Wednesday, February 01, 2012

Foreskins, clamps, and stabbings

Part of the interest in getting Google Alerts, at least as far as I am concerned, is that they provide diverse (if not surreally clashing) news items about the same topic. This week, I received a couple of links about male circumcision as HIV prevention strategy in low-resource, high HIV prevalence countries. A few years ago, three randomized controlled trials in Africa indicated that being circumcised significantly reduced risk of female-to-male HIV transmission. Male circumcision was then all the rage for awhile, but soon slipped off the front pages as it passed from 'research innovation' to 'yet another intervention to be implemented.'

Some countries in Africa are making male circumcision part of their HIV prevention strategy, though informing/convincing men to have their foreskins removed for this purpose, and actually getting it done, has proven slow going. There is some movement to change this. The New York Times has an article about new methods to speed the process of circumcision, complete with pictures of what to the untrained eye look (predictably?) like cock rings of a fairly utilitarian sort. The most promising of these devices seems to be the PrePex, which basically involves putting a ring around your Johnson, and cutting off blood circulation to the foreskin, until the latter comes off 'like a fingernail' as one proponent so sensitively put it. Apparently the clinical trials on male circumcision and HIV gave birth to a growing industry in foreskin removing clamps, from China's somewhat sinister sounding Shang Ring to the exoticism of the Turkish Ali's Klamp, to the device that terrorized many a South African penis a few short years ago, the infamous Malaysian Tara KLamp. That is the new story: which plastic gadget most cost-effectively whips off the African foreskin?

The other story on my Google Alert really goes in another direction. The Citizen, a Tanzanian newspaper has an item entitled 'One Hacked to Death in Male Circumcision Confrontation'. Apparently traditionalists in Tanzania are (very) opposed to the idea of medicalizing male circumcision and treating it similarly to an appendectomy; after all, circumcision in Africa is commonly viewed as a rite of passage for males, where the pain of circumcision is part of its meaning, and the act is part of a ritual performed by traditional practitioners. A crowd of those who have this 'old school' view of male circumcision confronted someone who was treating it more as a medical, disease prevention intervention, and things got ugly. Modernity meets tradition. So the clinical trials on HIV and male circumcision have not only given rise to plastic gadgets, but also some measure of inter-tribal conflict.

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Blogger Hugh said...

Three poorly-blinded, non-placebo-controlled, prematurely curtailed trials, with drop-out rates several times higher than the measured infection rates, found that less than two years after circumcising 5,400 men, 64 of them had HIV, 73 fewer than the non-circumcised control groups. That is the WHOLE basis of the much-quoted "up to 60% reduction" figure.

It is now becoming clear here, here, here and here, that wishful thinking trumps education and that men circumcised in mass-campaigns, and their partners, believe it has made them immune and they can throw caution to the winds. This, together with the low likelihood of circumcision itself having any effect on HIV transmission, is a recipe for disaster.

Here in New Zealand, we've been using a device like the PrePex for decades on (under-age, non-consenting) sheep - but not on their foreskins. It's called the Elastrator.

10:10 PM  
Blogger Stuart Rennie said...

OK Hugh, hang on to your Elasticator. Let me make a couple of comments.

You write that the circumcision trials were 'poorly blinded, non-placebo controlled, and prematurely curtailed'. Which sounds just dreadful. Or at least it does until you reflect on the fact that the studies couldn't be blinded, unless those involved in the trial had a very curious relationship with their Johnsons. Or that the studies were controlled (with a non-circumcising arm) but not with a placebo, because: what sort of placebo for circumcision could you possibly use? And the studies were stopped prematurely because investigators found that circumcision reduced risk of getting HIV, and continuing would have been unethical.

As for the risk reduction via circumcision, only a few men in a thousand will get HIV even in a high prevalence setting, but if you are circumcised, the chances are reduced further still. For the individual, the reduction of risk does not sound like much, but the idea is to put a dent in the epidemic from a population level. Hence the mass campaigns. I have my own doubts about how much circumcision will make an impact relative to other approaches, but they are not doubts based on intactivism.

It is curious that you apparently hold circumcision studies to very high standards of scientific rigor, but when it comes to data in support of your own position, the standards seem to plummet, and newspaper reports are good enough. That some newly circumcised men may overestimate how protected they are is a matter of concern, and if widespread enough, it could cancel the protective effects of being circumcised. But we need solid data of the magnitude of the problem in order to tackle it, not reports of circumcised men boasting about how much they are going to get laid.

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11:27 AM  
Blogger Hugh said...

Stuart Rennie: They could have given the control group a dummy operation, an incision in the region that they would close again without removing tissue, but would require all the care, counselling, etc. etc. etc. of a circumcision. They do it to test internal surgery where any ethical issues must be even stronger. If they didn't tell the subjects whether they'd had a circumcision, many would not know the difference, especially if they called it (accurately) a "circular incision".

But anyway, they have been promoting these studies as if they were the gold standard, when they patently are not. Humans are not lab rats and there are some experiments we just can't do on them. They can't be locked up with HIV+ partners to ensure that's who they have sex with.

I hold medical studies to a high standard when they claim to show that a serious and costly intervention is going to have a major effect on a grave epidemic, yes.

"The idea is to put a dent in the epidemic from the populaton level". But to get the men to sign up, they exaggerate the protection each is going to get at the individual level.

There are studies claiming that circumcision does not affect the rate of condom use - but they were carried out on the same over-researched populations that gave the original "HIV protection" effect. The same men were used to prove that getting (the best) part of your penis cut off does not harm your sexual experience - and by the same tiny handful of researchers who have everything to gain by all these experiments going in the direction they want.

I trust my knowledge of male human nature - confirmed by many reports - more than studies by these researchers with their agenda. Circumcised men are going to have unprotected sex because that's what they want to do. For many it will be why they got circumcised.

11:56 PM  
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