HIV 07: van Howe

Date: Fri, 13 Oct 1995 15:19:36 -0500

Wiswell has published that the foreskin CAUSES urinary tract infection based on studies, the design of which make it impossible to ever prove causality. Physicians who do not understand the lack of power in a retrospective chart review or who are promoting circumcision have actually believed Wiswell. Unlike Wiswell I have not intentionally been misleading, but was trying to provoke thought on this cloudy issue.

The experiment of circumcision in the United States has obviously failed to protect the men there from HIV infections. With 90% of men in their 20's and 30's circumcised, would circumcising the other 10% have made the HIV pandemic any different in the United States? It may have made it worse. Who knows? This needs to be thoroughly investigated, however, before circumcision can be recommended in the fight against HIV. An association calls attention to the need for further study. Any further conclusion is not warranted.

Also the AIDS rates in Asia reflect the locations where American servicemen prefer to get their R&R. This suggests that American males in their late teens and early twenties, 90% of whom are circumcised, may be a vector in spreading HIV throughout Asia. Why else would Guam have such a high rate of AIDS?

It has been suggested that the tight skin over an erect circumcised phallus predisposes it to abrasions, tears, and bleeding, which may increase the possibility of transmission of HIV during vaginal or anal intercourse. (Beaugi M. Conservative Treatment of Primary Phimosis in Adolescents [Traitement Me/dical du Phimoseis Congenital de L'Adolescent]. Saint-Antoine University. Paris VI. 1990-1991.)

There is also difficulty in adequately studying relatively rare events. Fortunately, while an HIV infection is deadly, it is rare. The WHO rates for AIDS in the US are 14 per 100,000. In order to draw reliable conclusions about rare illnesses, the number of patients studied need to be inordinately large. The flip side of this coin is that statistically, large numbers can prove things to be statistically different where no appreciable clinical difference exists (an example of this is Wiswell's studies on circumcision and urinary tract infections). The alternative is to study populations who are, for whatever reason, at a higher risk than the general population. The trouble with these studies is whether the results are applicable to the general population. Also the low number of patients decreases the statistical power of the results (which is why most of the studies looking at HIV and circumcision have huge 95% confidence intervals). All of these factors lead to perpetual uncertainty and proponents of different agendas using the samedata in different ways.

It is certainly not my role to promote disingenuous positions.

Bob Van Howe

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