D J Vance: "Male circumcision and HIV: Non‐blindedness and biases in RCTs..."

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    • D J Vance: "Male circumcision and HIV: Non‐blindedness and biases in RCTs..."

      Male circumcision and HIV: Non‐blindedness and biases in RCTs; female
      preferences; penile sensitivity, satisfaction and ambient stimulation; risk
      compensation; acceptance of insufficient condom use and personal hygiene
      and related externalities

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      GJMEDPH 2018; Vol. 7, issue 1
      Literature was reviewed in order to examine what the likely efficacy of male *Corresponding Author
      circumcision in combatting HIV‐AIDS might be. There is no reasonable doubt David J Vance
      that male circumcision in the absence of other measures does reduce the Independent Researcher
      transmission of HIV. Due to very substantial non‐blindedness in RCTs and Telephone No. +86 – 15261001593
      elsewhere, there is substantial uncertainty regarding the extent to which male
      circumcision in the absence of other measures could ultimately reduce HIVConflict of Interest—none
      transmission into the future, such that the Odds Ratios usually given of about
      0.4 for incident HIV infection of males with medical circumcision cannot be
      taken to be as applicable in contexts other than RCTs. The potential of non‐
      blindedness in studies and in societies, to effect things like reporting bias and
      subjective and actual sexual and behavioural outcomes is very generally very poorly understood and
      insufficiently included in analysis and projection of outcomes. Risk‐adjustment / disinhibition, such that
      circumcised men react to the partial protection of circumcision against HIV infection by engaging in riskier
      sexual behavior than they would have otherwise is almost certain to occur to substantial extent in most
      contexts. It seems very likely that circumcision does result in keratinization/ cornification of the glans, and
      also removes sexually‐sensitive skin, both of which result in reduced intensity of coital pleasure,
      notwithstanding the various benefits of this in prolonging the coition. Already even uncircumcised men prefer
      coition without a condom due to the greater intensity of sexual sensation, and it is logical that this preference
      for coition without a condom would be greater in circumcised men. Already there is great under‐use of
      condoms by African men. There is therefore a very real question of the extent to which male circumcision will
      result in substantial failure to achieve sufficient use of condoms in combatting HIV infection. This is offset by
      the possibility that it may be realistic to accept that sufficient use of condoms is not achievable in any case,
      because substantial non‐compliance is inherent. Also there is the very under‐examined question of how
      thorough sexual personal hygiene (if at all achievable) would modify the efficacies of both circumcision and
      condom use, and what the externalities of such thorough sexual hygiene might be when generalized to other
      infectious contexts improvable by better hygiene.

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