Wednesday, June 13, 2012

Africa HIV Claims

The American medical community and media has bought into the idea that circumcision is a valid tool for HIV prevention. The African studies showing a benefit are dubious; see "Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns".

The WHO, the American NIH, the American CDC, the Bill and Melinda Gates Foundation, and the governments of a few African countries (largely corrupt governments likely receiving kickbacks from American charities and medical device manufacturers) recognize the African HIV studies as valid. Additionally, virtually all of the meta-studies in the medical journals and publications accept the RCTs and they confirm that circumcision has an HIV-reduction benefit. To a casual onlooker, this appears to be a "medical consensus". But is it?

According to "How Well Do Meta-Analyses Disclose Conflicts of Interests in Underlying Research Studies", many meta-studies are not properly vetting the original study.

With any scientific or medical topic, the majority of new research will be funded by those trying to prove or disprove a theory. This is the scientific method. And that's how it should be. In this case, there are endless studies by organizations promoting a pro-circumcision point-of-view. The large volume of studies gives the impression that there is a "consensus" where all studies show the same result. In reality, it's a large number of studies by those trying to prove a point-of-view. This is not the same as consensus.

The question here is: what is the general consensus in the medical community on this issue? I would like to gain clarity. I am aware that numerous national medical organizations outside the US (e.g. Brazil, Australia) have rejected the notion that circumcision is a valid HIV-reduction tool.

So now here's the heart of the issue: I want to remove the Africa HIV claims from the lead of the Wikipedia circumcision article. Ultimately, I'd like to remove those claims entirely, but the lead is a good start. In the lead, these Africa HIV claims are front-and-center: someone skimming the article may see these claims and decide circumcision is good without reading rest of the article. That's why the pro-circumcision advocates want these claims in the lead! I can remove these claims if I can show that these claims don't represent consensus in the medical community.

What I am asking for is feedback either here or on Twitter for any references, sources, or ideas regarding whether or not there is medical consensus on this issue—and what it is.

6 comments:

  1. This issue is the African trials have nothing to do with infants, there needs to be a distinction between Voluntary Adult Circumcision and Involuntary Infant Circumcision, the latter being a human rights violation

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    1. I agree completely although it won't help for this precise issue. The human rights aspect isn't treated properly in the Wiki article. I will get to that...

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  2. The First Refutation of this propaganda is that Routine Infant Circumcision is a human rights violation. The first point to make then is that even if there are health benefits (& this is contested) that human rights take precedence over health benefits, and must not be violated in the pursuit of health benefits.


    The Second refutation is lack of medical consensus on the health benefits of circumcision in particular for infants or children. No Medical organisation in the world recommends infant circumcision, and since the wide publicity of the African Trials, medical organisations from Australia & The Netherlands have released explicit medical statements stating infant circumcision is niether required nor recommended.
    The Third Refutation is Relevance. In particular, that the data from the African RCT HIV Studies have zero relevance to infant children. The African research was conducted on paid adult male volunteers, who were part of Trials which went for between 18 to 24 months. And while these African studies have been widely criticised, if we put all our criticism of the African research aside, and take the results on face value, that male circumcision reduces the risk of HIV infections, over an 18 to 24 month period. The following can be said about relevance:


    Africa is a continent with High prevalence of HIV & when sexually transmitted it is predominantly via hetero-sexual transmission, whereas in western nations, HIV is a low prevalence disease, and when sexually transmitted is predominantly via homosexual transmission, or a disease spread in the injecting drug user community from needle sharing. The protective effect of circumcision if there is one, is only for heterosexual transmission protecting males from female infections. Females are not protected from male circumcision, with one trial showing women were infected at higher rates by circumcised men. Circumcision is not protective for MSM, not protective for IV Drug users, nor for contaminated blood. The relevance of the studies only applies to consenting adult male volunteers in high prevalence settings.
    Research outcome data and recommendations must logically follow from each other, therefore any recommendations can only apply to adult male volunteers in high prevalence settings. These outcomes cannot be applied to infants, nor in low prevalence settings.
    The outcome data has no relevance to newborn infants or children.
    Infants do not have sex.
    Infants have not chosen their sexual lifestyles.
    Infants may grow into men that want to be in faithful monogamous relationships.
    Most Infants born in low prevalence communities may never have exposure to a HIV infected sexual partner in their entire lives.
    Infants may grow into men that want to have an intact penis.
    Infants may grow into men that choose to practice safe sex, and use condoms consistently.
    Infants may grow into men, that choose to never travel to Africa, and to never have sex with HIV African infected women, or African sex workers.
    Infants may grow into men that choose celibacy for themselves.
    Infants may grow to be Gay Men.
    A man who is informed about sex, about safe sex, about condoms, and about circumcision, may make a choice for himslef on any of these matters for himself, and it is not necessary he be circumcised as a baby.
    Circumcision is not required in infancy and best left to the man to decide for himslef when he understands the sorts of choices he wants to make for himself.
    So if we give every benefit of the doubt to Pro-Circumcison advocacy, all they can ethically justify is that adult men, particularly those in high prevalence settings, be informed of circumcision's potential health benefits, along with the criticisms of circumcision, and it be left to adult men to make an informed consent decision for themselves.
    Ultimately, and the strongest argument against infant circumcision is "That taking the choice about a man's body away from him, particularly when he is an infant, is a human rights violation".

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    1. For me personally, I don't believe it is EVER acceptable to take a part of anyone's genitals away unless they really want it and know all the consequences. The circumfetishists are in this category (I have a theory on this that I'll post soon).

      Most men in American and in places where circumcision is common have no idea what a foreskin is or whether it has any function at all. Doctors generally don't know of the consequences themselves and, likewise, don't inform their patients of what will be lost. Presumably, these African men know that foreskin "feels good". I can't understand why they would agree to this... unless they're given misinformation.

      If circumcision really does have a protective benefit among heterosexual men, it is difficult to justify removing these statements from the Wikipedia article. This is the problem.

      The studies indicate a benefit for female-male transmission. Why wouldn't the equivalent in homosexual sex experience the same protective benefit? Aren't we talking about hardening a mucous membrane to reduce a pathogen vector?

      I am not comfortable with the argument that in high-prevalence areas circumcision is a valid treatment for HIV while it's not a valid treatment option in low-prevalence areas. This seems like a wobbly argument where we are splitting hairs. Either it is a valid treatment or it isn't. Why are some men entitled to a foreskin and others are not? This is pure silliness. I took someone out of my circles on G+ for making this very argument as it was so silly I couldn't be bothered to respond!

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    2. By "treatment" I mean "preventative measure". I guess I can't edit these comments!

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  3. I've been thinking about it; here's my pitch:

    1. Most circumcisions are done for non-therapeutic reasons on infants
    2. The Africa HIV claims---even if they are true---are relevant to adult men in areas with high HIV prevalence among heterosexuals

    Therefore:

    The Africa HIV claim should not be in the lead since those claims are not relevant to the majority of the reasons for circumcisions. As WP:LEAD states: "material in the lead should reflect its relative importance to the subject". At best, this viewpoint represents a very low level of importance to the subject.

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