STEPHEN STRAUSS:
No shortcuts in circumcision
CBC News Viewpoint | November 21, 2005 | More from Stephen Strauss
 Stephen
Strauss wrote articles, columns and editorials about science and
technology for the Globe and Mail for more than 20 years. He has also
authored three books, several book chapters, and for his efforts
received numerous awards. Through all his time in journalism, he still
remains smitten by the enduring wisdom of the motto of Austrian writer
Karl Kraus. Say what is.
Snippety, snip, snip. Could that be the sound of AIDS in retreat in Africa?
The auditory metaphor and its effect come to mind if you spend any time
reflecting on a much-publicized South African study tying a dramatic
decline in HIV infection rates to circumcision. But well might you
think just the opposite if you were apprised of the sometimes putrid
public health politics underlying publication of said study.
The facts seem straightforward on the surface. Some 3,000 young men –
hardly any married – were selected from a semi-rural area near
Johannesburg. Half were put in a group that got circumcisions, half in
a non-circumcised group. After more than a year, 20 of the circumcised
men had become HIV positive versus 49 of the uncircumcised men, this
even though the circumcised men had more sexual encounters.
The scientists were jubilant. "The result is equivalent to saying that
during the period [of the study] the intervention prevented six out of
10 potential infections," wrote the French and South African
researchers who conducted the research, adding, "this provides a degree
of protection against acquiring HIV infection equivalent to what a
vaccine of high efficiency would have achieved."
The finding was so striking, the researchers stopped the trial before
it was supposed to finish because the "protective effect of male
circumcision was so high it would have been unethical to continue."
That is to say, they thought there was no doubt that circumcision
protected against HIV infection.
Finally, the effectiveness of circumcision led the scientists to argue
that decision makers should herewith consider making circumcision of
all African men a public health priority.
Wonderful, except for all the ethical and methodological mud splattered on the findings.
As a background you should know the project grew out of more
than two decades of observation that places in Africa where
circumcision was the norm had less AIDS than the uncut places. We are
not, by the way, simply talking about Muslim Africa but also tribes
where male circumcision is part of a rite of passage into adulthood.
While scientists have been able to come up with numbers of physical
explanations for why what has sometimes been snidely called the "cut
cure" works, nobody has been certain about the connection. This is
because no previous studies have controlled for confounding factors –
age at circumcision, number of sexual partners, safe sex practices –
that could distort results. So the Johannesburg study was vital in
translating anecdote and intimation into believable science.
However, there was a fundamental ethical problem with its methodology.
The men were given HIV tests before the project began and 146 were
found to be HIV positive, but – underline the following in lipstick red
– they weren't told about their status as researchers "considered it
unethical to inform participants of their HIV status without their
permission."
Gasp. You don't tell people with a life-threatening, highly infectious
disease they are both sick and dangerous to others because knowing
somehow violates their sense of privacy?
To justify this position, French and South African scientists involved
argued that they were just respecting a fear of AIDS stigma so intense
that "many of these people prefer to be dead than rejected by their
communities."
Gasp again. This is a public health position so obviously crazy – think
in the Canadian context of not telling people with SARS they had it
because they would be stigmatized and quarantined – it led the British
journal The Lancet to reject the publishing of the AIDS paper on the
grounds it was ethically flawed.
And there may be a worse confusion to come. Not everyone
believes the HIV infection numbers in men who hadn't been circumcised
were so conclusive they justified the trial being shut down early. Part
of the concern was caused by two recent papers that suggest that
clinical trials claiming huge, big, early effects from drugs or other
treatments as often as not turn out to be statistical blips and not
true results.
Could that be the case here?
"My sense is that the circumcision study may have been stopped too
early and that there is a real danger we may be subjecting hundreds of
thousands or millions of men to having circumcisions that may not have
the benefit we assume," Jeremy Grimshaw, director of the Clinical
Epidemiology Program at the University of Ottawa, warns me about the
South African study.
Gasp a third time. So why stop a study when the number of people who
had become infected wasn't even half as large as the number who had the
disease to start with and weren't told they had it? My guess is a
guilty conscience. The doctors wanted an excuse to tell all the
infected of their condition, no matter the stigmatization, and the
early, positive statistics gave them just such an out.
My justification for this charge is that immediately after they closed
down the trial, the researchers changed the rules so they could inform
people of their disease, even if the people initially said they didn't
want to know.
Maybe other, still ongoing trials will support the cut cure, but for
the time being my faith in this one has gone snippety, snip, snip.
^TOP
CBC Ombudsman
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