How the circumcision solution in Africa will increase HIV infections

Paper published in Journal of Public Health in Africa,  Vol 2, No 1 (2011); 2:e4. doi:10.4081/jphia.2011.e4

The article was authored by Dr. Robert S. Van Howe, a pediatrician who has studied the harmful effects of infant circumcision. In this paper, Dr. Van Howe examines the oft-cited randomized clinical trials (RCTs) performed in Africa.

Based on the evidence collected in the RCTs and presented in the numerous studies based on the RCTs, Dr. Van Howe determined that the published results are overstated and unsupported by the evidence. He concludes that the "circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections."

Lack of scientific evidence

 

The results of three randomized clinical trials (RCTs) are often presented as proof beyond a reasonable doubt that male circumcision prevents HIV infection.2 After all, RCTs are the gold standard of medical experimentation. However, such accolades only apply to well-designed, well-executed trials. The three RCTs were neither.
 

The trials were nearly identical in their methodology and in the number of men in each arm of the trial who became infected. The trials shared the same biases, which led to nearly identical results. All had expectation bias (both researcher and participant), selection bias, lead-time bias, attrition bias, duration bias, and early termination that favored the treatment effect the investigators were hoping for. All three studies were overpowered such that the biases alone could have provided a statistically significant difference.
 

The common hypothesis for these trials was that male circumcision would decrease the rate of heterosexually transmitted HIV infections. A basic assumption adopted by the investigators was that all HIV infections resulted from heterosexual transmission, so no effort was made to determine the source of the infections discovered during the trial. There is strong evidence that this assumption was not valid.