Pro-circ myths 2-AIDS/HIV

[JohnC]

Since the publication of three African trials purporting to show that circumcision provides a degree of protection for male acquisition of HIV infection during heterosexual intercourse, those advocating routine circumcision in developed countries have unsurprisingly leapt on the findings to push their case.

There are two issues here: first, the meaning and integrity of the African studies; second, the relevance of any findings to a country such as Australia. I will deal with the latter in this post (though I'm happy to discuss the first if someone wants to raise it).

Taken on face value, the African data suggest circumcision offers about the same level of protection against AIDS for heterosexual males as the rhythmn method does against pregnancy (~50-60%). What would this mean in practice for Australian men?

Looking at the HIV Surveillance Report (published by the National Centre in HIV Epidemiology and Clinical Research (http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/page/Quarterly+Surveillance+Reports)) we see that of the 137 confirmed AIDS cases among males in 2007, 17 were the result of heterosexual contact. Repeat: 17 cases.

And looking further, 11 of those cases involved persons from "a high prevalence country" -- in other words, were almost certainly contracted in Africa.

So that leaves 6 cases in an entire calendar year where a man contracted AIDS in Australia as a result of heterosexual sex. This is a statistical non-event, and it would be utterly farcical to suggest this is a valid reason to circumcise anyone, let alone infants. Even if we believed the African studies and applied them here ...

Data from Australian HIV Surveillance Report, Vol 24 No 2 April 2008.

[Roopee]

Well? Personally? I think the argument that it will help prevent HIV/AIDS is a crock.

We'd do much better to teach our children the benefits of safe sex.

Thanks for posting that info:shakehands:

[JohnC]

In apparent repsonse to this thread, Circangel (previously Ron123) has posted the full text of this newspaper article (http://www.theaustralian.news.com.au/story/0,25197,24891191-23289,00.html) by Alex Wodak, a drug and alcohol person at Sydney's St Vincent's Hospital.

The central argument of this article is that comparison of Australian HIV infection rates between 1999 and 2007 shows that African data about the male hetrosexual acquisition of HIV is relevant to Australia and therefore public health concerns demand the encouragement of male circumcision.

I will now show that the data demonstrates the complete opposite of what Dr Wodak contends.

Since the hypothesis we are investigating is that circumcision reduces the likelihood of male hetrosexual acquistion of HIV, the portion of the dataset we are interested in is infection rates of adult/adolescent males through sexual contact as a proportion of the total.

The raw figures for 1999 are homosexual/bisexual 349; heterosexual 76; total 486. For 2007 they are homosexual/bisexual 658; heterosexual 126; and total 830.

Therefore, the percentage of male heterosexual HIV acquistion in 1999 was 15.6% and in 2007 15.2%. This is despite the fact circumcision prevalence fell by at least 15% in the affected age group (calculated from the median age).

But wait, there's more! The male heterosexual figures include persons who were either from a high-prevalence country, or who had sex with persons from a high-prevalance country ie were almost certainly contracted overseas. If we subtract these cases, then the percentage of male heterosexual HIV infections contracted in Australia by Australians fell from 8.2% in 1999 to 5.3% in 2007 (for a total of 44 cases). Yet circumcision rates also fell in the relevant age cohort.

The entire argument is therefore not only complete nonsense, but relies upon a quite wilful and unethical distortion of the data (which is available at the link I gave in my initial post).

[Sheer Bliss]

JohnC - where have you been hiding??

:yelclap: :yelclap: :yelclap: :yelclap: :yelclap: :yelclap:

[JohnC]

JohnC - where have you been hiding??

After battling on Bubhub a couple of years ago, I ended up feeling like I was bashing my head against a brick wall :( However, it is clear many thousands of parents consult this site every month, so I'm giving it another go :D

[Jakois]

After battling on Bubhub a couple of years ago, I ended up feeling like I was bashing my head against a brick wall :( However, it is clear many thousands of parents consult this site every month, so I'm giving it another go :D

Welcome back:flowerz: :smiliedance: :D.

[Tam-I-Am]

Have I read somewhere that while the data shows a decreased risk for men - it shows an increased risk for contracting HIV from a partner who is circed rather than not?

I seem to recall that...but honestly can't remember where or when I read it....

[JohnC]

Have I read somewhere that while the data shows a decreased risk for men - it shows an increased risk for contracting HIV from a partner who is circed rather than not?
I seem to recall that...but honestly can't remember where or when I read it....
You are correct. There has indeed been such a study showing a correllation between circumcision and increased risk for women in Africa. Analysis of European data shows the same trend.

However, while these correllations exist I do not think they show a plausible causality; we are more likely looking at the intrusion of social factors that have not been controlled for in the analysis. (In other words, even though I oppose routine circumcision, I would not use such studies at the moment to support my position.)

More broadly, the single most important correllation in developing countries seems to be between HIV infection and the percentage of women who are commercial sex workers.

Circumcision is, in my view, a massive diversion from the real and difficult issue of the position of women in high prevalence countries, and over the past 10 years infection rates among women have far outstripped those among men.

[Areca]

JohnC I heart you!

[lukaelmo]

JohnC I heart you!

Hey, me too, I remember you from ages ago :D.

Lol, I've got nothing constructive to say though, but when has that ever stopped anyone :laughing:.

[JohnC]

I would be interested to hear, in this thread, from anyone who is pro-circumcision and believes I have either misrepresented or misinterpretated the data.

But as it stands, the HIV/AIDS argument for circumcision looks like a complete furphy.

[OurLittleBlessing]

After battling on Bubhub a couple of years ago, I ended up feeling like I was bashing my head against a brick wall :( However, it is clear many thousands of parents consult this site every month, so I'm giving it another go :D

I want to say THANK YOU for opening my eyes (and DH's) to the facts about RIC.

We were pro RIC before reading your posts, and you have enlightened us on a lot of the myths surrounding the issue.

We are from an area where RIC is, in my opinion, done based on a lot of misinformation. I'm not trying to offend anyone, I'm just speaking from my experience. Hec, I was nearly one of them, and for me, it would have been for the wrong reasons.

Anyway, I just wanted to encourage you to keep up your good work :D.

[beebs]

Yes Johnc - your posts about RIC and immunisation are very informative. I have to be honest - I wasn't fussed either way about RIC before (I wouldn't do it to my child), but after reading your posts on the subject and doing some reading myself I am officially converted! Thanks and keep up the great work:flowerz:

[JohnC]

Thank you so much. It is actually incredibly heartening to know that I'm not just "preaching to the choir".

[jimmysmummy]

JohnC, you are a very articulate and intelligent individual.:yelclap:

[MimiGrace]

And i'm glad that there are people who have benefited from your posts :thumbsup:
maybe they need to go in the discussion section? so that we hear both sides next time though :detective:

[JohnC]

maybe they need to go in the discussion section? so that we hear both sides next time though :detective:

Sadly, it doesn't matter where I post. Note that I posted a link in the pro-circ thread to my critique of Wodak here. Response: not a peep, not here or there.

In the end, deciding to circumcise is in my view more about fashion than fact. When the justifications hit the evidence, they melt away like morning mist in the early sunshine.

No doubt some parents who have already circumcised their sons will be deeply offended by what I have just written. That is regrettable, but unavoidable. So there may be an outpouring of emotional anger, but I really doubt that anyone is going to examine the dataset and rationally explain why I am in error.

Of course, I may be wrong. It does happen ;)

[sockstealingpoltergeist]

Thank you for that information.

Nothing strikes fear into the hearts of mothers then the thought that we may have brought future suffering or the risk there of to our children.

It is fantastic to see these facts so clearly presented as I am then easily able to put forth a great case about my parenting decisions regarding circ to Pro circ family members and friends.:yes:

Keep posting.:)

[rainbow road]

thanks JohnC.

I reckon it's complete rubbish that circing prevents this this and that. Education and good hygiene is far more beneficial.

I am Jewish and will be the first in my family to not circumcise my sons (if I have any). I used to think religious reasons might cut it (pardon the pun) but I know deep down (and always have) there is no reason good enough for me to hack off a piece of my baby.

No one is going to touch on little hair on any of my babies heads and that can apply to all parts of their bodies.

[Lillynix]

This was a great read, thanks JohnC!

While I (and my circed DH) have always been anti-circ, it really is great to see information like this written clearly, without the heated emotion attatched so others can read this and hopefully take it on board and do some thinking rather than assuming it is an attack.

And Forkie, i'm sure I don't need to say it, but I will anyway :o

Good on you for sticking up for your beliefs and doing what you feel is ultimately the best for any future sons you may have and not continuing along with your religious tradition, simply because you're supposed to.

If the time ever comes, I wish you all the best and hope that you don't come to heads with too many family members over it :)

[rainbow road]

Thanks Dragonfly...I am sure it will bother many people in my family but then, they'll probably be bothered with my many other less conventional parenting plans. And besides, if they are so bothered I'll suggest I'll do it if they'd care to come with us and offer a part of their genitals to be cut off too. Bet that would change some minds quick fast.

[Beany]

Sadly, it doesn't matter where I post. Note that I posted a link in the pro-circ thread to my critique of Wodak here. Response: not a peep, not here or there.

It's never about the response from those that have been and done. They can't undo, after all. It's about those silent people that are reading, learning and questioning a cultural norm :)

[forbetoel]

It's never about the response from those that have been and done. They can't undo, after all. It's about those silent people that are reading, learning and questioning a cultural norm :)

:iagree:....I am sure there are many who have read and chnaged their mind about circing their little baby boy after reading one of your posts.:thumbsup::goodvibes:

[Fellow Traveler]

Hello All, I thought I'd add to this discussion. If you didn't know a second opinion was published in the Australian critiquing the Wodak article. I did a write up here (http://www.circumcisionandhiv.com/2009/03/circumcision-and-hiv-by-the-numbers.html). And a link to the second article can be found there. Enjoy.

[Fellow Traveler]

I also wanted to add this analysis that I worked out that goes along with the critique of Wodak's article. There is a WHO recommendation but the WHO recommendation applies only to countries with high prevalence and not to countries like the US. And let me just explain to you why, especially in the US, and other first world countries [like Australia], the HIV argument is pretty much BS. It's also a stupid policy in Africa and will almost certainly be a long term failure but for other reasons and as others have said would require a different thread.

To determine the probability of not becoming infected you can use the following formula:

(1 - [chance of transmission from sex])^[sexual encounters]

Now for the estimates, let's assume that there is a risk reduction of 50% for circumcised men. This is the number most often banted around by the popular media and those clowns at the UN and WHO in their reports from Africa. The probability of infection in any one encounter with an HIV positive partner varies depending on viral load, co-infection, and numerous other reasons. For example, people are most infectious soon after being infected. Infectiousness lessens after a few weeks which is one reason HIV spreads so fast in Africa, read The Invisible Cure: Africa, the West, and the Fight Against AIDS, by Helen Epstein, to find out why it's so infectious in Africa but not anywhere else.

Anyway, I've seen numbers for women infecting men range from 1/700 - 1/2500 and interestingly enough, a recent publication in the Lancent of Infectious Diseases and reported at Aidsmap (http://aidsmap.com/en/news/E1249D29-0DDE-4CFF-9CC7-16B3FADB3E59.asp), put the risk of an HIV infected woman infecting her male partner at 0.04%.

From Aidsmap:

Researchers conducting a meta-analysis of studies of the risk of HIV transmission during heterosexual sex have found that, in high-income countries prior to the introduction of combination therapy, the risk per sexual act was 0.04% if the female partner was HIV-positive, and 0.08% when the male partner was HIV-positive. However these rates were considerably higher in lower-income countries, if the source partner was in either the very early or the late stage of HIV infection, or if one partner had genital ulcer disease, write the researchers in the February issue of The Lancet Infectious Diseases.


They continue:


Pooling the data from studies in high-income countries, the researchers calculated that the risk of transmission from an HIV-positive man to his female partner was 0.08% per sexual act: in other words, it was likely to occur once every 1250 sexual acts. When it was the female partner who was HIV-positive, the male partner’s risk of acquiring HIV was 0.04% per sexual act – in other words, once every 2500 sexual acts.
I bolded the last, though it isn't pertinent to the discussion, I might come back to it later. I'll only say that is so obvious I don't know why they made a point of it. It was been well known that people were more infectious in early and late stages or if they had genital ulcer diseases. Also note that they said prior to the introduction to therapy which means the true rate may actually be lower now but we'll go with it.

So based on that, we'll start the estimate that the chance of infection is 0.06% a bit higher than published in the Lancet article. That means a male having unprotected sex with an HIV positive women has about a bit more than 1 in 1800 chance of being infected. Base line risk intact men vs circumcised men 1 random heterosexual contact with an HIV+ partner.

[1 - 0.0006]^1 99.94% ~= 0.06%
[1 - 0.0006 * 0.5]^1 ~=99.97% ~= 0.03%

But the HIV distribution in the US population is about 5 in 1000 or 1/200 [It's much lower in Australia BTW] so, in general, there is only a 1 in 200 chance that I'll encounter someone who is HIV positive. Actually the risk is much lower but we'll discuss that in a bit. Given that as a fact, a closer estimate of the risk of becoming HIV infected after the 1 encounters is more like:

The chance of event A (encountering an HIV positive individual in the general population) * the chance of event B the likely hood of getting infected during that encounter.

1/200 * 0.0006 = 0.000003 --- 1 - 0.000003 = 99.9997% = 0.0003%
1/200 * 0.0003 = 0.000006 --- 1 - 0.0000015 = 99.99985% = 0.00015%

Of course, the number of sexual encounters is important too. For 1,000 encounters, the difference is 1.5 hundreths of a percent. That's is what circumcision bought you, big deal. Over the course of 1,000 random encounters an intact guy has 1.5 hundreths of a percent larger chance of becoming HIV positive. Circumcised guys, party on!

Of course there are some caveats to this. First, your per-exposure risk might change based on other factors and the 1/200 is quite high since 75% of the HIV positive population are men. If women only account for about 1/4 of the total, this reduces the 1/200 to between say 1/700 or 1/1000. This is what it looks like when we adjust the prevelence among women:

1/700 * 0.0006 = 0.0000008571 --- 1 - 0.0000008571 ~= 99.99992% = 0.00008%
1/700 * 0.0003 = 0.0000004286 --- 1 - 0.0000004286 ~= 99.99996% = 0.00004%

That's a whole order of magnitude. Now we're talking about a difference of 4 thousandths of a percent if we have 1,000 random partners. Party on.

For Doctors, especially in the US or Australia, to entertain the notion that circumcision is going to in anyway impact a boys chances of acquiring HIV is very misleading, not truthful, or ethical. The commonly cited 50% has to be understood in context.

Circumcision as a prophylaxis for any STD is, if it is even true, over stated especially in first world countries like the US. I find courious though that it keeps getting pushed, consider HPV. Now here is something that we've been vaccinating against for over three years yet people still try and tie circumcision to HPV, why?

[ccc]

John Murray, associate professor at the University of NSW and the National Centre in HIV Epidemiology and Clinical Research, wrote an article in “The Australian- March 14th 2009” because of recent media events and research articles on Aids that may start to concern parents in whether circumcising their baby boys might be the best thing to do!
All overseas research and articles are normally critiqued by a panel of medical experts and then viewed for its validity and appropriateness within the Australian setting.
I believe this article will ease new parents minds…

The Australian
March 14, 2009
“Circumcision no barrier to HIV…REPORTS of successes against HIV of male circumcision trials in Africa have understandably raised concerns in parents as to whether baby boys born in Australia should be circumcised…There has even been commentary recommending the procedure as a means of reducing HIV risk ("Circumcision can curb HIV rates", Weekend Health, January 10-11)...Male circumcision is a promising intervention in countries in Africa, where levels of HIV infection can exceed 20 per cent of the adult population and where infection is spread predominantly through heterosexual sex…In these countries HIV testing is not routinely available. Given that finding out you are HIV-positive will not provide access to antiretroviral therapy but will often make you an outcast from family, friends and society in general, it means that there is a large number of HIV-infected individuals who do not know they are infected, who do not modify their behaviour and for whom their risk of HIV transmission is therefore high…General levels of other sexually transmitted infections and hygiene issues also contribute to high rates of HIV transmission…However, the situation is very different in Australia and other developed countries. Access to HIV testing and anti-retroviral therapy is almost universal, so that the number of HIV-infected individuals with undiagnosed infection is much lower. Hygiene is considerably better and prevalence of sexually transmitted infections is also lower…So in Australia the general population risk of HIV infection is significantly less…If you are still worrying about the risk factor for your newborn son you will have plenty of time to advise him to be careful; the average age of men newly diagnosed with HIV through heterosexual contact in 2006 was 46 years of age. No man under the age of 24 was diagnosed with HIV from heterosexual contact in that year, while 10 men over the age of 60 were. Rather than thinking of circumcising your new son to reduce his risk of heterosexual HIV infection, you should instead be lecturing your father about safe sex!...By far the largest number of HIV infections in men in Australia occurs through homosexual transmission…So although there is no room for complacency about the HIV epidemic in any country, male circumcision of newborns will have little impact on HIV risk in Australia.
John Murray is associate professor in the school of mathematics and statistics at the University of NSW and the National Centre in HIV Epidemiology and Clinical Research.”

The other concern is HPV. However, we have a vaccination program against HPV to alleviate fears of future increases in cervical cancers.
As a registered nurse with 2 uncircumcised boys, I know of the foreskins importance and functions. I have no fear my children will have ‘problems’(only a very small percentage ever do and can easily be rectified in most cases without resorting to circumcision!) and as they are seen to be the norm now, they will always feel comfortable in ‘the locker room’!
No medical group in Australia supports the routine circumcising of children, it is currently been investigated as a legal rights issue, and in the not so future distance, unless for religious reasons, it may become almost impossible to circumcise ones child here in Australia!

[serendipity22]

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