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Open Access Research article

Male circumcision for HIV prevention - a cross-sectional study on awareness among young people and adults in rural Uganda

Andrea Wilcken*, Flavia Miiro-Nakayima, Ramadhan NB Hizaamu, Thomas Keil and Dorothy Balaba-Byansi

BMC Public Health 2010, 10:209  doi:10.1186/1471-2458-10-209

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False assumptions

Hugh Young   (2010-06-21 14:59)  Independent researcher

This study assumes that the papers they cite contain the final truth about circumcision preventing HIV, and "awareness" means agreeing with that "truth", but science does not work that way.

There are many problems with the Auvert, Gray and Bailey studies. They were neither placebo-controlled nor double-blinded (the true gold standard of medical research) and though the paid volunteers for circumcision were randomised to be circumcised immediately or later, they were not a random sample of the general population. They were apparently recruited by snowball techniques, which tend to gather people from similar demographics, and may even have included a disproportionate number of men with sexual partners in common (whether they knew it or not).

It was assumed that all HIV transmission was (hetero)sexual, when this is often not the case. A number of confounding factors were assumed to be corrected by the randomisation process, when this may not be the case. They include early termination bias1, attrition bias (several times the number of men infected were lost from study), number of sexual partners, frequency of intercourse, nature of intercourse (especially "dry sex" reportedly almost exclusively a practice where the man is not circumcised2), use of condoms, and HIV status of partners. Some of these were measured, but only by self-report. Circumcision may change any of these (including even HIV status of partner/s, if it opens or closes access to a better or worse class of partner/s).

There are a number of countervailing studies, and contrary evidence continues to come in. In at least six African countries, more of the circumcised men have HIV than the non-circumcised men, according to the National Health and Demographic Surveys, as Way et al demonstrate.3Seventy-two per cent of new HIV infections in Malaysia are Muslim, while only 60.4% of the population is Muslim. (Virtually all Muslim men are circumcised, while men of the other religions of Malyasia are not.)

While circumcision may (or may not) partially protect men from infection by women, it does not protect women from infection by men, and may even increase the risk.4

Thus it may be that people who scored low for "awareness" actually understand the true effect of circumcision better than the authors.


1. Bassler D, Briel M, Montori VM, et al.
Stopping Randomized Trials Early for Benefit and Estimation of Treatment Effects: Systematic Review and Meta-regression Analysis
JAMA 2010, 303(12):1180-1187

2. Halperin DT.
Dry sex practices and HIV infection in the Dominican Republic and Haiti.
Sexually Transmitted Infections 1999, 75:445-446.

3. Way A, Mishra V, Hong V, Johnson K.
Is male circumcision protective of HIV infection?
AIDS 2006 - XVI International AIDS Conference Abstract no. TUPE0401

4. Wawer MJ, Makumbi F, Kisogi 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(9685):229-37

Competing interests

I maintain the Intactivism Pages , a site supporting genital autonomy for all ages and sexes, primarily as a human rights issue.

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Circumcision and HIV prevention

Mark Lyndon   (2010-06-21 14:56)  none

The use of medical circumcision for HIV prevention is not without controversy. See for example:
Male circumcision is not the HIV 'vaccine' we have been waiting for!

Competing interests

None declared

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