"should I get circumcised?/should we get our son circumcised?"

tallaght01

Lancet. 2007 Feb 24;369(9562):657-66

I like the above paper.

But is it enough for me to say "yes" when people from high risk regions or communities ask if they should get circumcised/get their son circumcised to afford some protection against HIV.

For those who don't have access to full text articles, the paper looks at the effect of circumcision on HIV acquisition in a town in Uganda. Results showed that circumcision is protective across a range of ages, social and demographic groups.

Up until then, there was some observational data to support the hypothesis that it was protective, but I think this was the first randomised trial. Like, I remmeber reading one previous trial, where most of the circumcised guys were muslims and never used alcohol. There were a number of other confounding factors, too.

But this study looks good.

norrie rugger

would education not be better than letting them think that think they are at less risk now?

I mean when health ministers are still telling then to take orange juice and the belief that riding a virgin will cure aids, then no preventative measures are going to work

norrie rugger

by the way, the same could be said here with regards to HPV no?

kmick

So circumcision is the new safe sex? Sounds like a load of old boots to me.

norrie rugger

it has been thought for years that circumcision did reduce the uptake of certain viral infections, by removing such a hospitable initial holding point for the wee gits

I just think that unless you combat the real problem of education then it is a futile exercise

tallaght01

No-one is suggestin that we should circumcise people and forget about it.

AIDS is a by-product of poverty, gender inequality, sexual violence, political instability, poor education and poor access to healthcare.

That's gonna take a long time to sort out.

But what if someone from Sudan asks about getting their son circumcised before they go back home. They say they hears that this study shows that cicumcised people were half as likely to contract HIV. And that adverse effects of circumcision only affects about 3% of those who were circumcised.

What would you say to them?

Lil' Smiler

tallaght01 wrote: »

But is it enough for me to say "yes" when people from high risk regions or communities ask if they should get circumcised/get their son circumcised to afford some protection against HIV.

Hey,

Can i ask how circumcision can offer some protection against HIV? never heard of that

norrie rugger

tallaght01 wrote: »

No-one is suggestin that we should circumcise people and forget about it.

AIDS is a by-product of poverty, gender inequality, sexual violence, political instability, poor education and poor access to healthcare.

That's gonna take a long time to sort out.

But what if someone from Sudan asks about getting their son circumcised before they go back home. They say they hears that this study shows that cicumcised people were half as likely to contract HIV. And that adverse effects of circumcision only affects about 3% of those who were circumcised.

What would you say to them?

All of what you describe above are the reasons why circumcision should not be used as a tool to fight the spread of Aids. It sends out the wrong signal regarding protection against the disease.
Is circumcision not already hugely widespread in Africa?
And is it widespread in the countries that swamped with HIV?

The answer to the question above could be a deciding factor

My personal opinion is that 50% is not a high enough preventative measure. The gentleman would only have to sleep with the same girl a few times to negate this possible benefit.

tallaght01

norrie rugger wrote: »

All of what you describe above are the reasons why circumcision should not be used as a tool to fight the spread of Aids. It sends out the wrong signal regarding protection against the disease.
Is circumcision not already hugely widespread in Africa?
And is it widespread in the countries that swamped with HIV?

The answer to the question above could be a deciding factor

My personal opinion is that 50% is not a high enough preventative measure. The gentleman would only have to sleep with the same girl a few times to negate this possible benefit.

I don't think that we should only begin to tacke HIV if we can deal with all the problems at once. I think if my son was growing up in a high risk environment, then I'd seriously think about having him circumcised.

Circumcision isn't widespread throughout Africa, outside of the muslim population.

And the "roughly" 50% risk reduction isn't per sexual encounter. It's a relative risk over a period of, I think, I think 24 months.From what I remember, the 95% CI was between about 30-70%. I haven't read the paper in ages. I was just reminded of it when a parent asked me about it.

What I'm saying is that circumcised guys had about half the risk of catching HIV, than non circumcised guys. I think that's pretty convincing. IN fact, the protective effect was higher in higher risk populations.

You can wait until they tackle all the other issues, but personally I think these findings are a big deal. Follow-up studies will be interesting, though, once we can allow for the dissemination of the knowledge that it reduces HIV acquisition and transmission.

kmick

tallaght01 wrote: »

What would you say to them?

Educate your son about sexual diseases and how they spread. Advising them to get circumcised so they have a 50% chance of getting aids is like saying everytime you meet a girl who may have aids flip a coin.
Heads = no jiggy
Tails = jiggy

At best it is bizarre advice at worst it is dangerously negligent.

tallaght01

kmick wrote: »

Educate your son about sexual diseases and how they spread. Advising them to get circumcised so they have a 50% chance of getting aids is like saying everytime you meet a girl who may have aids flip a coin.
Heads = no jiggy
Tails = jiggy

At best it is bizarre advice at worst it is dangerously negligent.

LOL a 0.5 relative risk doesn't mean u have a 50% chance of getting AIDS!!! :P

norrie rugger

tallaght01 wrote: »

I don't think that we should only begin to tacke HIV if we can deal with all the problems at once. I think if my son was growing up in a high risk environment, then I'd seriously think about having him circumcised.

Circumcision isn't widespread throughout Africa, outside of the muslim population.

And the "roughly" 50% risk reduction isn't per sexual encounter. It's a relative risk over a period of, I think, I think 24 months.From what I remember, the 95% CI was between about 30-70%. I haven't read the paper in ages. I was just reminded of it when a parent asked me about it.

What I'm saying is that circumcised guys had about half the risk of catching HIV, than non circumcised guys. I think that's pretty convincing. IN fact, the protective effect was higher in higher risk populations.

You can wait until they tackle all the other issues, but personally I think these findings are a big deal. Follow-up studies will be interesting, though, once we can allow for the dissemination of the knowledge that it reduces HIV acquisition and transmission.

With regard to all the rest of your post I am in total agreement but going by your thread topic.
If the parents are asking the question, then they are probably the type of people who could educate their son in the first place, so are not your target market for the cultural problems

I think we will agree to disagree on this on as I just think that it sends out the wrong message on its own.

norrie rugger

Now, I wonder what the Catholic Church view is on this.

They are the gits who will not allow condoms, what about circumcision purely to reduce the risk of infection

AtomicHorror

I thought those foreskin/HIV results were in some doubt these days... I'll go pubmedding for that.

tallaght01

AtomicHorror wrote: »

I thought those foreskin/HIV results were in some doubt these days... I'll go pubmedding for that.

No way, dude.
3 excellent randomised trails have been conducted in the last few years. At least one even controlled for behavioural modification (ie higher risk behaviour in the circumcised group).

Most people think that widespread circumcision could potentially have huge effects on HIV transmission rates.

Bottle_of_Smoke

tallaght01 wrote: »

But what if someone from Sudan asks about getting their son circumcised before they go back home. They say they hears that this study shows that cicumcised people were half as likely to contract HIV. And that adverse effects of circumcision only affects about 3% of those who were circumcised.

What would you say to them?

In that case I'd say yes. And obviously explain who it will offer some protection to and who it won't.

2Scoops

AtomicHorror wrote: »

I thought those foreskin/HIV results were in some doubt these days... I'll go pubmedding for that.

There are pretty compelling data to suggest that it's moderately effective in heterosexual encounters of the non-anal variety. Certainly, it doesn't appear to do any harm. As Tallaght01 pointed out, it's a relative risk reduction within a certain, relatively short, time frame; whether it will have a big impact if introduced to an area where HIV is widespread is anyone's guess, but I suspect any minor effect will be become irrelevant as prevalence increases.

AFAIK, the jury is still out on whether is is still protective in the context of anal sex.

Edit: On topic, a doctor shouldn't recommend it one way or the other - just provide the facts and leave it up to the mammies and daddies.

tallaght01

2Scoops wrote: »

I suspect any minor effect will be become irrelevant as prevalence increases.

.

With a relative risk reduction (if it's sustained over a long period....24 months was the study lenght in all 2 randomised trilas from what I can remember) of about 60%, then this has the potential to have a massive effect in areas of high prevalence.

Heterosexual spread is the main method of transmission worldwide, and reducing the risk by about half should also have some additional "herd immunity" benefits, too.

I'm lopking forward to seeing some more long term data, though.

2Scoops

tallaght01 wrote: »

With a relative risk reduction (if it's sustained over a long period....24 months was the study lenght in all 2 randomised trilas from what I can remember) of about 60%, then this has the potential to have a massive effect in areas of high prevalence.

Well, my point is that in places where HIV prevalence is very high, like Botswana, a 50% relative risk reduction over a 2 year period probably won't be as impressive at attenuating your lifetime risk of infection. Incidence looks like it will almost certainly decrease in the short term if a large scale intervention is employed (that's another story) but population prevalence will be slowest to react to any intervention. So being 50% less likely to get HIV than your uncircumcised neighbour in Botswana means less and less as prevalence increases.

tallaght01

2Scoops wrote: »

Well, my point is that in places where HIV prevalence is very high, like Botswana, a 50% relative risk reduction over a 2 year period probably won't be as impressive at attenuating your lifetime risk of infection. Incidence looks like it will almost certainly decrease in the short term if a large scale intervention is employed (that's another story) but population prevalence will be slowest to react to any intervention. So being 50% less likely to get HIV than your uncircumcised neighbour in Botswana means less and less as prevalence increases.

well, one of the trials was conducted in Uganda, which has been the first African country to reduce the upward trend of HIV infection.

I'm making a (premature) assumption, that the reduction in incidence will be seen longer term than the 2 years. Problem is that A) the studies were only ever really meant to be over 2 years anyway (the control group were offered delayed circumcision, the intervention groups were offered immediate circumcision). But the reality is that they had to end the trials anyway, as the intervention group had so much less seroconversions.

I'm also basing my assumption on a large scale intervention being employed. I think this will be wasted data, if there isn't some concerted effort to offer the procedure to people if a long term effect is shown. In that case, of course incidence will be effected before prevalence. But with an average 10 year lifespan for HIV sufferers in sub-saharan africa, we'd see the change in prevalence reasonably quickly I think.

AtomicHorror

tallaght01 wrote: »

No way, dude.
3 excellent randomised trails have been conducted in the last few years. At least one even controlled for behavioural modification (ie higher risk behaviour in the circumcised group).

Most people think that widespread circumcision could potentially have huge effects on HIV transmission rates.

Fair enough. But at the same time, if we could get the same result from cutting off a part of a person's earlobe, would it be as readily accepted? There's a certain cultural acceptance of circumcision in some societies (even an expectation of it) which sets the procedure apart from other forms of "mutilation", if we can call it that.

I would also be curious as to what affect circumcision has on other disease transmission rates, as the foreskin has a high concentration of Langerhans cells. That same cell concentration is a part of what makes the foreskin an attractive infection site for X4 HIV particles but it could conceivably have a significant role in sampling of antigens from various other STIs. It would be a first point of contact for most of these, and I imagine must be a major player in the initiation of adaptive immunity to STIs. Now I admit I haven't read much literature on the above, but I think it must certainly be an important consideration.

In a country with a (relatively) low risk of HIV transmission, and wide availability and cultural acceptance of barrier contraceptives, I certainly don't think the story is... clear cut?

That was terrible, sorry.

tallaght01

AtomicHorror wrote: »

Fair enough. But at the same time, if we could get the same result from cutting off a part of a person's earlobe, would it be as readily accepted? There's a certain cultural acceptance of circumcision in some societies (even an expectation of it) which sets the procedure apart from other forms of "mutilation", if we can call it that.

I would also be curious as to what affect circumcision has on other disease transmission rates, as the foreskin has a high concentration of Langerhans cells. That same cell concentration is a part of what makes the foreskin an attractive infection site for X4 HIV particles but it could conceivably have a significant role in sampling of antigens from various other STIs. It would be a first point of contact for most of these, and I imagine must be a major player in the initiation of adaptive immunity to STIs. Now I admit I haven't read much literature on the above, but I think it must certainly be an important consideration.

In a country with a (relatively) low risk of HIV transmission, and wide availability and cultural acceptance of barrier contraceptives, I certainly don't think the story is... clear cut?

That was terrible, sorry.

We're not talking about cutting a peice of an earlobe off, though. We're talking about offering a choice to have an operation that many people have done anyway. In a high prevalence country, where you could potentially reduce your risk/child's risk of cntracting HIV by 60%, it would be worth thinking about. It's certainly something people should be offered as an option.

I don't think it's such a big issue in Ireland.

Also, with regard to STIs and circumcision. I don't know of any trials that are of the same power as the HIV trials, but there is reasonable evidence that circumcision lowers the risk of syphilis and chancroid.

AtomicHorror

tallaght01 wrote: »

We're not talking about cutting a peice of an earlobe off, though. We're talking about offering a choice to have an operation that many people have done anyway.

I do get that. My point was that prior to recent evidence, all that separated them was that cultural acceptance of circumcision. The rationale for it was pretty much anecdotal.

tallaght01 wrote: »

In a high prevalence country, where you could potentially reduce your risk/child's risk of cntracting HIV by 60%, it would be worth thinking about. It's certainly something people should be offered as an option.

You make a very compelling case, I'd just be worried that the scope of the research has been too limited. The safety precedent for circumcision is pretty hard to doubt in any meaningful way, mind you.

tallaght01 wrote: »

I don't think it's such a big issue in Ireland.

Also, with regard to STIs and circumcision. I don't know of any trials that are of the same power as the HIV trials, but there is reasonable evidence that circumcision lowers the risk of syphilis and chancroid.

There were a couple of reasonable meta-analyses on both- they do indeed support circumcision. I haven't been able to find anything large scale, nor any decent meta-analyses, to support my notion of an immunologically important foreskin. It could as easily be an evolutionary dead-end or even an impairment rendered selectively neutral by a hefty immune defence. The afore-mentioned historical safety precedent for circumcision would back that up I suppose.

Fionnanc

IS this cost-effective? Most of these high prevalence HIV areas don;t have clean drinking water or proper sewerage system. Circumsizing men whould require general anaesthesia. What about the complications? Circumcising babies may be potentially dangerous. Training circumsizers properly would be expensive and unjustified in a 3rd world setting and even in a 1st world setting.

IF somebody asked me to cirumcise their older son before going to a high risk area for HIV I would say no. There is a definate, but small risk of morbidity and mortality with the procedure and the general anaesthetic compared to a potential risk only. The boy can behave himself, family can set boundaries.
Even if a surgeon agrees to perform the procedure-who should pay for it here?

tallaght01

I would imagine a large scale circumcision programme would be cost affective, if they could get anything resembling a 60% risk reduction on an individual level. Not to mention the reduction in the infective pool this would achieve.

HIV in many developing countries has decimated the most economically active part of the population. It effects the 20-45 age group predominantly. These are the people an economy relies on. In countries with no social security, these are the people with dependent families, who will starve without them.

If you ever go to an African hospital, the wards are full of people with AIDS related illnesses.

Asise from the financial cost, there's a huge human cost of death on that scale.

Circumcisions in Africa in children show a less than 3% complication rate, most of which are pretty minor complications.

To say the boys can behave themself and the families can set bondaries is not really being realistic in terms of the public health reality of the HIV epidemic.

Fionnanc

I get your point Tallaght, but the money spent on a mass circumcision program should be spent on proper sanitation/pesticides to hit mosquitoes/drain stagnant water.
Half the kids don't make it to 4 years old in a lot of 3rd world countries who don't have a HIV rate

tallaght01

For starters, where are these contries with 50% under 4 mortality rates? (the international standard is the under-5 mortality rate, though). Particularly these developed countries that also don't have much HIV? Even in west Africa, the child mortality rate is maybe 15% max.

Saying that circumcision isn't cost effective is very different to saying it shouldn't be the first priority. You're using the two terms interchageably.

Fair enough, malaria and sanitation are huge issues in developing countries.

BUt AIDS is still the biggest killer in developing countries.

Also, bear in mind the following:

1) Civil unrest is a huge problem in Africa. Who will be responsible for the upkeep and maintenance of sanitation systems, particularly in volatile regions? Circumcisions require pretty minimal maintenance/repair. Circs don't require general anaesthetics.

2) The data suggests that access to sanitation and malaria nets are improving. They are still crap, but they're improving. Access to HIV medicine is improving too. But even at current rates, the optimistic aim is that in 1 in 15 sufferers will have acces to antiretrovirals over the next decade. Only ONE African country has reversed the upward trend in HIV infections.

3) The study referred to shows a risk reduction of 60%. This is hugely significant. Malaria nets don't give this kind of risk reduction. Full on Malaria clinics do (In some studies), but this involves on-going drug treatment.

4) The significant improvements in child mortality that's been made over the last decade has been due to better malaria prophylaxis, improved vaccination, pure breatfeeding, and improved sanitation. But HIV is the one part of this puzzle that the world has been helpless in providing help with.

I'm not suggesting people should be forcibly circumcised. BUt the risk reduction is comparable to some vaccines, and if we had a HIv vaccine, we'd all be gunning for widespread coverage.