Back to the News 2005 page.CBC NEWS, November 21, 2005.
Stephen Strauss wrote articles, columns and editorials about science and technology for the Globe and Mail for more than 20 years. He has also authored three books, several book chapters, and for his efforts received numerous awards. Through all his time in journalism, he still remains smitten by the enduring wisdom of the motto of Austrian writer Karl Kraus. Say what is.Snippety, snip, snip. Could that be the sound
of AIDS in retreat in Africa?
The auditory metaphor and its effect come to mind if
you spend any time reflecting on a much-publicized
South African study tying a dramatic decline in HIV
infection rates to circumcision. But well might you
think just the opposite if you were apprised of the
sometimes putrid public health politics underlying
publication of said study.
The facts seem straightforward on the surface. Some
3,000 young men - hardly any married - were
selected from a semi-rural area near Johannesburg. Half
were put in a group that got circumcisions, half in a
non-circumcised group. After more than a year, 20 of
the circumcised men had become HIV positive versus 49
of the uncircumcised men, this even though the
circumcised men had more sexual encounters.
The scientists were jubilant. "The result is
equivalent to saying that during the period [of the
study] the intervention prevented six out of 10
potential infections," wrote the French and South
African researchers who conducted the research, adding,
"this provides a degree of protection against acquiring
HIV infection equivalent to what a vaccine of high
efficiency would have achieved."
The finding was so striking, the researchers stopped
the trial before it was supposed to finish because the
"protective effect of male circumcision was so high it
would have been unethical to continue." That is to say,
they thought there was no doubt that circumcision
protected against HIV infection.
Finally, the effectiveness of circumcision led the
scientists to argue that decision makers should
herewith consider making circumcision of all African
men a public health priority.
Wonderful, except for all the ethical and
methodological mud splattered on the findings.
As a background you should know the project
grew out of more than two decades of observation that
places in Africa where circumcision was the norm had
less AIDS than the uncut places. We are not, by the
way, simply talking about Muslim Africa but also tribes
where male circumcision is part of a rite of passage
into adulthood.
While scientists have been able to come up with
numbers of physical explanations for why what has
sometimes been snidely called the "cut cure" works,
nobody has been certain about the connection. This is
because no previous studies have controlled for
confounding factors - age at circumcision, number
of sexual partners, safe sex practices - that
could distort results. So the Johannesburg study was
vital in translating anecdote and intimation into
believable science.
However, there was a fundamental ethical problem with
its methodology. The men were given HIV tests before
the project began and 146 were found to be HIV
positive, but - underline the following in
lipstick red - they weren't told about their
status as researchers "considered it unethical to
inform participants of their HIV status without their
permission."
Gasp. You don't tell people with a life-threatening,
highly infectious disease they are both sick and
dangerous to others because knowing somehow violates
their sense of privacy?
To justify this position, French and South African
scientists involved argued that they were just
respecting a fear of AIDS stigma so intense that "many
of these people prefer to be dead than rejected by
their communities."
Gasp again. This is a public health position so
obviously crazy - think in the Canadian context
of not telling people with SARS they had it because
they would be stigmatized and quarantined - it
led the British journal The Lancet to reject the
publishing of the AIDS paper on the grounds it was
ethically flawed.
And there may be a worse confusion to come. Not
everyone believes the HIV infection numbers in men who
hadn't been circumcised were so conclusive they
justified the trial being shut down early. Part of the
concern was caused by two recent papers that suggest
that clinical trials claiming huge, big, early effects
from drugs or other treatments as often as not turn out
to be statistical blips and not true results.
Could that be the case here?
"My sense is that the circumcision study may have been
stopped too early and that there is a real danger we
may be subjecting hundreds of thousands or millions of
men to having circumcisions that may not have the
benefit we assume," Jeremy Grimshaw, director of the
Clinical Epidemiology Program at the University of Ottawa, warns me
about the South African study.
Gasp a third time. So why stop a study when the number
of people who had become infected wasn't even half as
large as the number who had the disease to start with
and weren't told they had it? My guess is a guilty
conscience. The doctors wanted an excuse to tell all
the infected of their condition, no matter the
stigmatization, and the early, positive statistics gave
them just such an out.
My justification for this charge is that immediately
after they closed down the trial, the researchers
changed the rules so they could inform people of their
disease, even if the people initially said they didn't
want to know.
Maybe other, still ongoing trials will support the cut
cure, but for the time being my faith in this one has
gone snippety, snip, snip.
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