November 3, 2013

November 3, 2013

Fit to Cut
Part 2

Welcome to another day in my life. Today is Sunday and I hope you are having a beary safe and great weekend. It is another busy weekend for the Dab Bears and me.

Yesterday, I started blogging on circumcision and HIV that I will conclude today.

The 2011 JIAS paper examined the evidence to support VMMC in sub-Saharan Africa and pointed out that only about 10 percent of the region’s HIV cases are among those younger than 15, and that prevalence jumps dramatically in those 15 and older. This correlation is “clearly consistent with sexual behavior as the main mode of transmission,” the authors wrote.

Gisselquist, along with Potterat and others, criticize epidemiologists for not tracing the source of individual infections when Africans test positive—in other words, for not doing the legwork in the field to see if something other than sex might have been at play. They point out that in three circumcision trials a significant proportion of men who acquired HIV did so while reporting either no sex or consistent condom usage, including 23 of the 69 transmissions in the South Africa study and 16 of the 67 new infections in the Uganda trial. (The Kenya trial did not publish such specific data.)

“I’d say, ‘Look at the evidence,’” Gisselquist says, addressing the authors of those studies. “‘This is the evidence you reported.’ But these guys are sitting under a tree in Baltimore and saying, ‘Well, we know it’s all from sex in Africa anyways.’”

Ronald Gray, who headed up the Uganda trial, says that all six of the men in the study who did not report intercourse during the period when they were infected did report sex both before and after that period. He theorizes they “likely misreported their sexual behaviors.”

“We know that self-reporting on sexual behavior is not good,” says OGAC’s Jason Reed. Stating a common point, he argues: “The fact that male circumcision was the only difference between these two groups of people across three studies, and that it still reduced their HIV incidence by the same proportion [in all three studies], would suggest that male circumcision is protecting them against whatever is putting them at risk.”

In 2011, Gregory J. Boyle, PhD, a consultant from Queens-land, Australia, and George Hill, vice president for bioethics and medical science at Doctors Opposing Circumcision in Seattle, published a lengthy criticism of the randomized controlled trials of VMMC in the Journal of Law and Medicine (JLM). The next year, the same journal published a 30-page rebuttal whose nine authors, including Robert Bailey, lambasted Boyle and Hill for recycling discredited theories and relying on “outmoded evidence, outlier studies and flawed statistical analyses.”

Like many dissidents, Boyle and Hill highlighted the observational studies of circumcision, some of which showed a correlation between lacking a foreskin and raised HIV risk, not the other way around. Potterat calls the overall findings of those earlier studies “a toss-up.”

The JLM rebuttal, which sneered at the dissidents’ “highly selective literature review,” pointed to one particular meta-analysis of observational studies that found circumcision had a 61 percent protective effect, thus negating any apparent inconsistencies in the study findings.

Skeptics have expressed concern that the early termination of the controlled trials over-estimated circumcision’s protective effect—a common statistical result of ending a trail prematurely. But the JLM rebuttal cited the fact that nearly five years of follow-up in two of the trials found that the reduction in risk only increased over time: to 67 percent risk reduction in the Kenyan study and 73 percent in the Uganda trial.

Recent research also is beginning to show that widespread circumcision is already having an appreciable effect on specific African communities. In Orange Farm, South Africa, the site of that country’s VMMC trial, the subsequent large-scale roll-out of the program has seen an estimated 57 to 61 percent reduced HIV incidence among circumcised men as compared with uncircumcised men. And in Rakai, Uganda, VMMC rates among non-Muslim men between 15 and 49 years old jumped from 5.6 percent between 2000 and 2003 to 25.3 percent in 2009. During that time, HIV incidence among all non-Muslim men dropped 22 percent, and researchers have calculated that 37 percent of that drop can be attributed to the scale-up of circumcision.

Another argument posed by the skeptics is the notion that recently circumcised men are likely to put themselves at increased risk of infection should they engage in unprotected sex before their wounds heal.

Robert Bailey, PhD, MPH, a professor of epidemiology at the University of Illinois at Chicago, who was the principal investigator for the Kenyan VMMC trial, has completed a study showing that 35 percent of men do start having sex again before the WHO-recommended six-week waiting period, but that only 7 percent do so before the wounds heal. He argues that an approximate two-week period of increased risk for these men, when compared with the permanent risk reduction of circumcision, is relatively insignificant.

A further area of concern is the phenomenon known as “risk compensation”—the notion is that if a man believes he is more invincible with a circumcised penis, he may be more likely to have unprotected sex or increase his number of partners. Research has been mixed in this area. Time will tell how men’s behavior plays out.

In the meantime, Seth Kalichman, PhD, a professor of psychology at the University of Connecticut, who published a 2007 article in PLOS Medicine questioning the VMMC trials for improperly accounting for risk compensation, says that a major challenge posed to circumcision efforts is how to communicate the practical implications of a “60 percent risk reduction” to African men without giving a false sense of security.

All the back and forth between the VMMC supporters and the dissidents aside, the march toward widespread circumcision in sub-Saharan Africa remains a major priority in global public health, and its detractors are few in number. Ronald Gray of Johns Hopkins says, “I’ve given up trying to respond to their many publications.”

“It’s a circular discussion that on some levels probably won’t ever be satisfied,” says Reed of OGAC. Regarding the dissidents, he says, “It’s a group of people that largely argue, I think, from an emotional place. I think our position is that no amount of scientific data is going to satisfy the very real issues that they have with the intervention. I think they try to make the case that it’s not valuable from a scientific standpoint, when in fact the problems that they have with it aren’t the science.”

Potterat, who explains that “skepticism is part of the fabric of my mind,” says he’s open to suggestion that circumcision is a worthwhile intervention, but is still waiting for what he considers solid evidence.

“We’re not saying we know,” Potterat says. “We’re saying there’s something wrong with this picture and we don’t know what’s going on, but neither do you. And I guess that really has stepped on people’s ideological, political, academic or other agendas that they just don’t want to see.”

Rachel Baggaley at the WHO sees the argument from a different perspective: that of Africans at high risk for HIV. “The denialists are often coming from places where HIV is not a massive threat to them. Whereas, if you’re a young man in South Africa, you’ve got such a high lifetime chance of acquiring HIV, that, frankly, to deny that opportunity to something that reduces that chance by 60 percent is rather paternalistic.”

Hope you have a beary safe and great Sunday!

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,

Daddy Dab