Male circumcision greatly reduces HIV risk [Archive]

Kaylee

13th December 2006, 04:09 PM

Well... I'm thinking the article doesn't give enough information; how can we know if this is causation or just merely correlation?

Some cuts and pastes from the article in the OP:
Dr. Anthony Fauci, director of the NIH's National Institute of Allergy and Infectious Diseases, said the institute ended both trials early and offered circumcision to all men involved in them. The trials began in 2005 and were due to go until mid-2007.

<snip>

Fauci said circumcision is not completely protective "and must be seen as a powerful addition to, not a replacement for, other HIV prevention methods." Fauci said the benefits could be negated by small decreases in condom use by men or if men add more sexual partners

I would be willing to bet that the men who get circumcised as adults for health reasons (despite how painful a procedure it is for adults) are also more careful to use condoms. The article doesn't mention any studies being done to compare condom use, number of sexual partners or other factors between circumcised and uncircumcised men.

fsol

13th December 2006, 04:11 PM

Iamme

13th December 2006, 04:12 PM

Chopping it off completely... would reduce the risk. I just read recently where this guy chopped off his own thing on purpose. I'm trying to remember why he did it...if he was a religious wacko or something.

Kaylee

13th December 2006, 04:23 PM

I'm sorry but...

It does have the potential to prevent many tens of thousands, many hundreds of thousands and perhaps millions of infections over coming years," Dr. Kevin De Cock, director of the World Health Organization's Department of HIV/AIDS, told reporters.

:D

How could I have missed that! Did Rueters accidently get the article from the Onion? :confused: :D

Chopping it off completely... would reduce the risk.
There ya go. Don't think WHO will recommend it though.

SteveGrenard

14th December 2006, 04:52 AM

http://www.healthnews-stat.com/?id=257&keys=HIV-circumcision-NIH

fuelair

14th December 2006, 06:14 AM

casebro

14th December 2006, 09:15 AM

http://www.healthnews-stat.com/?id=257&keys=HIV-circumcision-NIH

Hold on one second there. That study had a duration of ONE year. Doesn't it take up to ten years for a positive test? If so, wouldn't they have found more latent cases than new ones?

Likewise, I did notice that participants were "randomly assigned" to either group. Did they really find a bunch of guys to sign up to "Maybe get wacked" ? I can see guys who want it done, I can understand guys who don't, but 5,000 guys who would let a roll of the dice decide? I think you would have a hard time at that in places besides Kenya and Uganda. I wonder what the persuasion was?

That article doesn't give us numbers either. Just rates. No P factor. No stats at all. I hope there is a better published report.

fls

14th December 2006, 09:49 AM

Hold on one second there. That study had a duration of ONE year. Doesn't it take up to ten years for a positive test? If so, wouldn't they have found more latent cases than new ones?

I always enjoy reading criticisms that depend upon the assumption that the principle investigators were complete morons. :)

Likewise, I did notice that participants were "randomly assigned" to either group. Did they really find a bunch of guys to sign up to "Maybe get wacked" ? I can see guys who want it done, I can understand guys who don't, but 5,000 guys who would let a roll of the dice decide? I think you would have a hard time at that in places besides Kenya and Uganda. I wonder what the persuasion was?

It doesn't say that they signed up guys to "maybe get whacked", but rather that they randomly offered to whack guys.

Linda

ponderingturtle

14th December 2006, 09:56 AM

I always enjoy reading criticisms that depend upon the assumption that the principle investigators were complete morons. :)

Well to be fair, people here deal enough with woo's and CTers that it is often a valid assumption.

ImaginalDisc

14th December 2006, 09:57 AM

Katana

14th December 2006, 10:01 AM

I always enjoy reading criticisms that depend upon the assumption that the principle investigators were complete morons. :)
It's actually a valid question.

It doesn't say that they signed up guys to "maybe get whacked", but rather that they randomly offered to whack guys.

Linda
No. They were assigned to one of two groups.

From SteveGrenard's link:
Both trials involved adult, HIV-negative heterosexual male volunteers assigned at random to either intervention (circumcision performed by trained medical professionals in a clinic setting) or no intervention (no circumcision). All participants were extensively counseled in HIV prevention and risk reduction techniques.

And ImaginalDisc raised a question I had, too. What effect did the minimum 4-6 weeks of healing time have on the sexually activity of the circumcision group?

Obviously, there is more to the story than either of these links provides. If I find more detail, I'll provide it.

casebro

14th December 2006, 10:11 AM

It doesn't say that they signed up guys to "maybe get whacked", but rather that they randomly offered to whack guys.

Linda

If they randomly offered, but the final decision was up to the individual subject, then there was effectively no randomness to the study. Therefore, bad science. Because those circumcised could have been more health concious, used better prevention, chose better partners, etc, ad whatever.,

fls

14th December 2006, 10:22 AM

fls

14th December 2006, 10:25 AM

It's actually a valid question.

That's exactly my point.

Originally Posted by fls
It doesn't say that they signed up guys to "maybe get whacked", but rather that they randomly offered to whack guys.

No. They were assigned to one of two groups.

How is that different from what I said?

Linda

Katana

14th December 2006, 10:28 AM

That's exactly my point.

How is that different from what I said?

Linda

You said that they were randomly offered, and that's not the case at all. These men agreed to be randomly assigned to one of two groups (circ or no-circ). Saying that they were randomly offered makes it sound like they could either take it or leave it, which certainly gets at casebro's concerns. It's just not how the study was conducted, though.

fls

14th December 2006, 10:32 AM

http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm

Katana

14th December 2006, 10:35 AM

http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm

Was this directed at someone in particular?

joobz

14th December 2006, 10:41 AM

http://www3.niaid.nih.gov/news/QA/AMC12_QA.htm
Both trials recruited healthy, HIV-negative uncircumcised men who planned to remain near the study site for the duration of the trial. The trial in Uganda recruited men between 15 and 49 years old; the trial in Kenya recruited men between 18 and 24 years old.
After an initial HIV screening and a medical exam, eligible men were randomly assigned either to receive circumcision immediately or to wait two years before circumcision. All participants were closely followed for two years to collect information about their health, sexual activity, and theirs and their partners’ attitudes about circumcision; to counsel participants in HIV prevention and safe sex practices; and to check the HIV status of the volunteer. Participants in the Kenyan study were scheduled for six visits over the two-year follow-up, compared with four visits for the Ugandan trial participants. In addition to the study visits, men enrolled in the Kenyan trial were encouraged to receive all of their outpatient health care at the study clinics, which enabled researchers to collect information on the safety of the procedure and the number of other sexually transmitted diseases the men had during follow-up.

emphasis mine. So it's not a selection by the individual. In fact all have elected to get circumcised. The difference was when the two groups received it.
Now vs. 2 years from now.

In the immortal words of T'ai Chi, "Interesting.":)

Katana

14th December 2006, 10:46 AM

emphasis mine. So it's not a selection by the individual. In fact all have elected to get circumcised. The difference was when the two groups received it.
Now vs. 2 years from now.

In the immortal words of T'ai Chi, "Interesting.":)

But for the purposes of the study (and the data analysis), there was a circ and a no-circ group by random assignment of each man. I'm not sure what you meant by "not a selection by the individual." The no-circ group may ultimately be circed, but they won't be followed for the study beyond that.

fls

14th December 2006, 10:57 AM

You said that they were randomly offered, and that's not the case at all. These men agreed to be randomly assigned to one of two groups (circ or no-circ).

It is not clear from the descriptions what the sequence of events was. But it does not state that all men agreed to have a circumcision and then were randomly assigned into one of two groups. Rather, it states that the study participants were randomly assigned to one of two groups - circumcision now or circumcision in two years. And assignment to the circumcision now group would necessarily (I hope :)) mean that circumcision was offered, not that circumcision was forced upon them. It may have been the other way around - that the men agreed to be randomly assigned to one of two groups after being offered circumcision - but my point is that it does not say that. So it seems reasonable to think that there is a good possibility that it happened exactly as described until more information is available.

Saying that they were randomly offered makes it sound like they could either take it or leave it, which certainly gets at casebro's concerns. It's just not how the study was conducted, though.

It sounds like you have more information. How was the study conducted?

Linda

joobz

14th December 2006, 10:57 AM

But for the purposes of the study (and the data analysis), there was a circ and a no-circ group by random assignment of each man. I'm not sure what you meant by "not a selection by the individual." The no-circ group may ultimately be circed, but they won't be followed for the study beyond that.
Oh that was just a comment to an earlier post who thought that after the random selection of people, the man got to elect to have it done or not. further, the control group wasn't a group of people who would rather not have a circumcision. They all elected for it, which kinda removes that potential error.

But that delay due to healing question is quite interesting. Also, what is the sensation for a adult male circumcised vs. a baby? Meaning after healing, Is there heighten sensitivity that may make sex less frequent or more frequent?

I didn't dig deep, but it looked like the were also tracking sexual frequency. I wonder if the results are adjusted for that?

Capsid

14th December 2006, 10:58 AM

I have a procedural question. Did the period comparing infection rates between circumsised men and the control take into account the fact that a man with a damaged penis is going to be less sexually active than otherwise until he's done healing? In a period as short as one year, I'd imagine several weeks (or more) of healing time would be a significant delay in the resumption of sexual activity.

EDIT: I have no idea where that smiley came from.
The men were advised not to partake in sexual activity after the procedure until the wound had healed (a few weeks). Otherwise they might be at increased risk of infection. So the study coordinators had factored in the period of non sexual activity after cricumcision anyway.

fls

14th December 2006, 11:00 AM

Was this directed at someone in particular?

Nope. I'm just posting any additional links that I find (in case anyone hadn't come across them). There's also a WHO statement, but I didn't really see any additional details in there.

Linda

Katana

14th December 2006, 11:04 AM

It is not clear from the descriptions what the sequence of events was. But it does not state that all men agreed to have a circumcision and then were randomly assigned into one of two groups. Rather, it states that the study participants were randomly assigned to one of two groups - circumcision now or circumcision in two years. And assignment to the circumcision now group would necessarily (I hope :)) mean that circumcision was offered, not that circumcision was forced upon them. It may have been the other way around - that the men agreed to be randomly assigned to one of two groups after being offered circumcision - but my point is that it does not say that. So it seems reasonable to think that there is a good possibility that it happened exactly as described until more information is available.

It sounds like you have more information. How was the study conducted?

Linda
Yes, I have acknowledged that more info is needed.

To do the data analysis, they created a circumcised and an uncircumcised group for the two-year period-not a "circumcision offered" and "no circumcision offered" group. I guess I thought that that much was pretty clear from what we had so far.

casebro

14th December 2006, 11:10 AM

Katana

14th December 2006, 11:21 AM

ImaginalDisc

14th December 2006, 11:22 AM

The men were advised not to partake in sexual activity after the procedure until the wound had healed (a few weeks). Otherwise they might be at increased risk of infection. So the study coordinators had factored in the period of non sexual activity after cricumcision anyway.

That doesn't address my concern. In fact, that emphasises it. The uncircumsised men were having sex at normal rates while the recently circumsised men weren't having any. Surely, you see the cause for concern?

joobz

14th December 2006, 11:23 AM

Lesseee, 48% might mean 13 cases in the low risk group, compared to 25 in the high risk group. Out of 5,000 total. With 4-6 weeks off for healing after the procedure. Plus or minus latent cases turning up.* Any statisticians here care to figure repeatibility?

Or, use relative risk instead of comparative risk: High risk group, 99% chance of not contacting the disease after one year, vs 99 1/2% chance of being healthy with a fresh circimcision, at a cost of 4-6 weeks of no nookie...

* I tried googling <latency hiv> but only found stuff about how the virus can be latent during treatment. I coudn't seem to find anything recent re: latency of diagnosis. Anybody got better syntax?
I think they still use the ELISA assay. Doing a search, I found
http://hivinsite.ucsf.edu/InSite?page=kb-02-02-01

which had this line
Using the early-generation tests, antibody could be detected in most individuals by 6 to 12 weeks after infection. Newer-generation assays, including the third-generation antigen sandwich assays, can detect antibody at about 3-4 weeks after infection.(2 (http://javascript<b></b>:openWindow('InSite-KB-ref.jsp?page=kb-02-02-01&rf=2','References'))) This window period before the detection of antibody can be shortened by several days using antigen tests, and by several more days using nucleic acid detection methods.(3 (http://javascript<b></b>:openWindow('InSite-KB-ref.jsp?page=kb-02-02-01&rf=3','References'))) Therefore, in most individuals, the window period may be only 2-3 weeks if an all-inclusive testing strategy is used.
emphasis mine. Seems that if they were using most accurate measures, they could be off by 2-3week window. that's not a huge time lag in the study, but compound that with 1 month of no-nookie and potential change in nookie frequency...

ETA: and I thought i was all slick by providing this....DARN YOU KATANA!!!!

Wavicle

14th December 2006, 11:51 AM

casebro

14th December 2006, 11:58 AM

Katana

14th December 2006, 12:03 PM

I think they still use the ELISA assay. Doing a search, I found
http://hivinsite.ucsf.edu/InSite?page=kb-02-02-01

which had this line

emphasis mine. Seems that if they were using most accurate measures, they could be off by 2-3week window. that's not a huge time lag in the study, but compound that with 1 month of no-nookie and potential change in nookie frequency...

ETA: and I thought i was all slick by providing this....DARN YOU KATANA!!!!

:D

Awww. You were very slick, joobz.

fls

14th December 2006, 02:01 PM

Yes, I have acknowledged that more info is needed.

To do the data analysis, they created a circumcised and an uncircumcised group for the two-year period-not a "circumcision offered" and "no circumcision offered" group. I guess I thought that that much was pretty clear from what we had so far.

I don't think that's a valid distinction. It is well-recognized that not everyone who is offered treatment actually takes the treatment, yet we don't normally refer to the "treatment offered group". We still call it the "treatment group" under most circumstances. And the analysis has to be by intention-to-treat or else you will introduce bias and run the risk of making your results invalid. I'm not sure why you think this situation would be different and why my suggestion has to be wrong.

Linda

ImaginalDisc

14th December 2006, 02:05 PM

I don't think that's a valid distinction. It is well-recognized that not everyone who is offered treatment actually takes the treatment, yet we don't normally refer to the "treatment offered group". We still call it the "treatment group" under most circumstances. And the analysis has to be by intention-to-treat or else you will introduce bias and run the risk of making your results invalid. I'm not sure why you think this situation would be different and why my suggestion has to be wrong.

Linda

Because there's no such thing as a circumcision placebo. That makes a control group even harder to establish than it is in say, trials of drugs.

fls

14th December 2006, 02:06 PM

If they randomly offered, but the final decision was up to the individual subject, then there was effectively no randomness to the study. Therefore, bad science. Because those circumcised could have been more health concious, used better prevention, chose better partners, etc, ad whatever.,

It's not bad science. It's the difference between effectiveness and efficacy. Many (most?) researchers would consider effectiveness studies better than efficacy studies - especially in this kind of situation where you are looking at public policy issues. Just like the real world, some people would accept circumcision if you offered it and some people wouldn't. Intention-to-treat analysis eliminates the concerns you raised about differences in other behaviours leading to a false positive.

Linda

fls

14th December 2006, 02:09 PM

Because there's no such thing as a circumcision placebo. That makes a control group even harder to establish than it is in say, trials of drugs.

?

I can't tell how that addresses the issue of whether they were randomized before or after they were offered circumcision.

Linda

fls

14th December 2006, 02:13 PM

So if 30 days is the best time for the test, then 1 of 12 positives could be latent cases? Or not, just probabilities. I think I would want more stats form this study before I make an appointment at the surgeon's.

I don't think the results of this study should be applied to men outside of the study population (except maybe in specific circumstances). I'm not hauling my sons off to the surgeon, either. :)

Linda

kellyb

14th December 2006, 04:37 PM

I think ending the study early was a bad idea. If it was 50% at two years, it makes sense that that numbers would go down year by year after that.
I would be very, very surprised if it was still a 50% reduction at 10 or 20 years.

So we might end up with a situation where circumcision prevents HIV by something like 10% at age 30 if performed before puberty...but the idea that "circumcision prevents AIDS by 50%!!!" will be a very good excuse to not use condoms.

http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html
Although no detailed results have been released at this time, the National Institutes of Health statement makes it clear that the studies are being stopped because they revealed an approximate halving of risk of HIV infection in men who were circumcised.

That just doesn't make sense to me. Since they're about to make a move to change policy, it seems like they'd want to follow the two groups for a while to see what the deal is. I'd want to see the two groups compared at different years...say, 5 years in sequence, to see if there's an 80% reduction at one year, 50% at 2, 40% at 3, etc. before spreading the idea that circumcision prevents HIV by 50%.

Merko

14th December 2006, 04:51 PM

ImaginalDisc

14th December 2006, 04:53 PM

?

I can't tell how that addresses the issue of whether they were randomized before or after they were offered circumcision.

Linda

Good experimental design involves randomization, which this study fails to do, and involves appropriate controls. Subjects were not circumsised randomly, and they were not compared to similarly sexually active men, as they were wating for their wee-wee's to heal.

fls

14th December 2006, 05:05 PM

Good experimental design involves randomization, which this study fails to do, and involves appropriate controls. Subjects were not circumsised randomly, and they were not compared to similarly sexually active men, as they were wating for their wee-wee's to heal.

It states that they were circumcised randomly. Why do you think they weren't? Why do you think the controls weren't appropriate? If it occurs to you that the post-operative period may alter the risk of exposure and infection, don't you think it would also occur to the investigators?

Linda

kellyb

14th December 2006, 05:06 PM

Good experimental design involves randomization, which this study fails to do, and involves appropriate controls. Subjects were not circumsised randomly, and they were not compared to similarly sexually active men, as they were wating for their wee-wee's to heal.

I don't think the healing period would have that much of an effect (we're talking about a couple of months of healing out of a two year period.). And this study was randomized, and uncircumcised controls who were simply postponing circumcision are about as good as you're going to get.

The study design wasn't inherently flawed.

kellyb

14th December 2006, 05:12 PM

ImaginalDisc

14th December 2006, 05:19 PM

It states that they were circumcised randomly. Why do you think they weren't? Why do you think the controls weren't appropriate? If it occurs to you that the post-operative period may alter the risk of exposure and infection, don't you think it would also occur to the investigators?

Linda

I will not assume anything about the experimental design that isn't in writing.

joobz

14th December 2006, 05:25 PM

All the links seem to be broken (or maybe it's just my bad connection). Anyone with a (working) link, or who would care to write a sentence about what the proposed theory that would explain this is?

The only thing I can think of is that bad hygiene might more easily cause sores on uncircumcised mens' penises, thereby increasing infection risk. Perhaps the same thing for people who already had other veneral diseases.
the hypothesis i read was that there were a higher population of tcells arround the tip of the uncicumcised penis(related to smegma, maybe?), increasing the linklyhood for viral transfection.
i can't vouch for any of this though.

sorry i don't have the link with me.

fls

14th December 2006, 05:26 PM

Does anybody know when the actual study is going to be published?

I wonder if they compared the two groups at one year...and if it was 50% at one year, and the same at 2, or if it was even higher at one year...

That's the problem with stopping early (well, one of the problems). We get little trickles of information before we get published data. How long was it before we started to see actual studies from the WHI on stroke, etc., after the progestin/estrogen arm was stopped?

Linda

Merko

14th December 2006, 05:26 PM

T Cells outside the body? And then they would somehow return inside again, carrying the infection? Hmmm.

kellyb

14th December 2006, 05:27 PM

I will not assume anything about the experimental design that isn't in writing.

It was right there in the NIAID link fls gave.

After an initial HIV screening and a medical exam, eligible men were randomly assigned either to receive circumcision immediately or to wait two years before circumcision.

fls

14th December 2006, 05:28 PM

I will not assume anything about the experimental design that isn't in writing.

Ah, so your use of definitive statements was a clever ruse. ;)

Linda

kellyb

14th December 2006, 05:34 PM

That's the problem with stopping early (well, one of the problems). We get little trickles of information before we get published data. How long was it before we started to see actual studies from the WHI on stroke, etc., after the progestin/estrogen arm was stopped?

Linda
Do you think it will be a few months before the study is released? How long does the peer review process usually take?

joobz

14th December 2006, 05:50 PM

T Cells outside the body? And then they would somehow return inside again, carrying the infection? Hmmm.
Didn't mean to imply the t-cells were outside the body, just at a higher concentration at the tip. I was only conjuecturing the smegma link.

now that I had a few more minutes, heres from the link fls posted.

There are several proposed mechanisms for how male circumcision might reduce a man’s risk of HIV infection. The foreskin’s inner mucosal surface is more susceptible to HIV because it has more immune cells vulnerable to HIV infection than the external surface. Furthermore, the foreskin acts as a physical barrier, trapping HIV next to the mucosal surface of the penis for a longer period of time. In this moist environment, the virus can also survive longer, potentially increasing the risk of infection. Small tears in the foreskin as a result of intercourse could also promote entry of the virus. After circumcision the penile shaft and glans develops more epithelial keratinization, a process which makes the penis less susceptible to viral invasion

fls

14th December 2006, 06:00 PM

Do you think it will be a few months before the study is released? How long does the peer review process usually take?

I'd say it depends upon whether it is necessary for the process to be expedited. Usually it would be more than just a few months. Any guess on my part would have to come straight from my a**. :)

Linda

Kaylee

14th December 2006, 06:03 PM

I think it would be interesting to compare the two groups to a third group comprised of men with similar sexual activity, practices and hygiene levels*, but who were circumcised when they were infants.

* However, unless I missed it, I don't think either articles addressed this.

DanishDynamite

14th December 2006, 06:50 PM

The result isn't implausable. It might very well be correct. I, for one, could certainly see many scenarious whereby it might be true.

My only question is: So what?

kellyb

14th December 2006, 07:13 PM

Well if it's true, then the WHO is going to recommend routine infant circumcision more likely than not. The AAP might very well change their recommendations, too.

I don't find 50% plausible at all. It's not that I find the study design flawed, but two years isn't long enough to really get an idea on how effective circumcision is as an HIV preventive.
I can see it having a small effect, but I'd bet money on the 50% figure going down over time. In an area with endemic HIV and unsafe sexual practices, I'd imagine that circumcision just delays the average age of infection.
By how long, I don't know. And it could be argued that delaying the age of infection would still have a great benefit in the "big picture", but considering the gravity of the situation, I'm personally hesitant to endorse this without all of the facts available.

I'm also curious about the Kenya study going on right now regarding circumcision and male to female transmission. Since circumcised penises are more likely to cause vaginal abrasions, I can see that increasing the rate of transmission to females.

DanishDynamite

14th December 2006, 07:19 PM

Well if it's true, then the WHO is going to recommend routine infant circumcision more likely than not.
In which case the WHO is beyond redemption.

While circumcision might cut the spreading of HIV in half, the use of condoms reduces it by 98%.

One method requires the mutilation of infant boys. The other, infinitely more effective method, just requires the use of a condom.

Raphael

14th December 2006, 07:24 PM

ahhh...from "No Glove, No Love!" to "No Skin, you Win!"

kellyb

14th December 2006, 07:45 PM

In which case the WHO is beyond redemption.

While circumcision might cut the spreading of HIV in half, the use of condoms reduces it by 98%.

One method requires the mutilation of infant boys. The other, infinitely more effective method, just requires the use of a condom.

http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html
It is anticipated that news of these results will heighten interest in male circumcision from governments, non-governmental institutions, and the general public in a number of countries, in addition to increasing demand for male circumcision services. WHO, the UNAIDS Secretariat and their partners will review the detailed trial findings and will then define specific policy recommendations for expanding and/or promoting male circumcision.

Looks like they're going to do it.

:(

Foster Zygote

14th December 2006, 07:46 PM

Seems that if they were using most accurate measures, they could be off by 2-3week window.

That's better than being off by 2-3 inches. *BADUMP BUMP*

DanishDynamite

14th December 2006, 07:51 PM

http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html

Looks like they're going to do it.

:(
I don't get the same impression as you appear to, from the link you provided.

Also, it would be political and scientific suicide for the WHO to actually recommend male circumcision.

kellyb

14th December 2006, 07:59 PM

I don't think so.
How do you read this?
WHO, the UNAIDS Secretariat and their partners will review the detailed trial findings and will then define specific policy recommendations for expanding and/or promoting male circumcision.

Because it's AIDS we're talking about, I can totally see them promoting it, at least in areas with endemic HIV.

Interesting side not, it looks like female circumcision prevents AIDS somehow, too...
http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138

DanishDynamite

14th December 2006, 08:07 PM

I don't think so.
How do you read this?

Because it's AIDS we're talking about, I can totally see them promoting it, at least in areas with endemic HIV.
I see it as it says.

They will not be promoting it.
Interesting side not, it looks like female circumcision prevents AIDS somehow, too...
http://www.ias-2005.org/planner/Abstracts.aspx?AID=3138
Hilarious!

kellyb

14th December 2006, 08:12 PM

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/12/14//AIDS.TMP&type=health
This is not a magic bullet but a potentially important intervention,'' said Dr. Kevin De Cock, director of HIV/AIDS programs for the World Health Organization.

He said the agency will meet early next year to consider how African nations can safely offer the procedure on a massive scale. Adult male circumcision can cost anywhere from $25 to $500 in Africa, and De Cock said it will be impossible for African countries to provide without substantial foreign assistance.

I really think they're going to be promoting it.

joobz

14th December 2006, 08:13 PM

The question is, if the hypothesis of the foreskin being a breeding pool is true...wouldn't washing after sex be an effective compromise?

kellyb

14th December 2006, 08:18 PM

The question is, if the hypothesis of the foreskin being a breeding pool is true...wouldn't washing after sex be an effective compromise?

That wouldn't address enough of the theory of how foreskins might increase HIV infections. They're wanting to do something quickly to stop the spread of AIDS. They're not going to have time to work out the nuts and bolts of how circumcision prevents it.

DanishDynamite

14th December 2006, 08:21 PM

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/12/14//AIDS.TMP&type=health

I really think they're going to be promoting it.
Never happen. Trust me.

joobz

14th December 2006, 08:23 PM

That wouldn't address enough of the theory of how foreskins might increase HIV infections. They're wanting to do something quickly to stop the spread of AIDS. They're not going to have time to work out the nuts and bolts of how circumcision prevents it.
Sure. but what is the flip side? (didn't check the report). Is there a difference between circ and uncirced ability transmit to a partner?

kellyb

14th December 2006, 08:36 PM

Never happen. Trust me.

I dunno...
http://www.who.int/bulletin/volumes/84/7/news10706/en/

The results of the Orange Farm study in South Africa have been widely publicised in the region and discussed by leaders, members of parliaments (MP), health workers, the press and general public. As a result, there are already indications of increasing demand for male circumcision in traditionally non-circumcising societies in southern Africa. At the University Teaching Hospital in Zambia, demand has grown from 1 to 15 a month with a three-month waiting list. Demand at one Swaziland hospital is reported to have risen from less than one per month to 40 a month. Marwick Khumalo, a Member of Parliament (MP) for Lobamba in Swaziland was quoted in the local press: “All male children should be circumcised. To show my seriousness, I have taken all my sons for circumcision.” Kenyan MP Jimmy Angwenui said: “In order to stop the spread of HIV/AIDS male circumcision should be made mandatory by the government.”

The current position of WHO is that safe circumcision should be provided where people want it but that a policy decision on whether to promote it should wait until the results of the Kenya and Uganda trials are available.

If the other trial doesn't show an increased rate of transmission in circumcised males, the WHO will be advocating circumcision.

Sure. but what is the flip side? (didn't check the report). Is there a difference between circ and uncirced ability transmit to a partner?

That's being studied right now, and I think the results will be in in a few months.

articulett

14th December 2006, 09:45 PM

They said that the virus seems to find the foreskin environment a better "medium" for propagation.

I thought it was odd how they trumpeted it...We know that condoms really reduce aids--we know that handing them out and teaching people to use them, not only prevents aids...but also pregnancies--so why isn't that trumpeted? Oh that's right--Catholic and other Christian ministries (as mentioned in Randi's commentary.) As for the studies--were circumcised men likely to engage in less sex during the study period--you know, to allow time for healing and for the funny purple head to blend in with the rest of the skin?

Jorghnassen

14th December 2006, 09:55 PM

I don't think the healing period would have that much of an effect (we're talking about a couple of months of healing out of a two year period.).

We're talking about a couple of months over a one year period as the study was ended early. This would lead me to at least put some time dependence on covariates relating to sexual activity.

/otherwise people would have you believe winning an Oscar prolongs your life by 4 years...

pipelineaudio

14th December 2006, 11:58 PM

one more victim in the silent graveyard of non PC science findings

Katana

15th December 2006, 05:25 AM

I don't think the healing period would have that much of an effect (we're talking about a couple of months of healing out of a two year period.). And this study was randomized, and uncircumcised controls who were simply postponing circumcision are about as good as you're going to get.

The study design wasn't inherently flawed.

My thoughts exactly, although I might be a bit more concerned about the potential impact of the healing period. As Jorghnassen pointed out, some of the subjects (admittedly we don't know how many) were only enrolled as recently as September, 2005. A month or two out of commission may have had an impact, especially since they ended the study early. Again, without knowing how many were enrolled and circed when, hard to say, but it's something that I hope (and would expect) them to address in the published study.

Well if it's true, then the WHO is going to recommend routine infant circumcision more likely than not. The AAP might very well change their recommendations, too.

I don't find 50% plausible at all. It's not that I find the study design flawed, but two years isn't long enough to really get an idea on how effective circumcision is as an HIV preventive.
I can see it having a small effect, but I'd bet money on the 50% figure going down over time. In an area with endemic HIV and unsafe sexual practices, I'd imagine that circumcision just delays the average age of infection.
By how long, I don't know. And it could be argued that delaying the age of infection would still have a great benefit in the "big picture", but considering the gravity of the situation, I'm personally hesitant to endorse this without all of the facts available.

I'm also curious about the Kenya study going on right now regarding circumcision and male to female transmission. Since circumcised penises are more likely to cause vaginal abrasions, I can see that increasing the rate of transmission to females.

I have to agree also with your concerns about the duration of the study. They should have kept going.

That's interesting point about the male to female tramsission. Many studies have shown a decreased risk of male to female transmission of HPV with circumcision, so I would have thought that HIV would be similar. Then again, they are very different viruses. I just tried a search on the subject, but what I found were female-to-male transmission studies. If anyone finds something on male-to-female HIV transmission relative to circumcision status, could you share?

fls

15th December 2006, 05:38 AM

Also, it would be political and scientific suicide for the WHO to actually recommend male circumcision.

Can you elaborate on your reasoning?

Linda

fls

15th December 2006, 06:16 AM

That's interesting point about the male to female tramsission. Many studies have shown a decreased risk of male to female transmission of HPV with circumcision, so I would have thought that HIV would be similar. Then again, they are very different viruses. I just tried a search on the subject, but what I found were female-to-male transmission studies. If anyone finds something on male-to-female HIV transmission relative to circumcision status, could you share?

This is information gathered in conjuction with the studies referenced in the OP.

http://www.hopkinsmedicine.org/Press_releases/2006/02_08_06.html
http://www.retroconference.org/2006/Abstracts/25977.HTM

If anyone is interested, this is the clinical trial registration for the study (http://www.clinicaltrials.gov/ct/show/NCT00124878?order=1) above and for the Kenya study (http://www.clinicaltrials.gov/ct/show/NCT00059371?order=1) (I think).

Linda

Katana

15th December 2006, 06:33 AM

This is information gathered in conjuction with the studies referenced in the OP.

http://www.hopkinsmedicine.org/Press_releases/2006/02_08_06.html
http://www.retroconference.org/2006/Abstracts/25977.HTM

Linda

Thank you for the links, fls. Missed those.

The first one is interesting, but I didn't understand the math. They described a study of "more than 300 couples" but went on to say that 299 women contracted HIV from uncircumcised partners while 44 did from circumcised partners. It leaves me wondering just how many there were in each group.

The second one showed a reduction in risk but not a statistically significant one. It also sounds like the researchers ascertained the HIV status of the men by self report alone ("Men were interviewed to ascertain circumcision status."). That's somewhat problematic and a bit of a disappointment.

Darat

15th December 2006, 06:33 AM

Not addressing the science part of it but forget any hope of changing attitudes regarding female "circumcision" in African countries if the WHO starts to promote male circumcision. :(

fls

15th December 2006, 06:53 AM

Thank you for the links, fls. Missed those.

The first one is interesting, but I didn't understand the math. They described a study of "more than 300 couples" but went on to say that 299 women contracted HIV from uncircumcised partners while 44 did from circumcised partners. It leaves me wondering just how many there were in each group.

The second one showed a reduction in risk but not a statistically significant one. It also sounds like the researchers ascertained the HIV status of the men by self report alone ("Men were interviewed to ascertain circumcision status."). That's somewhat problematic and a bit of a disappointment.

I think they both refer to the same information - the first is a press release about an abstract that was going to be presented at a meeting, and the second is the actual abstract that was presented at the meeting. I included both links because the press release included additional information. The description of the study is a bit confusing. Even in press releases put out by the institution (where you'd think the authors of the study have some influence over how the information is presented) it seems that sometimes the details get lost in translation.

The HIV status was ascertained through serology (from the description of the trial). Did you mean ascertaining circumcision status through interview was problematic?

I think that the report represents "interesting information" rather than evidence of anything.

Linda

ponderingturtle

15th December 2006, 08:15 AM

The question is, if the hypothesis of the foreskin being a breeding pool is true...wouldn't washing after sex be an effective compromise?

The hypothesis I had heard was that there where cells in the foreskin that take the virus into the body dirrectly, and really what kind of breeding pool could there be? This is a virus and that needs to infect cells to breed, not a bacteria that likes a moist warm enviroment.

joobz

15th December 2006, 08:37 AM

The hypothesis I had heard was that there where cells in the foreskin that take the virus into the body dirrectly, and really what kind of breeding pool could there be? This is a virus and that needs to infect cells to breed, not a bacteria that likes a moist warm enviroment.
I thought it wasn't the foreskin cells but that the circumcised penis tip is keratinized, making it a tougher barrier to break through. So, not only does the circ remove the foreskin area(which has it's own mucous membrane that is suseptible to infection) but the tip as well.

As to "breeding ground" that was a poor choice of words. The moist environment is supposedly capable of sustaining the virus for longer times outside the body.

Although, can HIV propogate like normal viruses or must it function as a retrovirus. The question being, if there are tcells in the smegma, could they breed more viruses or is there not enough time (assuming hours to a day) for that to be a considerable source?

Jorghnassen

15th December 2006, 09:07 AM

one more victim in the silent graveyard of non PC science findings

Well, first it's not in the graveyard yet, and certainly not silent. Though maybe next time they can carry out the full study as planned instead of shutting it down when the interim results appeared positive, and wait to get the results published in a peer-reviewed journal before doing "science by press conference". Those findings would be much less controversial if their authors had followed a rigorous protocol.

Katana

15th December 2006, 09:19 AM

I think they both refer to the same information - the first is a press release about an abstract that was going to be presented at a meeting, and the second is the actual abstract that was presented at the meeting. I included both links because the press release included additional information. The description of the study is a bit confusing. Even in press releases put out by the institution (where you'd think the authors of the study have some influence over how the information is presented) it seems that sometimes the details get lost in translation.

The HIV status was ascertained through serology (from the description of the trial). Did you mean ascertaining circumcision status through interview was problematic?

I think that the report represents "interesting information" rather than evidence of anything.

Linda

{smacking my own forehead}

Sorry, Linda. I hadn't had my coffee yet. I just plain misread the very line I quoted. Ugh. Yes, I suppose that interviewing would be sufficient when ascertaining circumcision status.

Agreed. It's interesting if nothing else (unlike my observations). :blush:

ponderingturtle

15th December 2006, 09:30 AM

I thought it wasn't the foreskin cells but that the circumcised penis tip is keratinized, making it a tougher barrier to break through. So, not only does the circ remove the foreskin area(which has it's own mucous membrane that is suseptible to infection) but the tip as well.

That was not the mechanism that I had heard. The information there was that there was not alot of really good understaning the exact mechanism of infection in say vaginal intercourse in either dirrection.

Ah from here Link (http://www.circumstitions.com/Langerhans.html)
A keratinised, stratified squamous epithelium covers the penile shaft and outer surface of the foreskin. This provides a protective barrier against HIV infection. In contrast, the inner mucosal surface of the foreskin is not keratinised15 and is rich in Langerhans' cells,10 making it particularly susceptible to the virus. This is particularly important because during heterosexual intercourse the foreskin is pulled back down the shaft of the penis, and the whole inner surface of the foreskin is exposed to vaginal secretions, providing a large area where HIV transmission could take place.

Would seem to indicate that the idea that it is the unkeratinised portion of the foreskin not the glans that is the issue

As to "breeding ground" that was a poor choice of words. The moist environment is supposedly capable of sustaining the virus for longer times outside the body.

Although, can HIV propogate like normal viruses or must it function as a retrovirus. The question being, if there are tcells in the smegma, could they breed more viruses or is there not enough time (assuming hours to a day) for that to be a considerable source?

I do not know.

fls

15th December 2006, 09:52 AM

Well, first it's not in the graveyard yet, and certainly not silent. Though maybe next time they can carry out the full study as planned instead of shutting it down when the interim results appeared positive, and wait to get the results published in a peer-reviewed journal before doing "science by press conference". Those findings would be much less controversial if their authors had followed a rigorous protocol.

That's not really a fair assessment. It's always a fine ethical line in a controlled trial to have a group that you have not offered treatment to, especially when you have good reason to think the treatment is effective. Interim reviews are necessary in these kinds of studies, because no matter how much we want to have complete information, it is unethical to continue to purposely withhold the offer of treatment once you have strong evidence that it is effective. And if you shut down a major study early, you really are obliged to issue a press release telling why. I agree that it makes the process messier, but if the trade-off is between preventing a deadly disease and a nice tidy study with rigid adherence to a protocol, I'm glad that the choice is preventing a deadly disease.

Linda

Jorghnassen

15th December 2006, 10:37 AM

That's not really a fair assessment. It's always a fine ethical line in a controlled trial to have a group that you have not offered treatment to, especially when you have good reason to think the treatment is effective. Interim reviews are necessary in these kinds of studies, because no matter how much we want to have complete information, it is unethical to continue to purposely withhold the offer of treatment once you have strong evidence that it is effective. And if you shut down a major study early, you really are obliged to issue a press release telling why. I agree that it makes the process messier, but if the trade-off is between preventing a deadly disease and a nice tidy study with rigid adherence to a protocol, I'm glad that the choice is preventing a deadly disease.

Linda

Except in this case there already is a much more effective treatment, and that the subjects are healthy to begin with... In this case, given that the treatment does not prevent the disease (especially compared to an already existing treatment), and delays risky behaviour (effectively inducing something akin to treatment selection bias), I think it's unethical to call the treatment effective before the data goes under peer-review.

ponderingturtle

15th December 2006, 10:41 AM

Except in this case there already is a much more effective treatment, and that the subjects are healthy to begin with... In this case, given that the treatment does not prevent the disease (especially compared to an already existing treatment), and delays risky behaviour (effectively inducing something akin to treatment selection bias), I think it's unethical to call the treatment effective before the data goes under peer-review.

That depends on how accessable the alternatives are. This really does look like useing medicine to control the behavior of others. How about the old "if they where monogamous then it wouldn't be any issue at all" arguement about how to control STD's?

fls

15th December 2006, 10:51 AM

Except in this case there already is a much more effective treatment, and that the subjects are healthy to begin with... In this case, given that the treatment does not prevent the disease (especially compared to an already existing treatment), and delays risky behaviour (effectively inducing something akin to treatment selection bias), I think it's unethical to call the treatment effective before the data goes under peer-review.

What "effective treatment" are you referring to?

Linda

joobz

15th December 2006, 10:56 AM

That was not the mechanism that I had heard. The information there was that there was not alot of really good understaning the exact mechanism of infection in say vaginal intercourse in either dirrection.

Ah from here Link (http://www.circumstitions.com/Langerhans.html)

Would seem to indicate that the idea that it is the unkeratinised portion of the foreskin not the glans that is the issue

How does this contridict my statement?

...So, not only does the circ remove the foreskin area(which has it's own mucous membrane that is suseptible to infection) but the tip as well.
The glans in the uncirced is also an exposed mucous membranes that is susceptible to infection.

kellyb

15th December 2006, 11:01 AM

That depends on how accessable the alternatives are. This really does look like useing medicine to control the behavior of others. How about the old "if they where monogamous then it wouldn't be any issue at all" arguement about how to control STD's?

If we're talking about condom use, then I guess it is slightly similar, but there's just no other way. Convincing people to use condoms is the only way to really put a dent in HIV transmission. Even if circumcision does actually reduce the risk by 50% (which is really a rather extraordinary claim, in my opinion) in another couple of years, that 50% reduction will probably have many new people in the "treatment group" who have become infected, which will easily re-establish the one-for-one transmission ratio needed for a disease to remain endemic.

Now couple that with the "belief" that "circumcision prevents HIV"...and couple that with the human nature to want to find clever excuses to not use condoms in the heat of the moment, and we might have a bigger problem than we started out with.

Jorghnassen

15th December 2006, 11:05 AM

fls

15th December 2006, 11:09 AM

I think it's unethical to call the treatment effective before the data goes under peer-review.

The Declaration of Helsinski, Basic Principles for all Medical Research states that "Physicians should cease any investigation if the risks are found to outweigh the potential benefits or if there is conclusive proof of positive and beneficial results." The purpose of the independent review committee is to determine whether that standard has been reached. I realize that you are not obliged to agree with this standard as a matter of general opinion.

Linda

fls

15th December 2006, 11:12 AM

kellyb

15th December 2006, 11:16 AM

The thing here is that the treatment does not prevent the disease. If it turns out its apparent effectiveness is nothing but a statistical artefact caused by shoddy analysis (suppose, for example, that this reduced transmission of HIV was only a short term effect that disappears within a few months), misrepresenting circumcision as an effective treatment could have very negative consequences.

It's also worth noting that all of the participants recieved behavioral counseling throughout the study regarding things like condom use.
Would it be too far fetched to wonder if maybe the ones in the circ group were more likely to take that advice and use condoms during that time? Either because of the "newness" of their "new gear" making them more inclined to temporarily being open to consistently using condoms as part of the "new experience"...or maybe the discomfort of the healing period motivating them to have not gone through all that for nothing?

fls

15th December 2006, 11:19 AM

The thing here is that the treatment does not prevent the disease.

The peer-reviewed studies that have been done on this issue already (observational, case-control, RCT) consistently show a decreased risk of acquiring HIV long-term. That is what is referred to as disease prevention.

Linda

fls

15th December 2006, 11:24 AM

Now couple that with the "belief" that "circumcision prevents HIV"...and couple that with the human nature to want to find clever excuses to not use condoms in the heat of the moment, and we might have a bigger problem than we started out with.

It's also worth noting that all of the participants recieved behavioral counseling throughout the study regarding things like condom use.
Would it be too far fetched to wonder if maybe the ones in the circ group were more likely to take that advice and use condoms during that time? Either because of the "newness" of their "new gear" making them more inclined to temporarily being open to consistently using condoms as part of the "new experience"...or maybe the discomfort of the healing period motivating them to have not gone through all that for nothing?

Both of your points are valid issues to take into consideration. But I do find it kinda cute that first you come up with reasons why circumcised men will be less likely to use condoms and then reasons why circumcised men will be more likely to use condoms, depending upon what point you want to argue. :)

Linda

kellyb

15th December 2006, 11:28 AM

I guess what I don't understand is why you assume the people running this study are too stupid to figure this out themselves?

Linda

Sometimes bias can mimic stupidity. Let's take this guy, who was the head researcher in some of the previous studies that set the stage for these recent RTCs.

“Private practitioners also do it,” Dr. Halperin said. “In some places, it’s $20, in others, much more. Lots of the wealthy elite have already done it. It prevents STD’s, it’s seen as cleaner, sex is better, women like it. I predict that a lot of men who can’t afford private clinics will start clamoring for it.”

"Cleaner"..."women like it"...real scientific, huh?

http://www.nytimes.com/2006/12/13/he...rtner=homepage

I'm not saying this is what's necessarily going on with these NIAID studies, but it is something to keep in mind. Americans have historically been a little circumcision-happy, and used imperfect science to rationalise it in a medical way.
There were the really outlandish claims from a long time ago like "circumcision cures epilepsy" which...who knows where that came from...to the more recent ones like "circumcision prevents UTIs" where they forgot to factor in preemies who were inclined to UTI's simply be virtue of being premature, and also were too small and weak to be circumcised.

Katana

15th December 2006, 11:29 AM

It's also worth noting that all of the participants recieved behavioral counseling throughout the study regarding things like condom use.
Would it be too far fetched to wonder if maybe the ones in the circ group were more likely to take that advice and use condoms during that time? Either because of the "newness" of their "new gear" making them more inclined to temporarily being open to consistently using condoms as part of the "new experience"...or maybe the discomfort of the healing period motivating them to have not gone through all that for nothing?
Not to sound like I'm just going along with kellyb, but I had wondered the same.
Both of your points are valid issues to take into consideration. But I do find it kinda cute that first you come up with reasons why circumcised men will be less likely to use condoms and then reasons why circumcised men will be more likely to use condoms, depending upon what point you want to argue. :)

Linda

Or she is just being the good skeptic that she is!

;)

kellyb

15th December 2006, 11:35 AM

Both of your points are valid issues to take into consideration. But I do find it kinda cute that first you come up with reasons why circumcised men will be less likely to use condoms and then reasons why circumcised men will be more likely to use condoms, depending upon what point you want to argue. :)

Linda

Well I really hate circumcision. :p I do. I'm not unwilling to accept that it might actually have phenomenal medical benefits after all, but I do have a "leave no stone unturned" philosophy with this.
And considering the fact that the WHO seems to be preparing to recommend this on a large scale, I'm cautious. I'm afraid they're going to recommend something in haste out of a "do something quick!" mentality.

Jorghnassen

15th December 2006, 11:38 AM

The Declaration of Helsinski, Basic Principles for all Medical Research states that "Physicians should cease any investigation if the risks are found to outweigh the potential benefits or if there is conclusive proof of positive and beneficial results." The purpose of the independent review committee is to determine whether that standard has been reached. I realize that you are not obliged to agree with this standard as a matter of general opinion.

Linda

Because this is the kind of study were "conclusive proof of beneficial results" isn't easily obtained, because time-to-event data is inherently tricky to analyse and prone to bias. As I mentioned before, if you don't include some time dependence in the covariates (including all relevant ones), you may see a treatment effect that isn't there at all (e.g. winning an Oscar adding 4 years to one's life).

Kaylee

15th December 2006, 11:38 AM

I guess what I don't understand is why you assume the people running this study are too stupid to figure this out themselves?

You've asked this question several times, why? :confused:

It seems out of place to ask it in a skeptical forum. Also, as Jorghannessan already mentioned, "science by press conference" vs. getting the results published in a peer reviewed journal is not the best way to present findings.

Every field has had faulty studies. It's up to the researchers to prove that they didn't produce another faulty one, and its not incumbent for other researchers or the general public to trust that everything is just fine. I don't recall trust as being part of the scientific methodology.

Ben Tilly

15th December 2006, 11:41 AM

Merko

15th December 2006, 11:44 AM

I don't think advocating male circumcision of infants would be motivated by this study. But advocating voluntary circumcision of adolescents may be.

bpesta22

15th December 2006, 11:45 AM

In the name of science, I have just circumsized myself. I'm gonna log how long it takes for me to get back in the mood, and I will also log everytime it moves til then.

Perhaps whatever meds one takes after having his wanker lanced-- to prevent infection-- might also have impacted the results.

That said, from what I read above, the study seems well designed.

kellyb

15th December 2006, 11:50 AM

I don't think advocating male circumcision of infants would be motivated by this study. But advocating voluntary circumcision of adolescents may be.

I could be wrong, but I think circumcising infants might be more cost-effective compared to circumcision later.
I can't imagine the circumcision of adolescents becoming widespread without routine infant circumcision following close behind.
But I could very well be wrong, though, and I definitely hope I am.

ponderingturtle

15th December 2006, 11:53 AM

If we're talking about condom use, then I guess it is slightly similar, but there's just no other way. Convincing people to use condoms is the only way to really put a dent in HIV transmission. Even if circumcision does actually reduce the risk by 50% (which is really a rather extraordinary claim, in my opinion) in another couple of years, that 50% reduction will probably have many new people in the "treatment group" who have become infected, which will easily re-establish the one-for-one transmission ratio needed for a disease to remain endemic.

Now couple that with the "belief" that "circumcision prevents HIV"...and couple that with the human nature to want to find clever excuses to not use condoms in the heat of the moment, and we might have a bigger problem than we started out with.

The point is that if it cuts infection at one stage by any serious percentage, it will reduce the rate it infects everyone. Similar to herd immunity with the antivax kids.

Also why would this not improve the effectiveness of condom use? It would seem to make it less likely to have infection in the case of condom failure. And it is an option for areas where high grade condoms are not as available.

Katana

15th December 2006, 11:54 AM

ponderingturtle

15th December 2006, 11:54 AM

How does this contridict my statement?

The glans in the uncirced is also an exposed mucous membranes that is susceptible to infection.

The point being it is not the keritinsisation that leads to the protection but the removal of the unkeritinized foreskin. Which has a high concentration of the cells believed to bring HIV into the body.

fls

15th December 2006, 11:57 AM

Sometimes bias can mimic stupidity. Let's take this guy, who was the head researcher in some of the previous studies that set the stage for these recent RTCs.

"Cleaner"..."women like it"...real scientific, huh?

http://www.nytimes.com/2006/12/13/he...rtner=homepage

They do attitude surveys in conjunction with these studies. It is possible that these statements were based on data. :)

I'm not saying this is what's necessarily going on with these NIAID studies, but it is something to keep in mind. Americans have historically been a little circumcision-happy, and used imperfect science to rationalise in in a medical way.
There were the really outlandish claims from a long time ago like "circumcision cures epilepsy" which...who knows where that came from...to the more recent ones like "circumcision prevents UTIs" where they forgot to factor in preemies who were inclined to UTI's simply be virtue of being premature, and also were too small and weak to be circumcised.

Most of the researchers are non-Americans. ;)

Linda

Merko

15th December 2006, 11:57 AM

I could be wrong, but I think circumcising infants might be more cost-effective compared to circumcision later.
I can't imagine the circumcision of adolescents becoming widespread without routine infant circumcision following close behind.
But I could very well be wrong, though, and I definitely hope I am.

I don't care if it's cost-effective, it's just plain wrong. If people want to do stuff to their own bodies, that's fine. Doing it to helpless children, no way. Especially not for a 50% reduction to contract a disease that you can easily protect yourself from, with a much higher certainty.

Besides, the fact that they found so many volunteers suggests to me that adult circumcision can hardly be such an uncommon prodedure. Well, maybe they got paid. Still, I'm not sure even in those poor countries, people would readily part with it unless it was already a common tradition.

Merko

15th December 2006, 12:01 PM

They do attitude surveys in conjunction with these studies. It is possible that these statements were based on data. :)

Women must be having a very hard time in those areas anyway, if the men aren't even able to keep their dicks clean unless they are circumcised. Well, presumably they would still be as unable, but the dirt would have a greater tendency to just fall off by itself..

fls

15th December 2006, 12:01 PM

Not to sound like I'm just going along with kellyb, but I had wondered the same.

It's good to wonder. I just don't think it's necessary to go from "I wonder" to "I know".

Or she is just being the good skeptic that she is!

;)

Yeah, if everyone was jumping on the bandwagon, I'd be pointing out that the results must be interpreted with caution and don't apply to North America. :)

Linda

Jorghnassen

15th December 2006, 12:04 PM

The peer-reviewed studies that have been done on this issue already (observational, case-control, RCT) consistently show a decreased risk of acquiring HIV long-term. That is what is referred to as disease prevention.

Linda

Suppose this reduced risk is not as strong as the interim results would have you believe. Now consider a large population who instead of being given the full "education +circumcision with follow up" treatment of the study only receives circumcision. I wouldn't be surprised that the general population is also less likely to follow the guidelines with regards to safe sex (compared to the subjects of the study) and more likely to only consider the "circ prevents HIV" part of the message (because that part is easy to follow, once you're chopped, it's for life, it's not one of those pesky things you need to repeat over and over again, like buying and using condoms), possibly inciting more risky behaviour. Do you now understand why I prefer rigorous science over hasty "prevention"?

fls

15th December 2006, 12:06 PM

Because this is the kind of study were "conclusive proof of beneficial results" isn't easily obtained, because time-to-event data is inherently tricky to analyse and prone to bias. As I mentioned before, if you don't include some time dependence in the covariates (including all relevant ones), you may see a treatment effect that isn't there at all (e.g. winning an Oscar adding 4 years to one's life).

The medical researchers that I know are aware of this.

Linda

kellyb

15th December 2006, 12:07 PM

The point is that if it cuts infection at one stage by any serious percentage, it will reduce the rate it infects everyone. Similar to herd immunity with the antivax kids.

You're right. It could. Even if the lifetimes risk reduction is only 5 or 10%, you could say that 5 or 10% is better than 0%.
And according to the WHO article I linked to earlier, it looks like some governments might be considering making it mandatory. If they're talking about making it mandatory for infants, though, (or even routine for infants) I would just suggest adding the condition meatal stenosis (http://www.emedicine.com/ped/topic2356.htm) into the risk/benefit equation.

Also why would this not improve the effectiveness of condom use? It would seem to make it less likely to have infection in the case of condom failure. And it is an option for areas where high grade condoms are not as available

The reason why it would negatively affect condom use is because vague notions of circumcision preventing HIV by 50% would be an excellent excuse to not use condoms. Humans all over the whole world want to find reasons to not have to use condoms when push comes to shove. Any excuse seems like a good one when hormones are rushing through your brain. And "circumcision prevents AIDS by 50%!" is a really, really good excuse.

bpesta22

15th December 2006, 12:10 PM

So how's it hangin'?

Hey, I've got a tip for you....

:boxedin:

kellyb

15th December 2006, 12:19 PM

They do attitude surveys in conjunction with these studies. It is possible that these statements were based on data.

"Sex is better" and "women like it" based on data?
I'd be very curious to see what country that data is coming out of. American women seem to prefer circumcised, but I haven't found the same to be true in Europe. People like what they're familiar with.

ponderingturtle

15th December 2006, 12:20 PM

kellyb

15th December 2006, 12:30 PM

Yeah, if everyone was jumping on the bandwagon, I'd be pointing out that the results must be interpreted with caution and don't apply to North America

Actually, the "doesn't apply to North America" reason given by the NIAID was based off a 1992 survey showing that 77% of men were circumcised. But the rate now is much much lower, among babies, at least.
It was only a few years ago that the AAP decided circumcision had no medical benefit, and made the recommendation for it only to be done as a cultural or cosmetic procedure.
I think it could very easily be argued (and will, no doubt, be argued) that this new information does, in fact, apply to North America.

fls

15th December 2006, 12:31 PM

You've asked this question several times, why? :confused:

People here have brought up some of the issues that would have to be taken into consideration when designing, executing and analyzing the study. Since the people that designed, executed and analyzed the study are likely (and in this case I happen to have first-hand knowledge) to be experienced and knowledgable, it seems reasonable to expect that stuff that is obvious to us will also be obvious to them. And will be dealt with.

If you want to assume that these issues have not been dealt with, then it seems that you would have to assume that the researchers are not experienced or knowledgable (which I substitued with "stupid" to give it that extra kick).

It seems out of place to ask it in a skeptical forum. Also, as Jorghannessan already mentioned, "science by press conference" vs. getting the results published in a peer reviewed journal is not the best way to present findings.

The researchers were obliged to stop the study early and announced the reasons via press release. There have already been results published from this study (not on this issue), so the assumption should be that these results will also be published in a peer-reviewed journal. I don't think the researchers themselves expect the press release to be the last word.

Every field has had faulty studies. It's up to the researchers to prove that they didn't produce another faulty one, and its not incumbent for other researchers or the general public to trust that everything is just fine. I don't recall trust as being part of the scientific methodology.

I agree. I just think we should wait until we actually have the results before we decide whether or not the results are invalid.

Linda

ynot

15th December 2006, 12:31 PM

Jorghnassen

15th December 2006, 12:34 PM

And we understand that you would rather die, than be saved by ending any study early.

Appeal to emotion. Miraculous breakthroughs are hard to come by in general, but uncritical and hasty inference can lead to widespread damage.

fls

15th December 2006, 12:35 PM

"Sex is better" and "women like it" based on data?
I'd be very curious to see what country that data is coming out of. American women seem to prefer circumcised, but I haven't found the same to be true in Europe. People like what they're familiar with.

I was thinking Africa.

Linda

kellyb

15th December 2006, 12:35 PM

I agree. I just think we should wait until we actually have the results before we decide whether or not the results are invalid.

I don't think anyone is necessarily saying the study is definitely invalid.
We're just....troubleshooting... what we're going to be looking out for when the study is made available. :)

ponderingturtle

15th December 2006, 12:39 PM

Removing eyelids might reduce the incidence of conjunctivitis.
Removing lips might reduce the incidence of Mononucleosis.
Removing teeth might reduce the incidence of toothache.
Removing toes might reduce the incidence of athletes foot.
Removing tongues might reduce the incidence of people talking crap.
Removing brains might reduce the incidence of__________________

OK but most of those have very definite downsides, the downsides to circumcision seem to be highly subjective and from what I have looked at pretty moderate.

If it was a quick easy procedure to remove the appendix would you object to having it done in children, because the appendix is natural and it is likely most of them will never have a problem with it?

This seems to be strongly related to the Natural=Good fallacy, now maybe it is bad, but when I have looked into questions asking how satisfied adults who where circumcised(often for medical reasons) most thought it was an improvement.(around 60%)

So unless you can provide definite harm as experienced by those who have direct experience with both, why shouldn't I follow what seems to be the accepted medical wisdom that there is no strong reason to choose either way, each has certain minor problems/risks and benefits with it.

ponderingturtle

15th December 2006, 12:44 PM

Appeal to emotion. Miraculous breakthroughs are hard to come by in general, but uncritical and hasty inference can lead to widespread damage.

Yes, but then again I was thinking of it either way. How do you know it really is dangerous if you end the study just because the preliminary data suggests it is dangerous?

If you support ending studies because people are dieing, why not end studies because people are dieing by not getting the treatment?

Yes the first might be more common than the latter, but they rational behind both is the same, you can show that one group is in much more risk than the other, and prolonging the study will just lead to a certain number of complications on one side that is not acceptable.

So you seem to be a Damn the Consequences finish the study, no matter which side has the complications on, kind of guy.

joobz

15th December 2006, 12:52 PM

Removing eyelids might reduce the incidence of conjunctivitis.
Removing lips might reduce the incidence of Mononucleosis.
Removing teeth might reduce the incidence of toothache.
Removing toes might reduce the incidence of athletes foot.
Removing tongues might reduce the incidence of people talking crap.
Removing brains might reduce the incidence of__________________

Every medical treatment has a cost/benefit ratio to it.
That's why appendectomies are only performed when someone has appendicitis. If the incidince of appendicitis were large enough in the general population, it would most likely become a preventitive treatment. But as it stands, it only is performed as an intervention becuase the risk of surgery for a healthy individual outweighs the propability of needing an appendix removed.

Circumcisions performed for no real reason or medical benefit is stupid. There is no benefit. however, if we can stop the spead of a disease through a 1 time elective procedure, I see no reason to not recommend it.

fls

15th December 2006, 01:07 PM

I don't think anyone is necessarily saying the study is definitely invalid.
We're just....troubleshooting... what we're going to be looking out for when the study is made available. :)

Yeah, I just wanted to be clear that I wasn't complaining about the idea of picking these things apart.

Linda

kellyb

15th December 2006, 01:10 PM

I was thinking Africa.

Linda

You're right. I found some references to the acceptability studies.

http://www.psi.org/resources/pubs/male-circ.pdf

Despite the absence of traditional circumcision, an acceptability study conducted in 1998 showed that the Luo community has positive views about MC. More than 75 percent of Luo men and women equated MC
with greater cleanliness and reduced risk of STDs. More than 50 percent believed that circumcised men enjoy sex more and give greater sexual pleasure to their partners. Approximately 60 percent of Luo men
and women said they would prefer to be circumcised or to have a circumcised partner. Seventy-four percent of men and 88 percent of women said they would circumcise their son if affordable and safe services were available.

Although many people thought that circumcision would not be acceptable among a non-practicing group such as the Luo, the opposite proved true. By giving people clear information, they were able to make their own choice. The intervention was done on a very small budget (less than US $15,000), financed initially by the Belgium Government.

...not sure what to make of that...:confused:

fls

15th December 2006, 01:11 PM

Suppose this reduced risk is not as strong as the interim results would have you believe. Now consider a large population who instead of being given the full "education +circumcision with follow up" treatment of the study only receives circumcision. I wouldn't be surprised that the general population is also less likely to follow the guidelines with regards to safe sex (compared to the subjects of the study) and more likely to only consider the "circ prevents HIV" part of the message (because that part is easy to follow, once you're chopped, it's for life, it's not one of those pesky things you need to repeat over and over again, like buying and using condoms), possibly inciting more risky behaviour. Do you now understand why I prefer rigorous science over hasty "prevention"?

Yes. That attitude is shared by myself and the other medical researchers I know.

Linda

ponderingturtle

15th December 2006, 01:14 PM

Every medical treatment has a cost/benefit ratio to it.
That's why appendectomies are only performed when someone has appendicitis. If the incidince of appendicitis were large enough in the general population, it would most likely become a preventitive treatment. But as it stands, it only is performed as an intervention becuase the risk of surgery for a healthy individual outweighs the propability of needing an appendix removed.

Circumcisions performed for no real reason or medical benefit is stupid. There is no benefit. however, if we can stop the spead of a disease through a 1 time elective procedure, I see no reason to not recommend it.

Well being circumcised means you wont have any of the medical problems that cause you to get circumcised, not sure how many that is. The cost benefit for it seems to be pretty mild on both sides, not much cost or benefit either way. This could be drastically changed if the reduction in HIV transmission are true, especially in areas that have the highest rates of HIV infection.

But even with out it, there are modest medical benefits, paired with modest problems and risks to the procedure.

kellyb

15th December 2006, 01:15 PM

Circumcisions performed for no real reason or medical benefit is stupid. There is no benefit. however, if we can stop the spead of a disease through a 1 time elective procedure, I see no reason to not recommend it.

Would the same hold true for female circumcision? If it really and truly did reduce the spread of AIDS?

Kaylee

15th December 2006, 01:16 PM

Originally Posted by kellyb http://forums.randi.org/images/buttons/viewpost.gif (http://forums.randi.org/showthread.php?p=2178888#post2178888)
I don't think anyone is necessarily saying the study is definitely invalid.
We're just....troubleshooting... what we're going to be looking out for when the study is made available. :)
Yeah, I just wanted to be clear that I wasn't complaining about the idea of picking these things apart.

That's what I had thought, glad to find out that's not the case :) .

ponderingturtle

15th December 2006, 01:16 PM

You're right. I found some references to the acceptability studies.

http://www.psi.org/resources/pubs/male-circ.pdf

...not sure what to make of that...:confused:

Thanks looks like a great datapoint for the rabid anti-circ crowd.

ponderingturtle

15th December 2006, 01:20 PM

Would the same hold true for female circumcision? If it really and truly did reduce the spread of AIDS?

Given the proposed mechanism for effect, I can't see what effect removing the clitoris or the more extreme forms of female circumcision would have.

And I think most people would seem to find more definitive downsides to it as well. Can anyone cite a 60% satisfaction rate among females circumcised as sexually active adults?

kellyb

15th December 2006, 01:21 PM

Given the proposed mechanism for effect, I can't see what effect removing the clitoris or the more extreme forms of female circumcision would have.

And I think most people would seem to find more definitive downsides to it as well. Can anyone cite a 60% satisfaction rate among females circumcised as sexually active adults?

Can you find a link on the 60% satisfaction figure?

FC would possibly be effective for entirely different reasons.

kellyb

15th December 2006, 01:24 PM

Thanks looks like a great datapoint for the rabid anti-circ crowd.

What do you mean?

ynot

15th December 2006, 01:26 PM

OK but most of those have very definite downsides, the downsides to circumcision seem to be highly subjective and from what I have looked at pretty moderate.
"Most"?

If it was a quick easy procedure to remove the appendix would you object to having it done in children, because the appendix is natural and it is likely most of them will never have a problem with it?
Are you advocating the automatic mass surgical removal of all "non-essential" parts of the human body as a form of preventative medicine?

This seems to be strongly related to the Natural=Good fallacy, now maybe it is bad, but when I have looked into questions asking how satisfied adults who where circumcised(often for medical reasons) most thought it was an improvement.(around 60%).
In what way an improvement - hygienically? cosmetically? sexually?
I guess you mean "how satisfied adults were,"
So around 40% think no improvement or worse.

So unless you can provide definite harm as experienced by those who have direct experience with both, why shouldn't I follow what seems to be the accepted medical wisdom that there is no strong reason to choose either way, each has certain minor problems/risks and benefits with it.
If no good reason to do it, why do it? Less doctors doing circumcisions means more doctors to doing more worthwhile things.

ponderingturtle

15th December 2006, 01:28 PM

What do you mean?

Well those who constantly downplay the benifits of it, and play up all the downsides. Basicly those who view it as being the same as female circumcision and is an abomination that should be outlawed.

Like these people (http://www.mgmbill.org/)

ponderingturtle

15th December 2006, 01:36 PM

Can you find a link on the 60% satisfaction figure?

Damn looks like the circumcision thread from a few months ago in politics has expired already. time to google

link (http://www.cirp.org/library/sex_function/fink1/)
A total of 123 men were circumcised as adults. Indications for circumcision included phimosis in 64% of cases, balanitis in 17%, condyloma in 10%, redundant foreskin in 9% and elective in 7%. The response rate was 44% among potential responders. Mean age of responders was 42 years at circumcision and 46 years at survey. Adult circumcision appears to result in worsened erectile function (p = 0.01), decreased penile sensitivity (p = 0.08), no change in sexual activity (p = 0.22) and improved satisfaction (p = 0.04). Of the men 50% reported benefits and 38% reported harm. Overall, 62% of men were satisfied with having been circumcised.

FC would possibly be effective for entirely different reasons.

Possibly, but unlikely. And there is much better reasons why it is a bad thing than with male.

ponderingturtle

15th December 2006, 01:44 PM

"Most"?

Well wisdom teeth are commonly pulled before they present any trouble, as a preventative measure, in spite of it being so unnatural

Are you advocating the automatic mass surgical removal of all "non-essential" parts of the human body as a form of preventative medicine?

Nonsense, each part should be assessed independently, and have the risks and benefits looked at.

In what way an improvement - hygienically? cosmetically? sexually?
I guess you mean "how satisfied adults were,"
So around 40% think no improvement or worse.

Yes, but then again how much of a detriment did they find it. The problem is that they are so much yes or no statements, and not rating improved satisfaction in a more sliding scale.

If no good reason to do it, why do it? Less doctors doing circumcisions means more doctors to doing more worthwhile things.

There are moderate reasons to do it and not to do it. It is not like say breast enlargement that takes up many doctors time while having no medical benefit. What about all the cosmetic dentistry that is done instead of limiting their behavior to serious dental problems?

Unless there is a serious doctor shortage, this argument holds little merit and it is by far not the first procedure that should be eliminated in terms of how long it takes for the medical benefits of it.

kellyb

15th December 2006, 01:55 PM

Damn looks like the circumcision thread from a few months ago in politics has expired already. time to google

link (http://www.cirp.org/library/sex_function/fink1/)

I guess this must be a case of previously formed bias coloring how different people interpret the same information, because I'm not finding that information compelling at all. Not only did most of those men decide to get circumcised because they had issues to begin with, but almost half wished they hadn't even tried to get it corrected through circumcision after the fact.
So that would have extremely negative connotations for the overwhelming majority of men who don't have a problem with their foreskins in the first place.

But I think we're digressing here, anyway, since HIV transmission is a whole 'nother creature entirely.

Jorghnassen

15th December 2006, 01:57 PM

Yes, but then again I was thinking of it either way. How do you know it really is dangerous if you end the study just because the preliminary data suggests it is dangerous?

If you support ending studies because people are dieing, why not end studies because people are dieing by not getting the treatment?

Studies ending early because of harmful effects imply rapid and significant unexpected side effects of the treatment. So it makes sense to stop the trial quickly to prevent harm. On the other hand, positive effects are usually not as immediate, and inevitably, when they do occur, lead to further questions of long-term effects. If the subjects in an experiment are already sick and in danger of dying or suffering greatly in the short term, while the new treatment offers an immediate recovery, then you can talk about ending an experiment early in this case and offering the new treatment to all. In the case of HIV infection, we are starting with healthy subjects who could become infected at any point in the future, or not ever become HIV+ at all, so the experiment has to be carried over the long term. By ending this type of experiment early, you inevitably skew the results in favor of the treatment group because removal of the foreskin delays/reduces sexual activity over several weeks, and hence reduces infection rates temporarily. Recruiting subjects over several weeks likely compounds this problem. So "conclusive" early results in favor of the treatment are much harder to obtain by design.

I've said it before, studying time-to-event data is tricky, messy, time consuming and costly. You can't afford to do shoddy science.

ImaginalDisc

15th December 2006, 02:11 PM

Ah, so your use of definitive statements was a clever ruse. ;)

Linda

Excuse me? The men who were circumcised were a partly self-selected group. The trouble with self-selection effecting randomization is well known. The information provided about the study does not show anything that takes into account that problem, or the problem with the healing time needed for circumcision delaying the resumption of sexual activity making direct comparison to the control group difficult.

Whether circumcision effects HIV transmission rates is a good and important question, and this study doesn't appear to even try to answer it with sound methodology.

Edit to add:

My exchange with you over this began with your reply to Katana's post which I still think has a point and the information we have about the study so far doesn't answer her point:

Yes, I have acknowledged that more info is needed.

To do the data analysis, they created a circumcised and an uncircumcised group for the two-year period-not a "circumcision offered" and "no circumcision offered" group. I guess I thought that that much was pretty clear from what we had so far.

If a participant is offered treatment, and then refuses it, it isn't a randomly administered treatment. Random has an important meaning in data analysis.

ponderingturtle

15th December 2006, 02:26 PM

I guess this must be a case of previously formed bias coloring how different people interpret the same information, because I'm not finding that information compelling at all. Not only did most of those men decide to get circumcised because they had issues to begin with, but almost half wished they hadn't even tried to get it corrected through circumcision after the fact.
So that would have extremely negative connotations for the overwhelming majority of men who don't have a problem with their foreskins in the first place.

But I think we're digressing here, anyway, since HIV transmission is a whole 'nother creature entirely.

And it is only the respondants anyway. But how else can you challange the claims about how male circumcision is one of the worst possible forms of child abuse?

It is not a perfect study, but I can't find to many that look at what adults who are circumcised think to try to determine how significant its effects are?

ynot

15th December 2006, 02:27 PM

fls

15th December 2006, 02:27 PM

Excuse me? The men who were circumcised were a partly self-selected group.

How do you know that? What is written down is that men who were willing to be circumcised were randomized to receive circumcision or not. Where's the selection?

The trouble with self-selection effecting randomization is well known. The information provided about the study does not show anything that takes into account that problem, or the problem with the healing time needed for circumcision delaying the resumption of sexual activity making direct comparison to the control group difficult.

Whether circumcision effects HIV transmission rates is a good and important question, and this study doesn't appear to even try to answer it with sound methodology.

How do you know that? The study hasn't been published and we haven't been given any information about whether or not there actually were differences and what analytical methods were used.

Linda

ImaginalDisc

15th December 2006, 02:39 PM

How do you know that? What is written down is that men who were willing to be circumcised were randomized to receive circumcision or not. Where's the selection?

How do you know that? The study hasn't been published and we haven't been given any information about whether or not there actually were differences and what analytical methods were used.

Linda

Excuse me, I should not have attributed to you something you didn't say. I should know better than to post without reviewing a thread I haven't read in a few days. I went to to an earli