Talk:Ethics of circumcision/Archive 3

Applicability of African Trials
There are a lot of issues in using these Africa trials as a basis for claiming circumcision will lower HIV infections:

- Broader demographics show that circumcised men in several African countries had a higher rate of infection than intact men: Reference: Mishra V, Medley A, Hong R, Yuan Gu Y, Robey B. Levels and spread of HIV seroprevalence and associated factors: evidence from national household surveys. DHS Comparative Reports No. 22. Calverton (MD): Macro International Inc; 2009.

- Since the World Health Organization's programs to circumcise millions of men in sub-Saharan Africa began in Uganda and Kenya, the incidence of new cases of HIV in both countries has increased. Reference: Ministry of Health, ICF International, Centers for Disease Control and Prevention, U.S. Agency for International Development, WHO Uganda. Uganda AIDS Indicator Survey 2011. Kampala (Uganda): Ministry of Health; 2012. National AIDS Control Council, National AIDS and STD Control Programme. The Kenya AIDS epidemic: update 2011. Nairobi (Kenya): National AIDS Control Council; 2012. Orido G. Push for male circumcision in Nyanza fails to reduce infections. Standard (Kenya) website. 2013 Sep 11. Available at: www.standardmedia.co.ke/article/2000093293/push-for-male-circumcision-in-nyanza-fails-to-reduce-infections

- It doesn't take into account 'risk compensation' which researchers fear could actually increase risk: The failure of circumcision programs to lower HIV in Africa could be due to risk compensation, alterations in behavior in response to a lowering of their perceived risk. There is a trend in those communities that circumcised men believe they cannot be infected by HIV. Women prefer circumcised men believing them to be safe and HIV-free, increasing the tendency to not use a condom during sexual intercourse. Reference: Orido G. Push for male circumcision in Nyanza fails to reduce infections. Standard (Kenya) website. 2013 Sep 11. Available at: www.standardmedia.co.ke/article/2000093293/push-for-male-circumcision-in-nyanza-fails-to-reduce-infections

- In the trials themselves: - Researcher expectation bias − Many of the investigators had written papers advocating for male circumcision to prevent HIV infection prior to undertaking these RCTs. Siegfried et al. note, on the topic of research on circumcision to prevent HIV, that “researchers’ personal biases and the dominant circumcision practices of their respective countries may influence their interpretation of findings.” [93]

- Participant expectation bias − The majority of participants were convinced that circumcision would reduce their risk of HIV infection.[94]

- Lead time bias − Men randomized to the intervention arm of the trials (the group that was circumcised) were considered to be at risk for becoming infected from the time of the surgery, even though they were told to avoid sexual activity during the period of wound healing. Men in the control arm (the ones who were not circumcised) were able to be sexually active from the beginning of the study.

- Selection bias − Only men who were interested in a free circumcision were eligible to participate, and therefore may not have been representative of the general population.

- Attrition bias − For every man who became infected with HIV during the trials, 3.5−7.4 men were lost to follow-up. This is a serious methodological problem that could alter the statistical significance of the findings.[95]

- Early termination bias − Studies that are terminated early are more likely to overestimate any treatment effect.[96,97]

- Duration bias − Because men who were not initially circumcised were circumcised at the end of the study, long-term comparison of the effects cannot be accurately extrapolated, as some modelers have proposed.[98]

- Source of infection unknown − If the studies were designed to determine whether circumcision reduced the risk of heterosexually-transmitted HIV, the investigators should have confirmed that the infections were indeed transmitted through heterosexual sexual contact. They did not. Using the data reported, it is estimated that about half of the infections of the men in these studies were not sexually transmitted.[92]

- The cumulative treatment effect in these trials – which claimed a 38-66% relative risk reduction[99] – was an absolute risk reduction of 1.3%.[91] This is a very small effect, which could easily have resulted from the various forms of bias, rather than being a true treatment effect. The findings are not robust, given that all of the trials had nearly identical methodologies and nearly identical results.

As with other STIs, there is no evidence that circumcision has had any impact on lowering the incidence of HIV infection in the United States. Of the eight HIV studies in North American heterosexual men,[100,106-112] only one has found a significant association between circumcision and HIV infection risk: it actually found that circumcised men were at greater risk of HIV infection.[112] Furthermore, the HIV epidemic in the United States is concentrated among men who have sex with men (MSM) and injecting drug users. A meta-analysis of the studies published on this topic by the Centers for Disease Control and Prevention (CDC) found that the risk for HIV infection in MSM is the same in intact and circumcised men.[113] A subsequent study yielded similar results.[114]

RCTs carried out among adults in Africa are not relevant to children anywhere, since children are not sexually active and are therefore not at risk of HIV infection by sexual transmission. For adults, condoms are an effective means of preventing sexually transmitted infections, including HIV.[117] Other preventative interventions, such as “treatment as prevention” and pre-exposure prophylaxis, are more effective, less expensive, and less injurious than circumcision.[118,119]

93. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2003;3:CD003362. 94. Wilson NL, Xiong W, Mattson CL. Is sex like driving? HIV prevention and risk compensation. J Dev Econ. 2014;106:78-91. 95. Akl EA, Briel M, You JJ, Sun X, Johnston BC, Busse JW, et al. Potential impact on estimated treatment effects of information lost to follow-up in randomised controlled trials (LOST-IT): systematic review. BMJ. 2012;344:e2809. 96. Pocock S, White I. Trials stopped early: too good to be true? Lancet. 1999;353:943-4. 97. Bassler D, Briel M, Montori VM, Lane M, Glasziou P, Zhou Q, et al. Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. JAMA. 2010;303:1180-7. 98. Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, Hargrove J, et al. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med. 2006;3:e262. 99. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2009;2:CD003362. 100. Mishra V, Medley A, Hong R, Yuan Gu Y, Robey B. Levels and spread of HIV seroprevalence and associated factors: evidence from national household surveys. DHS Comparative Reports No. 22. Calverton (MD): Macro International Inc; 2009. 101. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. Afr J AIDS Res. 2008;7:1-8. 102. Ministry of Health, ICF International, Centers for Disease Control and Prevention, U.S. Agency for International Development, WHO Uganda. Uganda AIDS Indicator Survey 2011. Kampala (Uganda): Ministry of Health; 2012. 103. National AIDS Control Council, National AIDS and STD Control Programme. The Kenya AIDS epidemic: update 2011. Nairobi (Kenya): National AIDS Control Council; 2012. 104. Orido G. Push for male circumcision in Nyanza fails to reduce infections. Standard (Kenya) website. 2013 Sep 11. Available at: www.standardmedia.co.ke/article/2000093293/push-for-male-circumcision-in-nyanza-fails-to-reduce-infections 105. WHO/UNAIDS Technical Consultation. Male circumcision and HIV prevention: research implications for policy and programming. Conclusions and recommendations. 2007 March. 106. Chiasson MA, Stoneburner RL, Hildebrandt DS, Ewing WE, Telzak EE, Jaffe HW. Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine (crack). AIDS. 1991;5:1121-6. 107. Telzak EE, Chiasson MA, Bevier PJ, Stoneburner RL, Castro KG, Jaffe HW. HIV-1 seroconversion in patients with and without genital ulcer disease. Ann Intern Med. 1993;119:1181-6. 108. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practice. JAMA. 1997;277:1052-7. 109. Thomas AG, Bakhireva LN, Brodline SK Shaffer RA. Prevalence of circumcision and its association with HIV and sexually transmitted infections in a male US Navy population. San Diego (CA): Naval Health Research Center. Report No. 04-10; 2004. 110. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE. 2007;2(9):e861. 111. Warner L, Ghanem KG, Newman DR, Macaluso M, Sullivan PS, Erbelding EJ. Male circumcision and risk of HIV infection among heterosexual African American men attending Baltimore sexually transmitted disease clinics. J Infect Dis. 2009;199:59-65. 112. Rodriguez-Diaz CE, Clatts MC, Jovet-Toledo GG, Vargas-Molina RL, Goldsamt LA, García H. More than foreskin: circumcision status, history of HIV/STI, and sexual risk in a clinic-based sample of men in Puerto Rico. J Sex Med. 2012;9:2933-7. 113. Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men. JAMA. 2008;300:1674-84. Errata JAMA. 2009;301:1126-9. 114. Crosby RA, Graham CA, Mena L, Yarber WL, Sanders SA, Milhausen RR, et al. Circumcision status is not associated with condom use and prevalence of sexually transmitted infections among young black MSM. AIDS Behav. 2015 Oct 7. Epub ahead of print. 115. Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ. 2000; 320(7249):1592-4. 116. de Witte L, Nabatov A, Pion M, Fluitsma D, de Jong MAWP, de Gruijl T, et al. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med. 2007;3:367-71. 117. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. N Engl J Med. 1994;331(6):341-6. 118. Lima V, Anema A, Wood R, Moore D, Harrigan R, Mills E, et al. The combined impact of male circumcision, condom use and HAART coverage on the HIV-1 epidemic in South Africa: a mathematical model. 5th IAS Conference on HIV Treatment, Pathogenesis and Prevention, Cape Town, abstract WECA105; 2009. 119. Donnell D, Baeten JM, Kiarie J, Thomas KK, Stevens W, Cohen CR, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010;375(9731):2092-8.

Ten Beard (talk) 14:06, 3 April 2019 (UTC)
 * Or, more simply, reflect reliable sources. As we do. Alexbrn (talk) 18:19, 3 April 2019 (UTC)

Honestly I'm not sure what you are trying to say. Are you saying the entirety of all the sources above are not reliable? Ten Beard (talk) 19:06, 3 April 2019 (UTC)
 * Many are not WP:MEDRS. Basically this just looks like a typical POV-push backed by a laughable WP:WALLOFTEXT that will be rightly ignored. Succinct proposals, based on WP:RS, for improving the article, would OTOH be welcome. Alexbrn (talk) 19:50, 3 April 2019 (UTC)