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Rennie S, Gilbertson A, Hallfors D, Luseno WK. Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106293. [PMID: 33148776 PMCID: PMC8144939 DOI: 10.1136/medethics-2020-106293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 05/03/2023]
Abstract
The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision (VMMC) initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic 'success', and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets.
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Affiliation(s)
- Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam Gilbertson
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Denise Hallfors
- Retired, Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
| | - Winnie K Luseno
- Pacific Institute for Research and Evaluation, Chapel Hill Center, Chapel Hill, North Carolina, USA
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Feldacker C, Holeman I, Murenje V, Xaba S, Korir M, Wambua B, Makunike-Chikwinya B, Holec M, Barnhart S, Tshimanga M. Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe. PLoS One 2020; 15:e0233234. [PMID: 32544161 PMCID: PMC7297350 DOI: 10.1371/journal.pone.0233234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up. METHODS The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively. RESULTS Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to engage in their healing, and closed gaps in MC service quality. For scale, providers reinforced good post-operative counseling on AEs and texting instructions. Wage and age did not influence text response rates or potential AE texts. CONCLUSION Results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns solicited provider guidance and reassurance offered via text. Providers noted that men engaged proactively in their healing. 2wT between providers and patients should be expanded for MC and considered for other short-term care contexts. The trial is registered on ClinicalTrials.gov, trial NCT03119337, and was activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Isaac Holeman
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Medic Mobile, Nairobi, Kenya
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | | | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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Sivhabu V, Visser M. Constructions of sexuality and HIV risk among young people in Venda, South Africa: implications for HIV prevention. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 18:158-167. [PMID: 31282301 DOI: 10.2989/16085906.2019.1630449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people's sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people's sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions).
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Affiliation(s)
- Veronica Sivhabu
- a Department of Psychology , University of Pretoria , Pretoria , South Africa
| | - Maretha Visser
- a Department of Psychology , University of Pretoria , Pretoria , South Africa
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Rethinking prevention: Shifting conceptualizations of evidence and intervention in South Africa’s AIDS epidemic. BIOSOCIETIES 2017. [DOI: 10.1057/s41292-017-0062-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Saeedian M, Khalighi M, Azimi-Tafreshi N, Jafari GR, Ausloos M. Memory effects on epidemic evolution: The susceptible-infected-recovered epidemic model. Phys Rev E 2017; 95:022409. [PMID: 28297983 PMCID: PMC7217510 DOI: 10.1103/physreve.95.022409] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 12/20/2016] [Indexed: 12/02/2022]
Abstract
Memory has a great impact on the evolution of every process related to human societies. Among them, the evolution of an epidemic is directly related to the individuals' experiences. Indeed, any real epidemic process is clearly sustained by a non-Markovian dynamics: memory effects play an essential role in the spreading of diseases. Including memory effects in the susceptible-infected-recovered (SIR) epidemic model seems very appropriate for such an investigation. Thus, the memory prone SIR model dynamics is investigated using fractional derivatives. The decay of long-range memory, taken as a power-law function, is directly controlled by the order of the fractional derivatives in the corresponding nonlinear fractional differential evolution equations. Here we assume "fully mixed" approximation and show that the epidemic threshold is shifted to higher values than those for the memoryless system, depending on this memory "length" decay exponent. We also consider the SIR model on structured networks and study the effect of topology on threshold points in a non-Markovian dynamics. Furthermore, the lack of access to the precise information about the initial conditions or the past events plays a very relevant role in the correct estimation or prediction of the epidemic evolution. Such a "constraint" is analyzed and discussed.
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Affiliation(s)
- M Saeedian
- Department of Physics, Shahid Beheshti University, G.C., Evin, Tehran 19839, Iran
| | - M Khalighi
- Department of Physics, Shahid Beheshti University, G.C., Evin, Tehran 19839, Iran
| | - N Azimi-Tafreshi
- Physics Department, Institute for Advanced Studies in Basic Sciences, 45195-1159 Zanjan, Iran
| | - G R Jafari
- Department of Physics, Shahid Beheshti University, G.C., Evin, Tehran 19839, Iran
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran
- Center for Network Science, Central European University, H-1051 Budapest, Hungary
| | - M Ausloos
- GRAPES, rue de la Belle Jardinière 483, B-4031 Angleur, Belgium
- School of Management, University of Leicester, University Road, Leicester LE1 7RH, United Kingdom
- eHumanities group, Royal Netherlands Academy of Arts and Sciences, Joan Muyskenweg 25, 1096 CJ, Amsterdam, The Netherlands
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Van Howe RS. Expertise or ideology? A response to Morris et al. 2016, ‘Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe’. Glob Public Health 2017; 13:1900-1918. [DOI: 10.1080/17441692.2016.1272939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Robert S. Van Howe
- Department of Pediatrics, Central Michigan University College of Medicine, Saginaw, MI, USA
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Morris BJ, Barboza G, Wamai RG, Krieger JN. Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe. Glob Public Health 2016; 13:1889-1899. [PMID: 27043484 DOI: 10.1080/17441692.2016.1164737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A meta-analysis by Van Howe of 109 populations confirms the well-known association of male circumcision (MC) with reduced HIV prevalence. He then performed meta-regression adjusting for location, risk and MC prevalence. When one or two of these adjustments in combination were applied MC appeared protective, but when all three were introduced the association remained significant in high-risk populations, but not in general populations within Africa with a hypothetical MC prevalence of <25% or elsewhere with hypothetical MC prevalence of <75%. However, many MC prevalence values given differed from those reported in references cited (including all US studies). This and other problems invalidate his adjustments for MC prevalence, undermining most of his meta-regression results. Meta-regression is a highly sophisticated statistical tool and is prone to error if not applied correctly. The study contained a high risk of bias arising from confounding. We also question his use of crude, rather than adjusted, odds ratios and his inclusion of unpublished data, so precluding replication by others. Flawed statistics, opaque presentation of results and inclusion of previously repudiated arguments downplaying a role for MC in HIV prevention programmes should lead readers to be sceptical of the findings and conclusions of Van Howe's study.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute , University of Sydney , Sydney , Australia
| | - Gia Barboza
- b Department of African-American Studies , Northeastern University , Boston , MA , USA.,c School of Criminology and Criminal Justice , Northeastern University , Boston , MA , USA
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- d University of Washington School of Medicine and VA Puget Sound Health Care System, Section of Urology , Seattle , WA , USA
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Morris BJ, Wamai RG, Krieger JN, Banerjee J, Klausner JD. Male circumcision to prevent syphilis in 1855 and HIV in 1986 is supported by the accumulated scientific evidence to 2015: Response to Darby. Glob Public Health 2015; 12:1315-1333. [PMID: 26564989 DOI: 10.1080/17441692.2015.1104371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An article by Darby disparaging male circumcision (MC) for syphilis prevention in Victorian times (1837-1901) and voluntary medical MC programs for HIV prevention in recent times ignores contemporary scientific evidence. It is one-sided and cites outlier studies as well as claims by MC opponents that support the author's thesis, but ignores high quality randomised controlled trials and meta-analyses. While we agree with Darby that risky behaviours contribute to syphilis and HIV epidemics, there is now compelling evidence that MC helps reduce both syphilis and HIV infections. Although some motivations for MC in Victorian times were misguided, others, such as protection against syphilis, penile cancer, phimosis, balanitis and poor hygiene have stood the test of time. In the absence of a cure or effective prophylactic vaccine for HIV, MC should help lower heterosexually acquired HIV, especially when coupled with other interventions such as condoms and behaviour. This should save lives, as well as reducing costs and suffering. In contrast to Darby, our evaluation of the evidence leads us to conclude that MC would likely have helped reduce syphilis in Victorian times and, in the current era, will help lower both syphilis and HIV, so improving global public health.
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Affiliation(s)
- Brian J Morris
- a School of Medical Sciences and Bosch Institute, University of Sydney , Sydney , NSW , Australia
| | - Richard G Wamai
- b Department of African-American Studies , Northeastern University , Boston , MA , USA
| | - John N Krieger
- c Section of Urology, University of Washington School of Medicine and VA Puget Sound Health Care System , Seattle , WA , USA
| | - Joya Banerjee
- d Jhpiego, an affiliate of Johns Hopkins University , Washington , DC , USA
| | - Jeffrey D Klausner
- e Division of Infectious Diseases, Department of Medicine , David Geffen School of Medicine, University of California Los Angeles , CA , USA
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Giami A, Perrey C, Mendonça ALDO, de Camargo KR. Hybrid forum or network? The social and political construction of an international 'technical consultation': male circumcision and HIV prevention. Glob Public Health 2015; 10:589-606. [PMID: 25646671 DOI: 10.1080/17441692.2014.998697] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a 'hybrid forum' and 'network', this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a 'hybrid forum', which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation.
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Affiliation(s)
- Alain Giami
- a Team Gender, Sexual and Reproductive Health, F-94276 , Inserm, CESP Centre for Research in Epidemiology and Population Health, U1018 , Le Kremlin Bicetre , France
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Wamai RG, Morris BJ, Bailey RC, Klausner JD, Boedicker MN. Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress. Glob Public Health 2015; 10:639-66. [PMID: 25613581 PMCID: PMC6352987 DOI: 10.1080/17441692.2014.989532] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.
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Affiliation(s)
- Richard G. Wamai
- Department of African-American Studies, Northeastern University, Boston, Massachusetts, USA
| | - Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Robert C. Bailey
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeffrey D. Klausner
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, California, USA
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Morris BJ, Tobian AAR, Hankins CA, Klausner JD, Banerjee J, Bailis SA, Moses S, Wiswell TE. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. JOURNAL OF MEDICAL ETHICS 2014; 40:463-470. [PMID: 23955288 DOI: 10.1136/medethics-2013-101614] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
In a recent issue of the Journal of Medical Ethics,Svoboda and Van Howe commented on the 2012 changein the American Academy of Pediatrics (AAP) policy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology,erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being.Policies in support of parent-approved elective newborn circumcision should be embraced by the medical,scientific and wider communities.
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Mohta A. Editorial Comment from Dr Mohta to circumcision with a novel disposable device in Chinese children: a randomized controlled trial. Int J Urol 2012; 20:228-9. [PMID: 23003330 DOI: 10.1111/j.1442-2042.2012.03178.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Despite its long history and common practice, circumcision remains a controversial procedure. This article reviews the history of this operation, examines the controversy that surrounds it, and emphasizes the performing practitioner's responsibility to the patient and his family in guiding them through the complicated decision making surrounding newborn circumcision.
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Morris BJ, Bailey RC, Klausner JD, Leibowitz A, Wamai RG, Waskett JH, Banerjee J, Halperin DT, Zoloth L, Weiss HA, Hankins CA. Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care 2012; 24:1565-75. [PMID: 22452415 PMCID: PMC3663581 DOI: 10.1080/09540121.2012.661836] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, NSW, Australia.
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Wamai RG, Morris BJ, Bailis SA, Sokal D, Klausner JD, Appleton R, Sewankambo N, Cooper DA, Bongaarts J, de Bruyn G, Wodak AD, Banerjee J. Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa. J Int AIDS Soc 2011; 14:49. [PMID: 22014096 PMCID: PMC3207867 DOI: 10.1186/1758-2652-14-49] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 10/20/2011] [Indexed: 11/23/2022] Open
Abstract
Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.
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Affiliation(s)
- Richard G Wamai
- Department of African-American Studies, Northeastern University, Boston, MA, USA
| | - Brian J Morris
- School of Medical Sciences, University of Sydney, Australia
| | - Stefan A Bailis
- Research & Education Association on Circumcision Health Effects, Bloomington, MN, USA
| | - David Sokal
- Behavioral and Biomedical Research, Family Health International, Research Triangle Park, NC, USA
| | - Jeffrey D Klausner
- Department of Medicine, University of California, San Francisco Department of Public Health, USA
| | - Ross Appleton
- College of Professional Studies, Northeastern University, Boston, MA, USA
| | | | - David A Cooper
- Kirby Institute, St Vincents Hospital and University of New South Wales Sydney, Australia
| | - John Bongaarts
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Guy de Bruyn
- Perinatal HIV Research Unit, New Nurses Home, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Alex D Wodak
- Alcohol & Drug Unit, St Vincent's Hospital, Sydney, Australia
| | - Joya Banerjee
- Global Youth Coalition on HIV/AIDS, Pretoria, South Africa
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Wamai R, Morris BJ. ‘How to contain generalized HIV epidemics’ article misconstrues the evidence. Int J STD AIDS 2011; 22:415-6; author reply 416-7. [DOI: 10.1258/ijsa.2010.010460] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R Wamai
- Department of African-American Studies, Northeastern University, 360 Huntington Avenue, Boston, MA 02115, USA
| | - B J Morris
- School of Medical Sciences, University of Sydney, Sydney, Australia
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Forbes DA. "The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV" ... and now the case against. Comment. Med J Aust 2011; 194:97-8; author reply 101. [PMID: 21241226 DOI: 10.5694/j.1326-5377.2011.tb04179.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 12/05/2010] [Indexed: 01/17/2023]
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Banerjee J, Klausner JD, Halperin DT, Wamai R, Schoen EJ, Moses S, Morris BJ, Bailis SA, Venter F, Martinson N, Coates TJ, Gray G, Bowa K. Circumcision denialism unfounded and unscientific. Am J Prev Med 2011; 40:e11-2; author reply e13-4. [PMID: 21335254 DOI: 10.1016/j.amepre.2010.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 12/01/2010] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
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Green LW, Travis JW, McAllister RG, Peterson KW, Vardanyan AN, Craig A. Male circumcision and HIV prevention insufficient evidence and neglected external validity. Am J Prev Med 2010; 39:479-82. [PMID: 20965388 DOI: 10.1016/j.amepre.2010.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 04/26/2010] [Accepted: 07/16/2010] [Indexed: 01/06/2023]
Affiliation(s)
- Lawrence W Green
- Department of Epidemiology and Biostatistics, University of California at San Francisco, USA
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Cooper DA, Wodak AD, Morris BJ. The case for boosting infant male circumcision in the face of rising heterosexual transmission of HIV. Med J Aust 2010; 193:318-9. [PMID: 20854234 DOI: 10.5694/j.1326-5377.2010.tb03940.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 07/25/2010] [Indexed: 11/17/2022]
Abstract
Circumcision now to prevent heterosexual HIV transmission in 2030 makes sense.
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Morris BJ, Bailis SA, Waskett JH, Wiswell TE, Halperin DT. Medicaid coverage of newborn circumcision: a health parity right of the poor. Am J Public Health 2009; 99:969-71. [PMID: 19372502 DOI: 10.2105/ajph.2009.161281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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