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Male Circumcision and HIV Prevention

Insufficient Evidence and Neglected External Validity
      Recent editorials have asked the global health community to scale up male circumcision for HIV prevention in regions with HIV epidemics following the publication of three randomized controlled clinical trials (RCCTs) in Africa (in South Africa, Uganda, and Kenya).
      • 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.
      • Bailey R.C.
      • Moses S.
      • Parker C.B.
      • et al.
      Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial.
      • Gray R.H.
      • Kigozi G.
      • Serwadda D.
      • et al.
      Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial.
      • Weiss H.A.
      • Halperin D.
      • Bailey R.C.
      • Hayes R.J.
      • Schmid G.
      • Hankins C.A.
      Male circumcision for HIV prevention: from evidence to action?.
      • Klausner J.D.
      • Wamai R.G.
      • Bowa K.
      • Agot K.
      • Kagimba J.
      • Halperin D.T.
      Is male circumcision as good as the vaccine we've been waiting for?.
      One editorial concluded: “The proven efficacy of MC [male circumcision] and its high cost-effectiveness in the face of a persistent heterosexual HIV epidemic argues overwhelmingly for its immediate and rapid adoption.”
      • Halperin D.T.
      • Wamai R.G.
      • Weiss H.A.
      • et al.
      Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence heterosexual epidemics: the time has come to stop debating the basic science.
      This “Current Issue” review questions not the internal validity of the studies, but their external validity, an issue that has been discussed more generally in two commentaries,
      • Green L.W.
      • Glasgow R.E.
      • Atkins D.
      • Stange K.
      Making evidence from research more relevant, useful, and actionable in policy, program planning, and practice: slips “twixt cup and lip.”.
      • Green L.W.
      The Prevention Research Centers as models of practice-based evidence: two decades on.
      an editorial,
      • Patrick K.
      • Scutchfield F.D.
      • Woolf S.H.
      External validity reporting in prevention research.
      and a systematic review of research on prevention trials
      • Klesges L.M.
      • Dzewaltowski D.A.
      • Glasgow R.E.
      Review of external validity reporting in childhood obesity prevention research.
      in this journal. External validity is the issue that questions the generalization from the RCCT results to a policy of “immediate and rapid adoption” of circumcision of men across Africa.
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      References

        • 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. 2005; 2: e298
        • Bailey R.C.
        • Moses S.
        • Parker C.B.
        • et al.
        Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial.
        Lancet. 2007; 369: 643-656
        • Gray R.H.
        • Kigozi G.
        • Serwadda D.
        • et al.
        Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial.
        Lancet. 2007; 369: 657-666
        • Weiss H.A.
        • Halperin D.
        • Bailey R.C.
        • Hayes R.J.
        • Schmid G.
        • Hankins C.A.
        Male circumcision for HIV prevention: from evidence to action?.
        AIDS. 2008; 22: 567-574
        • Klausner J.D.
        • Wamai R.G.
        • Bowa K.
        • Agot K.
        • Kagimba J.
        • Halperin D.T.
        Is male circumcision as good as the vaccine we've been waiting for?.
        Future HIV Ther. 2008; 2: 1-7
        • Halperin D.T.
        • Wamai R.G.
        • Weiss H.A.
        • et al.
        Male circumcision is an efficacious, lasting and cost-effective strategy for combating HIV in high-prevalence heterosexual epidemics: the time has come to stop debating the basic science.
        Future HIV Ther. 2008; 2: 399-405
        • Green L.W.
        • Glasgow R.E.
        • Atkins D.
        • Stange K.
        Making evidence from research more relevant, useful, and actionable in policy, program planning, and practice: slips “twixt cup and lip.”.
        Am J Prev Med. 2009; 37: 187-191
        • Green L.W.
        The Prevention Research Centers as models of practice-based evidence: two decades on.
        Am J Prev Med. 2007; 33: S6-S8
        • Patrick K.
        • Scutchfield F.D.
        • Woolf S.H.
        External validity reporting in prevention research.
        Am J Prev Med. 2008; 34: 260-262
        • Klesges L.M.
        • Dzewaltowski D.A.
        • Glasgow R.E.
        Review of external validity reporting in childhood obesity prevention research.
        Am J Prev Med. 2007; 34: 216-223
        • Gisselquist D.
        Points to consider: responses to HIV/AIDS in Africa, Asia, and the Caribbean.
        Adonis and Abbey, London2008 (chapter 7)
        • Weiss H.A.
        • Quigley M.A.
        • Hayes R.J.
        Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis.
        AIDS. 2000; 14: 2361-2370
        • Siegfried N.
        • Muller M.
        • Deeks J.
        • et al.
        HIV and male circumcision—a systematic review with assessment of the quality of studies.
        Lancet Infect Dis. 2005; 5: 165-173
        • Garenne M.
        Long-term population effects of male circumcision in generalized HIV epidemics in sub-Saharan Africa.
        Afr J AIDS Res. 2008; 7: 1-8
        • Connolly C.
        • Simbayi L.C.
        • Shanmugam R.
        • Nqeketo A.
        Male circumcision and its relationship to HIV infection in South Africa: results of a national survey in 2002.
        S Afr Med J. 2008; 98: 789-794
        • Talbott J.R.
        Size matters: the number of prostitutes and the global HIV/AIDS pandemic.
        PloS One. 2007; 2 (www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0000543): e543
      1. Lima V, Anema A, Wood R, 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.

      2. Bailey RC, Moses S, Parker CB, et al. The protective effect of male circumcision is sustained for at least 42 months: results from the Kisumu, Kenya trial. Oral presentation at the XVII International AIDS Conference, Mexico City; August 7; Abstract 16237 (2008). www.aids2008.org/Pag/PSession.aspx?s=288.

        • Turner A.N.
        • Morrison C.S.
        • Padian N.S.
        • et al.
        Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda.
        AIDS. 2007; 21: 1779-1789
        • Wawer M.J.
        • Makumbi F.
        • Kigozi G.
        • et al.
        Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial.
        Lancet. 2009; 374: 229-237
        • Bailey R.C.
        • Egesah O.
        • Rosenberg S.
        Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya.
        Bull World Health Organ. 2008; 86: 669-677
        • Nyakairu F.
        Uganda turns to mass circumcision in AIDS fight.
        Reuters Africa, 2008, Aug 13
      3. Irin, Swaziland: Circumcision gives men an excuse not to use condoms.
        UN Office for the Coordination of Humanitarian Affairs, 2008 Jul
        • Lalor K.
        Child sexual abuse in sub-Saharan Africa: a literature review.
        School of Social Sciences and Law, Dublin Institute of Technology, 2004
        • Aniekwu N.
        • Atsenuwa A.
        Sexual violence and HIV/AIDS in sub-Saharan Africa: an intimate link.
        Local Environ. 2007; 12 (informaworld.com/smpp/content∼content=a777659228&db=all): 313-324
        • Brewer D.D.
        • Potterat J.J.
        • Roberts J.M.
        • Brody S.
        Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania.
        Ann Epidemiol. 2007; 17: 217-226
        • Okeke L.I.
        • Asinobi A.A.
        • Ikuerowo O.S.
        Epidemiology of complications of male circumcision in Ibadan, Nigeria.
        BMC Urol. 2006; 6: 21
        • McAllister R.G.
        • Travis J.W.
        • Bollinger D.
        • Rutiser C.
        • Sundar V.
        The cost to circumcise Africa.
        Int J Men's Health. 2008; 7: 307-316
      4. Cold CJ, Taylor JR. The prepuce. BJU Int 83(1S):34–44.

        • Foss A.M.
        • Vickerman P.
        • Heise L.
        • Watts C.H.
        Shifts in condom use following microbicide introduction: should we be concerned?.
        AIDS. 2003; 17: 1227-1237
        • Foss A.M.
        • Vickerman P.
        • Heise L.
        • Watts C.H.
        Will shifts from condom to microbicide use increase HIV risk?.
        Int Conf AIDS. 2002; 14 (gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102254121.html)
        • Gusongoirye D.
        Rwanda: nothing can fight HIV/AIDS better than discipline.
        The New Times (Kigali), 2008, Feb 12
        • Anders T.F.
        • Sachar E.J.
        • Kream J.
        • et al.
        Behavioral state and plasma cortisol response in the human neonate (newborn).
        Pediatrics. 1970; 46: 532-537
        • Anand K.J.
        • Hickey P.R.
        Pain and its effects in the human neonate and fetus.
        N Engl J Med. 1987; 317: 1321-1329
        • Lander J.
        • Brady-Fryer B.
        • Metcalfe J.B.
        • Nazarali S.
        • Muttitt S.
        Comparison of ring block, dorsal penile nerve block and topical anesthesia for neonatal circumcision: a randomized controlled trial.
        JAMA. 1997; 278: 157-162
        • Williams N.
        • Kapila L.
        Complications of circumcision.
        Br J Surg. 1993; 80: 1231-1236
        • Paediatric Death Review Committee: Office of the Chief Coroner of Ontario
        Circumcision: a minor procedure?.
        Paediatr Child Health. 2007; 12: 311-312
        • Royal Australasian College of Physicians
        Ethics: a manual for consultant physicians.
        (Sydney, Dec 1998)
        • Siegfried N.
        • Muller M.
        • Volmink J.
        • et al.
        Male circumcision for prevention of heterosexual acquisition of HIV in men.
        Cochrane Database Syst Rev. 2003; (CD003362)
        • Donovan B.
        • Ross M.W.
        Preventing HIV: determinants of sexual behaviour.
        Lancet. 2000; 355: 1897-1901

      Linked Article

      • Circumcision Denialism Unfounded and Unscientific
        American Journal of Preventive MedicineVol. 40Issue 3
        • Preview
          Although three RCTs1–3 and dozens of observational studies have confirmed 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 are unethical and immoral.
        • Full-Text
        • PDF
      • Male Circumcision As a Component of Human Immunodeficiency Virus Prevention
        American Journal of Preventive MedicineVol. 40Issue 3
        • Preview
          A paper by Green et al.1 questions the external validity of the three RCTs of medical male circumcision for HIV prevention, all of which reported 50%–60% reduction of HIV acquisition in heterosexual circumcised men. The trials differed in the age of participants, background HIV incidence, and surgical techniques, and it is very encouraging that they achieved such similar results. Here, we address the key points from that paper:
        • Full-Text
        • PDF