Bloodborne HIV: Don't Get Stuck!

Best evidence: Yes, circumcised men seem to transmit HIV faster

One randomized controlled trial looked at the issue.[1] During 2003-7, researchers in Uganda ran a study to “test whether male circumcision would reduce transmission of HIV…to their uninfected female sex partners.” The study recruited HIV-positive intact men and their HIV-negative partners (wives, steady partners), then on a random basis circumcised some men but not others, and then followed all partners, testing women from time-to-time to see who got HIV (to be sure a woman’s HIV came from her man, the study confirmed that a couple’s HIV were similar).

The study found circumcised men were 1.58 times more likely to transmit compared to intact men: 18% (17 of 92) of  women with circumcised partners got HIV compared to only 12% (8 of 67) of women with intact partners.[1] But because the trial saw only 25 new infections, there was a 28% chance this result was a statistical accident (due to chance only).

Notably, the relative risk for women with a circumcised man increased over time: during the first 6 months partners of circumcised vs intact men were 1.46 times more likely to get HIV; from 6-12 months, they were 1.52 times more likely to get HIV; from 12 to 24 months, they were 2.3 times more likely to get HIV. (However, these statistics are unreliable because of small numbers of infections.)

But the study was stopped early…

By design, the trial planned to follow all women for two years: “the female acquisition end point cannot be determined prior to the completion of the trial.” [p 40 in reference 2]. This trial design makes sense, because once men are circumcised to see what happens to women’s HIV risk, men’s foreskin cannot be reattached.

Despite the plan to follow women for two years, the research team stopped the trial early. The excuse was that the study was unlikely to show circumcising an HIV-positive reduced the risk he would infect his partner.

Here’s what Jim Thornton (former editor, British Journal of Obstetrics and Gynaecology) says about stopping the trial early[3]: “Consider a treatment which affects husbands and wives. Treating one automatically treats the other. Evidence accumulates that it is good for the husband but results are unclear for the wife. It would be bonkers to stop when interim data showed a non-significant harmful trend for wives, on the grounds that the treatment was never going to be good for them, and then go ahead and implement it!   But that’s what the authors of the only trial ever to test the effect of male circumcision on HIV transmission to the woman did…”.

The trial was unethical (and illegal?)

The trial was unethical by design: Researchers recruited HIV-positive men even if they were not willing to learn their HIV status and to warn their partner. “[A]bout a quarter” of HIV-positive men did not tell their partners they were HIV-positive.[1]

Following women at risk without warning them is unethical. It may have been illegal as well. According to Ugandan law, “any person who unlawfully or negligently does any act…which he or she knows or has reason to believe to be likely to spread the infection of any disease dangerous to life commits an offence and is liable to imprisonment for seven years.”[4]

Researchers (and UNAIDS) disregard women’s risk to get HIV from circumcised men

The research team recommended “…circumcision for remaining HIV+…men who had completed their 2 year follow-up…”[5] Compounding the damage, researchers did not insist on couple counseling before circ’ing HIV-positive men, even though many women were not aware their partners had HIV.

Similarly, the research team recommended circ’ing men in Africa whether they are HIV-positive or not, and without insisting on prior HIV tests and couple counseling. UNAIDS offers the same anti-women advice: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative.”[6]

Don’t forget women’s non-sexual risks for HIV!

There’s a lot of evidence that much if not most HIV among women in Africa comes from healthcare and other bloodborne risks. For example:

• A survey among students 5 high schools in Umgungundlovu District of KwaZulu-Natal found 135 HIV-positive girls of which 77 (35%) reported they were virgins.[7]
• 15 studies of new HIV infections in pregnant and early postpartum women in Africa report women getting new infections at rates from 6.1% to 19% per year;[8] these rates are higher — many are much higher — than could be expected from sex.

References

1. Wawer MJ, 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. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2905212/ (accessed 22 October 2018).

2. Wawer MJ, Seerwadda D. Randomized trial of male circumcision: STD, HIV and behavioral effects in men, women and the community. Protocol. 2007. Available at: https://doi.org/10.1371/journal.pmed.0050116.sd001 (accessed 9 May 2020). This  document is also available as supplementary material Text S1 in: The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med 2008. Available at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050116 (accessed 26 April 2018).

3. Thornton J. This’ll turn you feminist. blog post on Ripe-tomato.org. Available at: https://ripe-tomato.org/2014/12/21/thisll-turn-you-feminist/ (accessed 18 April 2018).

4. Wesaka A. Lab technician arrested over falsification of HIV test results. Daily Monitor, 8 March 2018. Available at: http://www.monitor.co.ug/News/National/Lab-technician-arrested-falsification-HIV-test-results/688334-4334338-o0n96tz/index.html (accessed 23 April 2018).

5. Wawer MJ. NCT00124878: Trial of male circumcision: HIV, sexually transmitted disease (STD) and behavioral effects in men, women and the community. Available at: https://clinicaltrials.gov/ct2/show/NCT00124878 (accessed 25 April 2018).

6. Quote from p. 7 in: UNAIDS, 2008. Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations. Available at: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf (accessed 1 December 2011).

7.  Kharsany ABM, Buthelezi TJ, Frohlich JA, et al. HIV infection in high school students in rural South Africa: role of transmissions among students. AIDS Res Hum Retroviruses 2014; 30: 956-965. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179919/ (accessed 13 February 2018).

8. Gisselquist D. Missed signals: not investigating HIV incidence in pregnant women in Africa. SSRN, 17 April 2018. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3153795 (accessed 20 April 2018).