Breakthrough study of 2011 and the tools for curbing HIV

The journal Science has named the HPTN 052 clinical trial, a study looking at the ability of antiretroviral medication to prevent HIV transmission, as the 2011 Breakthrough of the Year:

Led by study chair Myron Cohen, M.D., director of the Institute for Global Health and Infectious Diseases at the University of North Carolina at Chapel Hill, HPTN 052 began in 2005 and enrolled 1,763 heterosexual couples in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States and Zimbabwe. Each couple included one partner with HIV infection. The investigators randomly assigned each couple to either one of two study groups. In the first group, the HIV-infected partner immediately began taking a combination of three antiretroviral drugs. The participants infected with HIV were extensively counseled on the need to consistently take the medications as directed. Outstanding compliance resulted in the nearly complete suppression of HIV in the blood (viral load) of the treated study participants in group one.

In the second group (the deferred group), the HIV-infected partners began antiretroviral therapy when their CD4+ T-cell levels—a key measure of immune system health—fell below 250 cells per cubic millimeter or an AIDS-related event occurred. The HIV-infected participants also were counseled on the need to strictly adhere to the treatment regimen.

It was found that those taking the medication while their immune system was still highly healthy were 96% less likely to transmit HIV to their partners. This result was so stupendous that, even though the trial is still ongoing, an early public release of the findings was ordered. It is important that people know how to best combat transmission. That spread of information is what is needed to prevent the spread of infection:

“On its own, treatment as prevention is not going to solve the global HIV/AIDS problem,” said Dr. Fauci. “Yet when used in combination with other HIV prevention methods—such as knowing one’s HIV status through routine testing, proper and consistent condom use, behavioral modification, needle and syringe exchange programs for injection drug users, voluntary, medically supervised adult male circumcision, preventing mother-to-child transmission, and, under some circumstances, antiretroviral use among HIV-negative individuals—we now have a remarkable collection of public health tools that can make a significant impact on the HIV/AIDS pandemic.”

“Scale-up of these proven prevention methods combined with continued research toward a preventive HIV vaccine and female-controlled HIV prevention tools places us on a path to achieving something previously unimaginable: an AIDS-free generation,” Dr. Fauci added.

I added the emphasis to the above excerpt because I am reminded of the utter irresponsibility displayed by PZ Myers on this issue in the past. While I still very much like what the guy has to say on many subjects, he was dead wrong to dismiss any one of the listed tools. In this case, he specifically dismissed the notion that there is any evidence whatsoever that circumcision has any impact on HIV infection rates. As I’ve documented elsewhere, he is absolutely wrong on the facts. That evidence does exist and it is important that it is known. That is why Dr. Fauci noted it amongst all the other ways we must use to combat this disease. HIV/AIDS is one of the most serious epidemics facing the developing world today; no one should be proud to exacerbate the problem, especially when the motivation is ideological in nature – we’re talking about god damned human lives here.

Nope, wrong

PZ has a post about circumcision where he goes through the arguments in favor of the procedure based upon a video. (I haven’t watched the video nor will I because from what I gather it’s just a hack piece which does not focus on circumcision as performed by medical professionals in a medical setting.) Two of the arguments he quotes are apparently from a single guy and should just be boiled down to one: ’cause religion says to do it. Another one appeals to tradition, which is also a bogus argument, but then PZ has this last one:

The health benefits. Total bullshit. As one of the speakers in the movie explains, there have been progressive excuses: from it prevents masturbation to it prevents cancer to it prevents AIDS. The benefits all vanish with further studies and are all promoted by pro-circumcision organizations. It doesn’t even make sense: let’s not pretend people have been hacking at penises for millennia because there was a clinical study. Hey, let’s chop off our pinkie toes and then go looking for medical correlations!

PZ is wrong. The evidence has not suddenly vanished that circumcision prevents the transmission of HIV in high risk groups. Furthermore, it is blatantly invalid to dismiss this evidence because it may be used by pro-circumcision organizations, whatever those are.

If PZ wants to argue that circumcision holds little to no health benefits in places like the United States and other low risk nations for certain diseases, he can do that and be perfectly accurate. But if he wants to argue that circumcision has zero benefits in all circumstances, then he is in denial of the preliminary evidence.

Circumcision

Any time male circumcision is discussed, people can usually be described in one of three ways: 1) those who have had it done and thus favor it. 2) those who have not had it done and thus do not favor it. 3) Women. This third category doesn’t have any significant, inherent bias that can be easily detected (at least by me). That notion is true for Christiane Northrup and her anti-circumcision article.

Believe it or not, circumcision was introduced in English-speaking countries in the late 1800s to control or prevent masturbation, similar to the way that female circumcision–the removal of the clitoris and labia–was promoted and continues to be advocated in some Muslim and African countries to control women’s sexuality. [1]

Routine female circumcision, which has been practiced in some cultures, is completely unacceptable. Few people would argue otherwise. In fact, the United Nations has issued a decree against it. Circumcision is a form of sexual abuse whether it’s done to girls or boys.

I never like this tactic. Northrup first mentions female circumcision and does so relevantly – circumcision has been used as a tool to control sexuality. But then she goes on about it in the next paragraph, quickly trying to draw a connection between it and male circumcision. These are two entirely different things. One is violent, messy, often comes with complications, and is emotionally scarring in most instances. Who can guess which one I just described?

We justify male infant circumcision by pretending that the babies don’t feel it because they’re too young and it will have no consequences when they are older. This is not true. Women who experience memories of abuse in childhood know how deeply and painfully early experiences leave their marks in the body. Why wouldn’t the same thing apply to boys?

What does “abuse” mean in this context? While the article is generally well written, this paragraph is a bit of a mish-mash. Northrup tries equating female and male circumcision, goes on about pain, and throws in abuse, undefined. If female circumcision is meant here, it’s quite odd since Northrup talks about childhood trauma. If female circumcision isn’t meant here, then abuse first needs to be defined, then Northrup needs to explain why she is equating what happens to an infant to what happens to older children; one will remember the event – a key aspect in what defines “traumatic”.

In medical school, I was taught that babies couldn’t feel when they were born and therefore wouldn’t feel their circumcision. Why was it, then, that when I strapped their little arms and legs down on the board (called a “circumstraint”), they were often perfectly calm; then when I started cutting their foreskin, they screamed loudly, with cries that broke my heart? For years, in some hospitals, surgery on infants has been carried out without anesthesia because of this misconception!

The “pain argument” is often used by anti-circumcision advocates. That’s seemingly fair enough, especially coming from someone qualified like Northrup (who is an M.D.), but she quickly undermines the argument by pointing out the use of anesthetic. If hospitals are now using them, then there is virtually no pain, right? So…argument defeated?

But these are justifications that science has been unable to support. Nor is there any scientific proof that circumcision prevents sexually transmitted diseases.

This includes the recent studies done in Kenya, South Africa, and Uganda by Ronald H. Gray, a professor at Johns Hopkins University. He recently reported that men who were circumcised were less likely by half to contract HIV virus and less likely by one-third to become infected with HPV and herpes. [2]

While this sounds promising, I agree with my colleague George Denniston, M.D., who said, “The United States has high rates of HIV and the highest rate of circumcision in the West. The “experiment” of using circumcision to stem HIV infection has been running here for decades. It has failed miserably. Why do countries such as New Zealand, where they abandoned infant circumcision 50 years ago, or European countries, where circumcision is rare, have such low rates of HIV?”

When I first read this article, I had no knowledge of the author or anything of that nature. Upon reading the above excerpt, I assumed the person was a journalist or a passionate advocate, but not a doctor.

The evidence continues to mount that HIV transmission is reduced with circumcised penises during penile-vaginal intercourse. A number of studies have supported this. It’s surprising enough that Northrup disagrees on the point, but what really raises an eyebrow is her quote of George Denniston. Yes, the U.S. has a relatively high rate of HIV and yes, many in the U.S. are circumcised. So what? Where’s the evidence? Right now I see a broad correlation: the U.S. has a lot of two things. Okay, that’s great, but are there studies showing that HIV transmission is no different in circumcised versus uncircumcised men? Could other factors be at play? Given that the HIV prevention studies are based upon vaginal sex, could the higher acceptance of homosexuality be a contributing factor in the U.S. versus poorly developed, less accepting nations? What about number of partners? Do Americans tend to have more partners than others? There just needs to be more than a simple correlation.

Similarly, one of the main reasons people choose to have their child circumcised is they believe that it’s nearly impossible to keep an uncircumcised penis clean. This also isn’t true.

The best I have for the U.S. is a simple anecdote of a friend who got a circumcision at age 22 due to recurrent infections, and this was despite reportedly vigilant cleaning. Of course, on the whole, Northrup is right; it isn’t that hard to clean basically any part of the body, including the foreskin area. But one important caveat: for the West. Developed nations have constant access to showers and baths. Poorer nations where HIV is rampant are not always so high on hygiene. While cleaning is possible, the reality is that it may not always happen. That can be remedied, but I personally have to favor circumcision over a long and constant hygiene education program.

The next part of Northrup’s argument is titled “Religious Reasons”, but instead of really giving any or arguing against them, she describes how one religion does it and then concludes,

This allows the parents to practice their faith and adhere to tradition while protecting their child from a painful, medically-unnecessary procedure. This is far superior to what baby boys are subjected to in most hospitals. I know. I’ve done hundreds of circumcisions personally.

Again, the “pain argument” seems to be undermined.

Circumcision also has profound implications for male sexuality.

No. The evidence is weak, subjective, inconclusive, and extremely difficult to compare.

It would seem that a far better argument for the anti-circumcision crowd would be to just put the onus on the pro-circumcision crowd. Why do it at all? Here are basically the only real arguments.

1) Religion. This one sucks because all religions hold many falsehoods, tend to be based upon falsehoods, and do not offer actual arguments, only decrees and dogmas.

2) Tradition. So what? Circumcision is a non-moment in a baby’s life; he won’t remember it. The only way out of this is to say it’s a moment for a family. That might be true for Jews and some other religious groups (which aren’t merely doing it out of tradition, but religion, obviously), but it hardly seems to be the secular norm. And do families ever celebrate circumcisions later in life? What good comes out of this? There seems to be no point, no benefit from this reason.

3) Aesthetics. This is highly subjective, but more than a few accounts enthusiastically describe uncircumcised penises in negative terms. This is likely also true of circumcised penises, but would seem to be less so. This argument holds more water in countries where circumcision has become the norm.

The first two arguments are weak and dismissible. The third offers the most strength, I think. There seems to be no harm and it looks better by many standards. At the very least, this is a good argument against the level of vociferous opposition.