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joya banerjee [ profile ] |
| Subject: |
Piece published in the AJPM: Circumcision Denialism Unfounded and Unscientific
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| Sent: |
Feb 24th, 2011 - 12:38:35 |
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Circumcision Denialism Unfounded and Unscientific.pdf
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Dear All,
I'd like to share with you a piece I co-authored, just published in
the American Journal of Preventive Medicine.
Best Wishes,
Joya Banerjee
Co-Founder & Advisory Council Member
Global Youth Coalition on HIV/AIDS
joya.banerjee (at) gmail.com
+27 82 309 4982
http://www.ajpm-online.net/article/S0749-3797(10)00791-9/fulltext
Circumcision Denialism Unfounded and Unscientific
Re: Green et al, Male Circumcision and HIV Prevention: Insufficient
Evidence and Neglected External Validity.
To the Editor:
Despite the fact that three randomized controlled trials (RCTs) 1–3
and dozens of observational studies have confırmed that medical male
circumcision reduces the risk of HIV acquisition in men by at least
60%,4 Green et al.5 continue to question its effectiveness, and would
deny millions of men—and their female partners—a proven, permanent,
and inexpensive method to reduce their lifetime risk of HIV infection.
Such denialism in the face of the ongoing pandemic is unethical and
immoral.
The argument that the clinical trials of medical male circumcision
lack external validity because of ideal counseling conditions and
condom promotion is nonsensical because both study arms were equally
exposed to those non-circumcision interventions. The concern that the
measures of effect are not durable is not supported by evidence from
the Kenya trial showing that the protective effect of medical male
circumcision was sustained— and actually strengthened—at 54 months of
follow-up.6
Outside of study settings, a wealth of ecologic data shows that
countries with widespread male circumcision consistently have low HIV
prevalence. In West Africa where nearly all men are circumcised, HIV
has been circulating for more than 80 years. Yet, as is true of all
countries where male circumcision is nearly universal, no country in
that region has an adult HIV prevalence greater than 6%.4
Advocates of medical male circumcision are not arguing for—as Green et
al. suggest—a “shift from condom use to reliance on circumcision for
HIV prevention.”5 Medical male circumcision has been integrated into
the WHO’s recommended prevention package of HIV testing and
counseling, treatment for sexually transmitted infections, and
provision and promotion of safer sex practices, including condoms.
Medical male circumcision also benefıts women. In addition to direct
protection from Trichomonas vaginalis, bacterial vaginosis, herpes
simplex virus, and cervical cancer, a recent meta-analysis found that
“circumcision may confer a 46% reduction in the rate of HIV
transmission from circumcised men to their female partner.”7 Further,
the population effect, or herd immunity, means that with fewer
HIV-infected men, far fewer women would be at risk.
With respect to the concern that men might engage in riskier sexual
behavior after circumcision, data from the three RCTs1–3 and a
prospective cohort study8 found no overall increases in risk behavior
following circumcision. Among the Kenya RCT participants, Mattson et
al.9 found that risk behavior actually decreased over the course of 12
months.
While Green et al.5 attempt to stall efforts to scale up medical male
circumcision by citing debunked arguments,10 modeling reveals that in
sub-Saharan Africa alone, widespread circumcision could avert up to 2
million new HIV infections and 300,000 deaths over the next 10 years,
many of those among women.11 The urgency has never been more apparent
or the evidence more clear: Further delay is counter-productive.
Deliberate misrepresentation of data, broad generalizations, and poor
understanding of research methodology undermine efforts to prevent
millions of premature deaths annually. It is time to mobilize
suffıcient resources to provide safe and widespread medical male
circumcision in high-HIV-burden countries.
Joya Banerjee, MS
Global Youth Coalition on HIV/AIDS, South Africa
Jeffrey D. Klausner, MD, MPH
University of California
San Francisco, California
Daniel T. Halperin, PhD
Harvard School of Public Health
Boston, Massachusetts
Richard Wamai, PhD
Northeastern University
Boston, Massachusetts
Edgar J. Schoen, MD
University of California
San Francisco, California
American Academy of Pediatrics Task Force on
Circumcision 1988–1989
Stephen Moses, MD, MPH
Departments of Medical Microbiology
Medicine and Community Health Sciences, University of Manitoba
Winnipeg, Manitoba, Canada
Brian J. Morris, DSc, PhD
School of Medical Sciences
University of Sydney
Australia
Stefan A. Bailis, PsyD
Research & Education Association on Circumcision
Health Effects, Bloomington, Minnesota
Francois Venter, FCP (SA)
WHI (Wits Institute for Sexual & Reproductive Health
HIV and Related Diseases)
Department of Medicine
University of the Witwatersrand
Johannesburg, South Africa
Neil Martinson, MBBCH
Perinatal HIV Research Unit
Johns Hopkins School of Medicine
Baltimore, Maryland
Thomas J. Coates, PhD
Michael and Sue Steinberg Professor of Global AIDS
Research, David Geffen School of Medicine
University of California
Los Angeles, California
Glenda Gray, MBBCH
Perinatal HIV Research Unit
University of Witwatersrand, South Africa
Kasonde Bowa, MSc, MMed
University Teaching Hospital, University of Zambia
References
1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren
A. Randomized, controlled intervention trial of male circumcision for
reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med
2008;2(11):E298.
2. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV
prevention in young men in Kisumu, Kenya: a randomized controlled
trial. Lancet 2007;369(9562):643–56.
3. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV
prevention in men in Rakai, Uganda: a randomised trial. Lancet
2007;369(9562):657– 66.
4. Klausner JD, Wamai RG, Bowa K, Agot K, Kagimba J, Halperin D. Is
male circumcision as good as the vaccine we’ve been waiting for?
Future HIV Ther 2008;2(1):1–7.
5. Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN,
Craig A. Male circumcision and HIV prevention insuffıcient evidence
and neglected external validity. Am J Prev Med 2010;39(5):479–82.
6. Bailey RC, Moses S, Parker CB, et al. The protective effect of
adult male circumcision against HIV acquisition is sustained for at
least 54 months: results from the Kisumu, Kenya trial. Presented at
the XVIII International AIDS Conference; 2010 July 23; Vienna,
Austria; Abstract #FRLBC101.
7. Hallett TB, Alsallaq RA, Baeten JM, et al. Will circumcision
provide even more protection from HIV to women and men? New estimates
of the population impact of circumcision interventions. Sex Transm
Infect 2010. Advance online article.
8. Agot KE, Kiarie JN, Nguyen HQ, et al. Male circumcision in Siaya
and Bondo districts, Kenya: prospective cohort study to assess
behavioral disinhibition following circumcision. J Acquir Immune Defıc
Syndr 2007;44(1):66 –70.
9. Mattson CL, Campbell RT, Bailey RC, et al. Risk compensation is not
associated with male circumcision in Kisumu, Kenya: a multi-faceted
assessment of men enrolled in a randomized controlled trial. PLoS One
2008;3(6):e2443.
10. Wamai RG, Weiss HA, Hankins C, et al. Male circumcision is an
effıcacious, lasting and cost-effective strategy for combating HIV in
high-prevalence AIDS epidemics. Future HIV Ther 2008;2:399–405.
11. Williams BG, Lloyd-Smith JO, Gouws E, et al. The potential impact
of male circumcision on HIV in sub-Saharan Africa. PLoS Med
2006;3:E262.
No fınancial disclosures were reported by the authors of this paper.
doi:10.1016/j.amepre.2010.12.005
Published by Elsevier Inc. on behalf of American Journal of Preventive
Medicine Am J Prev Med 2011
2 Banerjee et al / Am J Prev Med 2011
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