations. On-line: http://www.unicef-irc.org/publications/pdf/repcard3e.pdf

Warner, L., Ghanem, K.G., Newman, D.R., Macaluso, M., Sullivan, P.S., Erbelding, E.J., (2009) Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J. Infect. Dis., 199(1), 59-65.

Worobey, M., Watts, T.D., McKay, R.A., Suchard, M.A., Granade, T., Teuwen, D.E., Koblin, B.A., Heneine, W., Lemey, P., Jaffe, H.W. (2016) 1970s and ‘Patient 0’ HIV-1 genomes illuminate early HIV/AIDS history in North America. Nature, 539(3), 98-101.

 

In 10 out of 18 countries circumcised men were more likely to have HIV than non-circumcised men

Summary answer:

Data for most of the countries do not achieve statistical significance. Even for those that do, there are grave doubts about the reliability of the data as many men report being circumcised when they are not, or are only partially so, having undergone various ritual, tribal cutting practices. Those same practices also spread HIV, making it likely that some men caught their HIV in this way, further complicating the data. Confounding from other sources, such as migration, and high infidelity, divorce and remarriage rates also explain some of the results. This is a very weak and problematic data set which does not trump better quality data from dozens of epidemiological studies, several reviews, and meta-analyses, indicating that the association between lack of circumcision, and HIV infection, is real.

Detailed answer:

At first glance this would appear to undermine the assertion that circumcision protects against HIV. After all if, in more than half of the countries examined, the correlation is the reverse it contradicts the assertion. So it is no surprise to find this argument heavily touted by intactivists. Often a quote, from the USAID DHS report number 22 (from which it is derived, see: Mishra et al., 2009), is used:

in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher

A Google search will find this quote everywhere. Repeat offenders are Mark Lyndon, an intactivist from Manchester, England, and Hugh Young, who runs the circumstitions website. It is also used by prominent, and widely published, intactivist Robert S Van Howe (Van Howe & Storms, 2011; Van Howe, 2015).

Of course the argument is spurious, and on multiple grounds. Aside from the old adage that correlation is not causation, it has already been used elsewhere on this site as an example of quote-mining (http://circfacts.org/sloppy-logic/#slog27).

Reading the original quickly throws up issues with the sample sizes. At the top of page 14 we find, “some of the estimates presented in this report are based on small numbers of cases in survey samples, and should be interpreted with caution”. And a footnote on p. 110 reads, “Note: HIV prevalence estimates for ‘not circumcised’ men for Guinea and Niger are based on small numbers of cases”. Looking at the actual sample sizes we find that the non-circumcised samples for Guinea, Niger and Senegal are just 18, 14 & 56 men respectively. Given the relatively low rates of HIV in those countries (0.9, 0.8 & 0.5 respectively) one does not have to be a statistician to realise that it is quite likely there would not be a single HIV positive man in such small samples (and, indeed, there isn’t). So how can one possibly tell, for those countries, if there is a correlation? On that basis alone one can therefore discount 3 of those 10 countries. And in no case do the authors attempt any statistical analysis to determine if the differences they report are significant. So let’s do that!

Happily, one does not need a degree in statistics to do this, just a calculator, and this link: https://graphpad.com/quickcalcs/contingency1/  Take the data in table 9.4 of the USAID report, work out the actual numbers who are HIV positive and negative for each group (circumcised or not) and enter them into the table in the link. One can do either a Chi-squared test, or a Fisher’s exact one. For our purposes it makes little difference, the results are similar. The ones given in the table below are Fisher’s, except for India, for which the program indicated Chi-squared should be used owing to the large data sets. The countries in which circumcised men seemed to be more likely to have HIV are here called the “contrary countries”, the rest “conforming countries”. The p values are in brackets after the country. Any p value more than 0.05 is not considered significant, and is marked below by an asterisk.

Contrary countries                      Conforming countries

Cameroon (0.005)                       Burkina Faso (0.12*)

Guinea (1.0*)                                Cambodia (1.0*)

Haiti (0.03)                                   Côte d’Ivoire (0.64*)

Lesotho (<0.0001)                      Ethiopia (0.40*)

Malawi (0.02)                              Ghana (0.74*)

Niger (1.0*)                                   India (0.03)

Rwanda (0.04)                            Kenya (<0.0001)

Senegal (1.0*)                              Uganda (0.002)

Tanzania (0.25*)

Zimbabwe (0.12*)

So, for only eight countries were the data sets, and differences between them, large enough to achieve statistical significance. This makes nonsense of the claim about 10 out of 18 countries having higher HIV prevalence in circumcised men. It should be 5 out of 8. And for one of those (Rwanda) the significance is borderline.

This issue with the small sample sizes (though without the more detailed analysis above) has been pointed out in comments threads ad nauseam but intactivists take little notice (as is typical). The problems are only beginning, however. The above analysis assumes that the data are accurate, but it is not clear how many of those men who claim to be circumcised actually are. The study was based on a questionnaire. Nobody got the men to drop their pants to check if they really were circumcised. This matters, a lot. As Van Howe delights in (correctly) pointing out, self-report of circumcision status can be unreliable (Van Howe, 2013; and references therein). Many men report being circumcised when, in fact, they are not.

The problem is related to the nature of many circumcisions in Africa. For many African men circumcision is part of a coming of age tribal ritual. It is performed by a shaman, with no regard to hygiene or pain control (in fact being able to bear the pain is part of the ritual). But not all that goes on actually counts as circumcision in the medical sense. Various foreskin cutting practices that fall short of a circumcision may be carried out instead. Sometimes the cutting is dropped altogether, but the other elements preserved, in a ritual that may have included circumcision in the past.

Consequently, many men who have gone through such ceremonies consider themselves circumcised, and identify themselves as so, but they are not. In Lesotho, for example, when men who identified themselves as circumcised were asked to drop their pants for confirmation, only half actually were fully circumcised. 27 % had undergone some sort of foreskin cutting, but which fell short of circumcision, and 23 % had undergone no cutting at all (Thomas et al., 2011). Lesotho, it should be noted, is one of those contrary countries.

The problem with ritual tribal circumcisions is not restricted to whether the men actually are circumcised in the first place. Ritual circumcision in Africa is one of the few instances where a non-sexual mode of transmission of HIV has been shown to be significant. Many of the victims (which is an appropriate term regarding circumcision in this case) are youths and young men who are already sexually active and, consequently, HIV infected. As the shaman works his way along the line-up, going slice, slice, slice, with his razor blade, spear tip, or whatever sharp implement is used, and one just one fellow in the line-up has HIV, the implications for those that follow are obvious. HIV gets on the blade, is transferred to the next victim, and so on down the queue. In fact one can find freshly circumcised virgins in these countries who are HIV positive, having contracted it from their tribal circumcision.

This issue was identified in 2007 by Brewer et al (2007) in Tanzania, Lesotho and part of Kenya. The first two are “contrary countries”. It has since been highlighted in Cameroon, another “contrary country” (Ndiwane, 2008). So, aside from whether these men actually are properly circumcised, or have just had some other foreskin cutting, there is a high likelihood they many got their HIV from their unhygienic tribal circumcision. It is safe, hygienic medical circumcision that is being touted as protective. Not dangerous, unhygienic tribal cutting practices. Consequently, data from any countries in which such practices prevail must be treated as suspect. The men may not even be circumcised in the first place and, even if they are, they may have caught their HIV from some dangerous tribal ritual, not by sex.

So, we can now discount Lesotho, Tanzania and Cameroon. The Zimbabwe data too must be treated as suspect. In a study conducted in 2010 – 2011, it was found that 58 % of circumcised Zimbabwean men had been circumcised by a traditional provider, or family friend, 31.2 % of them at age 15 or more, rather than by medical professionals (Chikutsa et al., 2013). The difference reported in the USAID report did not achieve statistical significance anyway.

In Haiti there is some indication that foreskin cutting practices that fall short of full circumcision are practiced (George et al., 2012). Haiti also has the issue of a rather modest sample size that is, statistically, only moderately significant. Using the data in the report, the difference amounts to just five individuals. Enough to be skewed by just a few households (these were household surveys).

So now we are left with Malawi and Rwanda as the sole remaining “contrary countries” out of the original ten. In fact the observation that Malawi appeared to contradict the protective effect of circumcision was used to great effect in that country to stall the implementation there of circumcision (Poulin & Muula, 2011), doubtless with many lives lost as a result. However, we now have some explanations.

Tribal, and partial, circumcision is practised by the Lomwe and some other ethnic groups in Malawi (Bengo et al., 2010; Rennie et al., 2015), but others are likely fully circumcised, being Muslim. Thus, although Mutombo et al. (2015) did not consider tribal circumcision to be a significant driver of the epidemic in Malawi, we know that many Malawian men participating in the USAID survey were not fully circumcised. Mutombo et al. did note a much higher HIV rate in those who had been through a tribal circumcision and, as part of the ceremony, had had unprotected sex shortly after (“ritual sex”). So having unprotected sex whilst the penis is still healing from a tribal circumcision puts men at much higher risk of catching HIV. Quelle surprise.

Most men in Southern Malawi are circumcised, in contrast to the Central and Northern regions, where most men are not; but the south is also the poorest part of the country, and the men there frequently travel to the cities in search of work. Whilst there they are not celibate, and some end up infected. Meanwhile, back home, their wives get lonely and stray, thereby exposing themselves to the virus too. They also have a high divorce and remarriage rate. Those who stay at home, and are in faithful relationships, are less likely to have HIV. Those who travel far in search of work, or who repeatedly divorce and remarry, are more likely to be infected. So the anomaly there is due to patterns of migration and multiple marriages (Poulin & Muula, 2011). In short, that bane of epidemiology – confounding factors (see also: http://circfacts.org/medical-benefits/hivaids/#hiv4), and compounded by the familiar problem of whether those men who report being circumcised actually are.

So now only Rwanda remains. The difference reported is barely significant (in fact it amounts to just 7 individuals) and, with only one doctor for every 16,700 people in 2010
(https://www.cia.gov/library/publications/the-world-factbook/fields/2226.html), we can be quite confident that the few men who claimed to be circumcised are unlikely to have had it done by a doctor. And that’s assuming they are accurate in claiming to be circumcised in the first place. So the same doubts apply as with the other “contrary countries”.

These problems have been pointed out to intactivists repeatedly, whether in comments threads or in published rebuttals (e.g. Morris et al., 2016). But still they keep peddling the claim. Lyndon has, at least, taken on board the fact that unhygienic tribal circumcisions are to blame for some of the anomalous data, but still peddles the argument because:

the whole rationale for the RCTs into female-to-male transmission was a purported correlation between high rates of male circumcision and low rates of HIV” (comment on 24 July 2017 at http://www.patheos.com/blogs/friendlyatheist/2017/07/13/there-are-good-reasons-for-male-circumcision-debunked).

But his argument for using the USAID data is nonsense. The correlation is there. One cannot trump dozens of epidemiological studies, several reviews, and meta-analyses showing the correlation, with one contrary, but weak, data set that includes sample sizes too low to be of use, unreliable self-reports about being circumcised, and the clear presence of major confounding. To continue to use this argument, knowing there are so many problems, is just dishonest. No reputable body gives credence to the argument. Only intactivists do.

References

Bengo, J.M., Chalulu, K., Chinkhumba, K., Kazembe, L., Maleta, K.M., Masiye, F., Mathanga, D. (2010) Situation analysis of male circumcision in Malawi. Report by the College of Medicine, 136 pages.

Brewer, D. D., Potterat, J. J., Roberts, J. M. Jr., Brody, S. (2007). Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania. Annals of Epidemiology, 17, 217–226.

Chikutsa, A., Ncube, A.C., Mutsua, S. (2013) Male circumcision and risky sexual behaviour in Zimbabwe: Evidence from the 2010 – 2011 Zimbabwe Demographic and Health Survey. DHS Comparative Reports No. 102, USAID.

George, C., Brennen, D., Roberts, R., Rabie, A., Read, S. (2012) Getting to zero: Male circumcision for HIV prevention in the Bahamas. West Indian Med. J., 61(9), 921-3.

Morris, B.J., Barboza, G., Wamai, R.G. & Krieger, J.N. (2016). Circumcision is a primary preventive against HIV infection: Critique of a contrary metaregression analysis by Van Howe, Global Public Health, ePub ahead of print.

Mishra, V., Amy M., Rathavuth H., Yuan G., Robey, B. (2009). Levels and Spread of

HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. DHS Comparative Reports No. 22. USAID.

Mutombo, N., Maina, B., Jamali, M. (2015) Male circumcision and HIV infection among

sexually active men in Malawi. BMC Public Health, 15(1051), 1-9.

Ndiwane, A. (2008). Laying down the knife may decrease risk of HIV transmission: Cultural practices in Cameroon with implications for public health and policy. Journal of Cultural Diversity, 15, 76–80.

Poulin, P., Muula, A.S. (2011) An inquiry into the uneven distribution of women’s HIV infection in rural Malawi. Demographic Research, 25, article 28, 869-902.

Rennie, S., Perry, B., Corneli, A., Chilungo, A., Umar, E. (2015) Perceptions of voluntary medical male circumcision among circumcising and non-circumcising communities in Malawi, Global Public Health, 10(0), 679-91.

Thomas, A.G., Tran, B.R., Cranston, M., Brown, M.C., Kumar, R., Tlelai, M. (2011) Voluntary medical male circumcision: A cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho. PLoS One, 6(11), e27561.

Van Howe, R. S. (2013). Sexually transmitted infections and male circumcision: A systematic review and meta-analysis. ISRN Urology, 2013, article 109846, 1–42.

Van Howe, R. S. (2015). Circumcision as a primary HIV preventive: Extrapolating from the available data. Global Public Health, 10, 607–625.

Van Howe, R. S., & Storms, M. R. (2011). How the circumcision solution in Africa will increase HIV infections. Journal of Public Health in Africa, 2(1), 11-5.

Lead-time bias argument

It doesn’t take a rocket scientist to know that if you have part of your penis cut off you are probably not going to have sex in the near future, thereby reducing the probability of catching the virus over a set time; the study never addresses this issue.”

The above quote is from “The Science of Circumcision”, an error-riddled YouTube video by self-styled British “skeptic” Myles Power. It is one of the “methodological flaws” intactivists claim compromised the African randomised controlled trials on circumcision and HIV. In published articles it is referred to as “lead-time bias”, and is used by Boyle & Hill (2011), and mentioned by Darby & Van Howe (2011), and Van Howe & Storms (2011). In parallel to the Ugandan trial on HIV, one was also conducted on HSV, HPV and syphilis, so Storms (2009) also used the lead-time bias argument to attack its finding that circumcision protected against HSV. As did the widely-published Robert S. Van Howe, who took his usual haughty tone (Van Howe, 2013):

The potential for lead-time bias in any cohort study or clinical trial is taught and emphasized in the most basic classes on research design. How was this potential source of bias missed by the highly regarded researchers at Johns Hopkins, the reviewers who approved funding for these studies at the National Institutes of Health, and the editors and peer-reviewers at highly regarded medicals [sic] journals such as The Lancet and The New England Journal of Medicine? To compensate for the deficiencies of these individuals, a post hoc adjustment of six weeks lead time was made. Six weeks were chosen to be on the conservative side.

Van Howe applied a “correction” on this basis to a series of results for various STDs that did not suit his desired conclusion that circumcision is ineffective against them.

The argument appears also on intactivist websites (e.g. Doctors Opposing Circumcision), in the popular intactivist YouTube video “The Elephant in the Hospital Room” (which is even worse than Myles Power’s one), and in comments threads.

At first glance it seems reasonable. Freshly circumcised men are not going to use their tender organs right away, so this would seem to introduce a bias into the results in favour of an apparent protective effect. The problem is that, contrary to the claims of intactivists, it was taken into account and found not to be important.

The S. African trial took it into account directly by incorporating a 6-week healing period into their calculations. They found it played only “a minor role in explaining the effect of the intervention” (Auvert et al., 2005). In response to the use of the lead-time bias argument against the HSV findings, the authors of the original study calculated the effect it would have and found that the protection afforded by circumcision was still significant (p = 0.02). They also mentioned that 85 % of subjects healed in as little as four weeks, so six is erring on the high side (Tobian et al., 2009), not Van Howe’s “conservative side”.

The Kenyan and Ugandan trials used a different approach. Instead, they measured HIV at baseline, 6, 12 and 24 months. Now, if the effect was due to abstinence during healing it should all be concentrated in the first six month period. It wasn’t. In fact it was sustained throughout the study period, if anything growing stronger over time (Bailey et al., 2007; Gray et al., 2007). So whatever was causing the effect, it was not abstinence during healing. The S. African trial, it should be noted, found the same, their subjects being monitored at 0, 3, 12 and 21 months. So that trial accounted for it in two different ways.

Of course this has been pointed out to intactivists (Wamai et al., 2012; Morris et al., 2014) but they take no notice and carry on peddling the argument as if it still stood. This is normal behaviour for pseudoscientists.

References

Auvert, B., Taljaard, D., Lagarde, E., Sobngwi-Tambekou, J., Sitta, R., Puren, A. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial. PLoS Medicine, 2(11), 1112-22.

Bailey, R.C., Moses, M., Parker, C.B., Agot, K., Maclean, I., Krieger, J.N., Williams, C.F.M., Campbell, R.T., Ndinya-Achola, J.O. (2007) Male circumcision prevention for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet, 369(9562), 643-56.

Boyle, G.J., Hill, G. (2011) Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns. J. Law Med., 19, 316-34.

Darby, R., Van Howe, R.S. (2011) Not a surgical vaccine: there is no case for boosting infant male circumcision to combat heterosexual transmission of HIV in Australia. Australian and New Zealand Journal of Public Health, 35(5), 459-65.

Gray, R.H., Kigozi, G., Serwadda, D., Makumbi, F., Watya, S., Nalugoda, F., Kiwanuka, N., Moulton, L.H., Chaudhary, M.A., Chen, M.Z., Sewankambo, N.K., Wabwire-Mangen, F., Bacon, M.C, Williams, C.F.M., Opendi, P., Reynolds, S.J., Laeyendecker, O., Quinn, T.C., Wawer, M.J. (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet, 369(9562), 657-66.

Morris, B.J., Hankins, C.A., Tobian, A.A.R., Krieger, J.N., Klausner, J.D. (2014) Does Male Circumcision protect against sexually transmitted infections? Arguments and meta-analyses to the contrary fail to withstand scrutiny. ISRN Urology, 2014, Article ID 684706, 23 pages.

Storms, M.R. (2009) Male circumcision for the prevention of HSV-2 and HPV infections (Letter to the editor). New England J. Med., 361(3), 307.

Tobian, A.A.R., Serwadda, D., Gray, R.H., (2009) Male circumcision for the prevention of HSV-2 and HPV infections (Reply). New England J. Med., 361(3), 307-8.

Van Howe, R.S., Storms, M.R. (2011) How the circumcision solution in Africa will increase HIV infections. J. Public Health in Africa, 2(e4), 11-5.

Wamai, R.G., Morris, B.J., Waskett, J.H., Green, E.C., Banerjee, J., Bailey, R.C., Klausner, J.D., Sokal, D.C., Hankins, C.A. (2012) Criticisms of African trials fail to withstand scrutiny: Male circumcision does prevent HIV infection. J. Law Med. 20, 93-123.

In Malawi HIV doubled after the circumcision campaign began

This claim began to circulate after it appeared in an on-line newspaper, “Malawi24”, in 2015:

https://malawi24.com/2015/08/04/circumcision-disaster-malawi-hiv-infection-rate-doubles/

The article asserts that:

Statistics cited by the BBC in a report marketing Medecins Sans Frontieres (MSF), one of the world’s renowned NGOs working on public health, show that HIV infection rate in Malawi has doubled in recent years despite a range of interventions put in place to tackle the spread of the virus that have included relentless campaign on condomisation and circumcision.

According to the report, HIV rates have doubled in Malawi moving from 10% to 20% in 1 year. Strangely, this has been the same period that Malawians have been manipulatively forced to go through circumcision in masses with the promise that it reduces the contraction of HIV.”

The anti-circumcision tone “manipulatively forced”, and lack of details about where to find this BBC report so it can be checked, should set alarm bells ringing. And one only has to read a little further to find the author conceding that “some Malawians trashed the results claiming they were sensationalised and exaggerated”.

But the best part is at the end:

This article has been updated. An earlier version credited the statistics cited by the BBC to MSF. However, MSF have denied that they gave the statistics to the BBC. The organisation says the claims the BBC made that 1 in every 5 people are HIV positive in Malawi were “grossly unfounded and sensationalised” with the aim of ‘grabbing headlines’.  Malawi24 apologises for any inconveniences caused.”

In short, the figures are bogus, and the claim was, in effect, retracted by the same on-line paper that originally made it! Yet it keeps turning up in comments threads, opinion pieces, and (alarmingly) is being peddled to Africans by the disturbing intactivist website vmmcproject.org.

Do intactivists not bother to read their own sources?

Why do they think that an unreliable, un-sourced, retracted, on-line newspaper report trumps hard data carefully collected by medical and scientific professionals?

Some facts (real ones, not intactivist ones), from more credible sources:

The circumcision program in Malawi was formally launched in 2012, although uptake was initially rather low, at 11.5 % after two years, being hampered by religious and cultural beliefs, as well as a lack of resources to fully implement it. But over the period 2011 to 2013, i.e. straddling the initiation of the circumcision program, new HIV infections declined from 55,000 in 2011 to 34,000 in 2013 (National AIDS Commission, 2014).

As of 2016, the HIV prevalence in Malawi was 10.6 % for the age group 15 to 64 years (MPHIA 2016).

References

MPHIA (2016) Malawi Population-based HIV Impact Assessment, December 2016. On-line: http://phia.icap.columbia.edu/wp-content/uploads/2016/09/MALAWI-Factsheet.FIN_.pdf

National AIDS Commission (2014) National HIV Prevention Strategy, 2015-2020. National AIDS Commission, Malawi. On-line: http://hivstar.lshtm.ac.uk/files/2016/05/Malawi-National-HIV-Prevention-Strategy-2015-2020.pdf