Confusing Rebuttal of a Rebuttal Regarding Male Circumcision in Africa Males; Effectiveness of Circumcision Questioned

In 2007, WHO/UNAIDS recommended male circumcision as an HIV- preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered.

Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%.

In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to- female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.

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Source – Paul Causey  MSM-Asia
16 March 2012
Rebuttal of the Above Study Claiming Circumcision Does Not Inhibit HIV Rejected:

Local scientists have dismissed a new study that claims male circumcision does not offer protection against HIV after all.

The study claims the cut increases the spread of HIV/Aids and can only reduce its transmission by 1.3 per cent at most. It faults the methodology of past studies in Kenya, Uganda and South Africa that showed circumcision offers up to 60 per cent protection to HIV negative men in heterosexual relations.

National AIDS and STIs Control Programme said the new study is “flawed”, lacks proper peer review and was probably influenced by doctors opposing circumcision, a medical lobby that sees the cut as abuse. “WHO experts recommended male circumcision in 2007 after many scientific studies. Such critics have always been there since circumcision began,” said Nascop’s head of HIV prevention Dr Peter Cherutich.

The dissenting study was published by Australia’s Thomson Reuters in their Journal of Law and Medicine. The authors insisted that the WHO/ UNAIDS recommendation in 2007 ignored a vast body of contradictory evidence. According to the article, the studies had selection bias, inadequate blinding, problematic randomisation, experimenter bias, lead time bias, supportive bias, participant expectation bias, time- out discrepancy, and lack of investigating of non-sexual HIV transmission among other problems.

However, male circumcision manager at Nascop Dr Athanasius Ochieng says the science behind the cut is irrefutable. “Hardening of foreskin helps in removal of white blood cells that make uncircumcised men more vulnerable to HIV,” he told a forum organised by Internews in Nairobi yesterday.

He says the two dissenting researchers never declared their interest as required, yet one had close relationship with doctors opposing circumcision. Mass circumcision campaigns in Africa continue to receive millions in funding from leading organisations, including WHO and Unicef. At least 400,000, men mostly in Nyanza ,have been circumcised in Kenya since the drive was launched four years ago.

Senior manager for Male Circumcision Consortium in Kenya Dr Mores Loolpapit said in West Africa, where nearly all men are circumcised, HIV prevalence has never exceeded 6 per cent. “But in Southern Africa where most men are not, the frequency has always been more than 10 per cent,” he said. The Kenyan researchers said circumcision has more benefits beyond HIV, including reduction of cases of cervical cancer in women. They also said it gives men better hygiene and lowered risk of acquiring other STIs like Herpes.

By John Muchangi