Circumcision and AIDS: Harvard Doctors Respond to Criticism

Could a whole coalition of highly accomplished, super educated doctors and researchers -- the ones who work at and advise the Gates Foundation, the World Health Organization, the American Academy of Pediatrics, and the Harvard School of Public Health -- all be wrong?

Or are their critics hindering them from saving lives?

As described in our recent feature story about circumcision, three studies conducted in

Africa in the past decade generated a whopping amount of press and have been the catalyst for tens of millions of dollars being pumped into campaigns to circumcise African men in an effort to stem the spread of AIDS.  These three randomly controlled clinical trials (the three "African RCTs," as they are sometimes called) were carried out in (I'm linking to the source material here): Uganda, South Africa, and Kenya.

These three famous studies have, in fact, had challenges. John Geisheker, head of an organization called Doctors Opposing Circumcision, says that researchers "did a marvelous job of attracting Gates Foundation money and creating a halo around the organization" and that people are "trying to capitalize on the Africa market. If American medical companies like Allied can get a hold of this money, they can make billions. The Africans don't even realize they're being used like guinea pigs." He said that when he's contacted the Gates Foundation with contradictory research and warned them to slow down, he doesn't even get a response.

The bigwigs in the international health arena have largely ignored criticism and are forging ahead with plans to circumcise 20 million African men by 2015. 

Who's right?

All of the studies and counterstudies on the subject matter are enough to make one's head spin. For those of you interested in going down this rabbit hole, I've linked to the initial studies (above), read through much of the criticism, and contacted people at the Gates Foundation as well as the Harvard School of Public Health to see if they would respond to some of the points made by detractors.

Here is what I found.

First, I contacted the Gates Foundation, but despite the fact that it has invested millions of dollars into this project, I was told that it didn't have anyone who could speak to me about this matter.

Then I contacted Dr. Max Essex, chairman of the Harvard School of Public Health's AIDS Initiative, with the following four questions. I purposely cited articles that have been published rather than link to websites run by anticircumcision activists.

1) The three RCTs say that circumcision reduces risk of HIV infection by 53
to 60 percent.  Critics argue that that is the "relative reduction" as
opposed to the "absolute reduction" and that if the absolute reduction were
used as a comparison, the numbers would be statistically insignificant.
Thoughts? (This article lays out that argument more clearly:
http://www.salem-news.com/fms/pdf/2011-12_JLM-Boyle-Hill.pdf )

2) Education and condoms are far cheaper than circumcision, so why spend
tens of millions of dollars on circumcision rather than direct that money
toward education and condom use? (http://www.icgi.org/Downloads/IAS/McAllister.pdf)

3) Circumcision is sometimes referred to as a "vaccine" (see New York Times
article of January 31 :
http://www.nytimes.com/2012/01/31/health/aids-prevention-inspires-ways-to-simpli
fy-circumcision.html?pagewanted=all)
Do you find this accurate? Misleading? What is the status of a
vaccine for HIV/AIDS?

4) Some articles have suggested that removing the foreskin prevents HIV
transmission because HIV enters through the Langerhans cells; yet there are
competing articles alleging that the Langerhans cells actually "lap up" the
virus and protect against it. See :
http://www.nature.com/nm/journal/v13/n3/full/nm0307-245.html


Dr. Essex responded: "it seeems to me that male circumcision would be even less expensive than condoms + education.   It only costs 50-75 $ as a one time event.   Hovever the
person in our group who is most knowlegeable on  MC is Dr Rebeca Plank.  I'll cc
heer on this."  [sic]


Dr. Plank then wrote:

"I will defer to Dr. Essex where it comes to prospects for a vaccine against HIV and also about the basic science of Langerhans cells as he knows much more about these topics than I do.

I can say, however, that male circumcision is a one-time intervention with life-long benefit. It can be likened to a vaccine in that REDUCES (but does not eliminate) the risk of infection with a particular agent, and also REDUCES the risk of that infection establishing itself in the community (herd immunity), which is one of the public health principles on which all vaccines stand. Male circumcision for HIV prevention is like getting vaccinated PLUS hand-washing, not touching one's face, mask-wearing when appropriate to prevent the flu rather than remaining unvaccinated and trying to rely on hand-washing, not touching one's face, mask-wearing alone to prevent the flu.

As Dr. Essex has indicated, male circumcision is much cheaper than condoms + education (one male circumcision in southern Africa is < U$100 and each condom costs almost U$1.00 -- although circumcised men should still use condoms consistently). The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recently published modeling data that one HIV infection would be averted for every 5-15 men newly circumcised. Compared to other public health interventions male circumcision is extremely effective (please see Nanchen Prev Med. 2011 Feb 1;52(2):159-63. Epub 2010 Dec 3 that estimates 38-92 people would have to be treated for ten years each with cholesterol lowering medicine to prevent one death from heart attack -- and we put a lot of stock in these cholesterol lowering medicines which are much, much more expensive than one circumcision).

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000109

Another recent publication estimates that to scale-up male circumcision in the areas of Africa that have both 1) very high prevalence rates for HIV and 2) low prevalence rates of male circumcision, it would cost US$2 billion yet would result in net savings (due to averted treatment and care costs) of US$16.51 billion.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001132

Furthermore, despite the widespread availability of education + condoms in a country like Botswana for years and years, the HIV incidence and prevalence continued to be extraordinarily high, with the most recent statistics (2008) showing that in certain age groups the HIV prevalence rate reaches 40% (in the US the HIV prevalence is < 2%). It can be likened to obesity or diabetes in the US. People know that a salad is better for their health than potato chips or ice cream: salad is widely available as is education about the dangers of obesity, yet education and availability of healthy food have not been able to control the obesity epidemic in our own country. Human behavior isn't easy to understand and it is even harder to control.

Regarding the salem-news article you sent, those at the highest levels of public health science and implementation (WHO and UNAIDS) have reviewed the methodology, statistics and results of the three randomized trials of male circumcision and they are in full support of scale-up of this service as soon as possible. We are already delayed. There is a lot of highly charged and emotional controversy about male circumcision, despite peer-reviewed data from randomized control trials considered the gold standard in clinical medicine, that sadly is impeding scale-up. Men and their female partners are getting infected with HIV unnecessarily. If this were a vaccine that came in a sterile glass vial it would almost certainly be celebrated and not debated."