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    Friday, February 23, 2007

    Cutting AIDS: Circumcision works:

    Circumcision may provide even more protection against AIDS than was realized when two clinical trials in Africa were stopped two months ago because the results were so clear, according to studies being published today.

    The trials, in Kenya and Uganda, were stopped early by the National Institutes of Health, which was paying for them, because it was apparent that circumcision reduced a man's risk of contracting HIV from heterosexual sex by about half. It would have been unethical to continue without offering circumcision to all 8,000 men in the trials, federal health officials said.

    That decision, announced on Dec. 13, made headlines around the world and led the two largest funds for fighting AIDS to say they would consider paying for circumcisions in high-risk countries. But the final data from the trials, to be published today in the British medical journal The Lancet, suggest that circumcision reduces a man's risk by as much as 65 percent.

    The newspaper article did a good job of summarizing the methods, and included this quote from Anthony Fauci, the director if the National Institute of Allergy and Infectious Diseases:

    ...he will say officially that circumcision cuts a man's risk by about half, because the validity of clinical trials depends on following randomized groups of patients, not selected groups.

    Here are the actual results (registration required, but you do get the full text):

    During the study, seroconversion occurred in 22 participants in the circumcision group and 47 of those in the control group. The 2-year HIV incidence was 2·1% (95% CI 1·2–3·0) in the circumcision group and 4·2% (3·0–5·4) in the control group (p=0·0065);

    That 50%-65% decrease isn't so dramatic after all. It's really a 2% reduction in absolute risk. But, every little bit helps, I suppose. Circumcision can be to the developing world what statins are to the West.

    And of course, we will help:

    .....President Bush's $15 billion AIDS initiative and the World Health Organization are considering paying for circumcisions in high-risk countries, but must work out what training and equipment they would require circumcisers to have.

    They could ask these these guys, they've been practicing it for millenia.

    There are other potential obstacles, however:

    The uneven power relations implied by the way in which developed countries are doing trials in developing countries for a practice that has been declared medically unnecessary for babies in the west could give rise to a perception of new forms of colonialism.

    Maybe we should declare it medically necessary in the West, too. Circumcise our sons to save the world.

    posted by Sydney on 2/23/2007 08:47:00 PM 5 comments


    Male infant circumcision has a zero percent effectiveness rate for HIV prevention, since male infants do not have sex.

    Circumcision should be an individual decision at the appropriate age, not a parental one immediately after birth.

    By Blogger KipEsquire, at 9:36 PM  

    I was being sarcastic.

    There's a reason, though, for targeting infants.

    Public health campaigns work best when they can be administered to the entire population indiscriminately. When the difference in infection rates are 4% vs. 2%, a large number of people have to submit to the procedure to realize a net social benefit.

    It's more difficult to circumcise a full grown man. At least in this country. The potential complications - infection, scarring, accidentally misplaced cuts - have to be explained, as well as the benefits. In this case, it's a reduction of his risk by 2 percentage points. Not very convincing for the amount of bother he has to go through.

    By Blogger sydney, at 9:10 AM  

    I think I get the sarcasm, but it's not readily apparent. Regardless, your justification for targeting infants is off.

    ...a large number of people have to submit to the procedure to realize a net social benefit.

    Those infants do not consent to achieving a net social benefit. They have an inherent right to ownership of their bodies. Parents only act as guardians when surgery is indicated. With circumcision as it's generally practiced, there is no indication. Potential HIV protection, particularly small as you point out, is not an indication.

    Those males who do not have unprotected sex with HIV-positive women already receive the maximum protection. Circumcision doesn't help. Indiscriminate, medically unnecessary genital surgery on those who can't consent is not appropriate for a disease that requires specific behavior for infection. Consequences matter.

    I don't think you're specifically advocating targeting infants, but people are already using analysis similar to yours to justify targeting infants. Look at every statement uttered by the UN and WHO.

    The potential complications - infection, scarring, accidentally misplaced cuts - have to be explained, as well as the benefits.

    In the scenario, though, the male being circumcised gets to weigh how useful these are. Scarring exists any time a male is circumcised. The other risks are present whether the patient is an adult or an infant. The only difference with infants is that the doctor does not inform the patient, nor does he get the boy's consent.

    Again, you're right that the reduction isn't compelling. But just because it's easier on infants does not alter the reality that 2% (or even 4%) is sufficient. Prevention is only potential. We wouldn't advocate removing breast tissue from infant girls, even though they face a greater risk of breast cancer than the risk of foreskin-related problems facing intact men.

    Still, I like that you crunched the numbers to indicate how "50% to 65%" isn't really as profound as it appears.

    By Anonymous Tony, at 12:43 PM  

    I was kind of surprised at how low the incidence rate of HIV was in the study. We always hear that AIDS is "rampant" in Africal. That could be because:

    1) They only followed the men for a short period of time. Longer follow-up may have resulted in higher incidence rates.

    2) AIDS may be over-reported in African nations. The study required laboratory proof of HIV infection. It isn't too much of a stretch of imagination to believe that African governments may over-report clinical AIDS without laboratory proof in order to score more money from relief organizations.

    By Blogger sydney, at 1:36 PM  

    Valid points. There is too much of an agenda here, or at least potential to perpetuate an agenda, for the media to be reporting this as breathlessly as they are.

    Your first point is the one that sticks out most, I think. Both trials were cut short. HIV risk is not a short-term risk here. There is no small window, after which it has passed. To promote such a permanent surgery on adult men, and then to propose it for infants, it's heartless and irresponsible.

    Essentially, this story reinforces that there's money to be had in treating Africans as if they're stupid and unable to respond to education. Whether it's to prop up a favored dictator or to implement feel-good medicine, it fits the stereotype.

    By Anonymous Tony, at 8:44 AM  

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