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New Zealand AIDS Foundation
March 1995:
...
In a review of the literature, de Vincenzi and Mertens concluded that ...lack of distinction between susceptibility and infectivity, inadequate control for confounding variables, potential selection bias and misclassification of exposure, inappropriate choice of a comparison group, and publication bias, may lead to under- or overestimation of the association [between circumcision and HIV status]. It is difficult to predict the net effect of these sources of bias. Furthermore, the magnitude of the association varies strongly between studiesand its crude measure is overestimated in some reports.
Another meta-analysis, by Moses et. al (1993) concluded A considerable body of evidence exists, though not completely consistent, linking non-circumcision in men to increased risk of HIV.
...
Kreiss et al. questioned 316 HIV seropositive and 186 HIV seronegative men and found (after correcting for race, history of IV drug use and history of syphilis) that among uncircumcised men, the proportion of HIV risk attributable to uncircumcised status was 50%
That is, that other things being equal an uncircumcised man is twice as likely as a circumcised man to contract HIV. A later publication (Kreiss 1993) based on the same data is more specific, adding in this study
and in Seattle
.
Being uncircumcised can have no direct effect on the risk of any practices except insertive penetration, being docked (and to a much lesser extent, docking) or mutual masturbation using cum as a lubricant, but the only practice subjects were asked about was receptive anal sex. Kreiss says (personal communication) that this finding is paradoxical. A correlation between uncircumcision and syphilis suggests one possible indirect connection, and the presence of CD4 receptor cells in the foreskins of rhesus macaques, another. A correlation was also found between being circumcised and IV drug use. This was not discussed.
However, the subjects' (un)circumcision status was determined by asking, though the small number of men described as uncircumcised (77, 59 of them HIV seropositive and only 18 HIV seronegative) meant a small number of incorrect reports could significantly change the outcome. Three men's statuses were not recorded.
Surick et al (cited in Vincenzi (1994)) found that 17.7% of uncircumcised men and 8.4% of circumcised men misclassified themselves, throwing serious doubt on any study relying on self-reporting, especially where the number of men in either category is small.
Kreiss et al. assume that men choose their sexual partners regardless of their circumcision status. The existence of magazines and clubs for uncircumcised men indicates that this is not so.
These uncertainties cast serious doubt on the conclusion that The potential impact of circumcision as an intervention strategy to reduce both homosexual and heterosexual transmission of HIV could be significant and warrants further evaluation.
- Kreiss (1993) (The conclusion was more emphatic in Kreiss (1992)). The potential impact of penotomy would be even more significant. The human rights affront of neonatal male circumcision differs greatly in degree, but not in kind, from that of female genital mutilation. Debate on this issue (Fink (1987) et seq.) is contentious and emotional (men are naturally attached to their foreskins....), and seems to be to some extent a reawakening of age-old issues around circumcision that have little to do with health or hygiene.
The value of meta-analyses is open to question where so much emotional freight is carried: the average of a number of flawedstudies will also be flawed.
...
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