Reader Comments

Post a new comment on this article


Posted by vanhowe on 24 Feb 2010 at 16:54 GMT

Dear Editors:

I read the recently published commentary by Seth Kalichman,[1] but with so many statements that are either factually inaccurate or have no factual basis I found it hard to take his comments seriously. For example:

1. The inclusion of Rwanda as the country as the focus of this intervention. In Rwanda the prevalence of HIV infection is 2.1% in men who are not circumcised and 3.5% in men who are circumcised. So based on their past experience circumcising all of the males in Rwanda would increase the number of HIV infections in men by 69%.[2] Most people would consider that a step in the wrong direction.

2. There is no evidence that the risks and complications are lower for a circumcision performed on a neonate rather than an adult. In fact, one study has found that the risks were greater in circumcision performed after the neonatal period.[3]

3. There is no evidence that circumcision reduces penile trauma during intercourse. Only one study has looked at this issue. It found that circumcised men trended toward more penile abrasions.[4]

4. Why would a neonatal circumcision be so much less expensive than an adult circumcision? Both use a similar technique and anesthetic.

5. When 55% effectiveness is demonstrated outside of a research setting, in which all of the forms of built-in bias overestimated the treatment effect, then it is reasonable to use that number.[5] No one ever expects an intervention to work as well it did in a research setting!

6. There have been no observational studies that have shown that infant circumcision reduces the risk of HIV infection. Several have shown no change in risk.[6] With no evidence that infant circumcision is an effective preventive, why propose such a thing?

7. The models projecting reductions in HIV infections over 20 years assume that complication and effectiveness in a research setting can be duplicated in the general public and that a 2-year trajectory will be maintained for more than 20 years. These are all sketchy assumptions. I wouldn’t invest in a company with this as their business plan.

8. When Kalichman wrote, “Anticircumcision groups resemble other antiscience and antimedicine extremists including AIDS denialists who refute public health realities to maintain entrenched belief systems [ref13],” and cited his own book as a reference.

9. When Kalichman denied the possibility of risk compensation, although reports from Africa are that men are getting circumcised so they can stop using condoms.

Kalichman’s commentary would have been much more informative if had discussed the human rights issues, the science that undermines with his position, and how alternative preventive measures (condoms, aggressive treatment of sexually transmitted infections, anti-retroviral therapy, abstinence, limiting the number of sexual partners) compare to circumcision. If given a choice between complete protection with a condom, why would anyone choose to be circumcised?

1. Kalichman SC. Neonatal circumcision for HIV prevention: cost, culture, and behavioral considerations. PLoS Med 2010; 7(1): e1000219.

2. Demographic and Health Surveys. Chapter 15: HIV Prevalence and Associated Factors. In Rwanda National Health and Demographic Survey for 2005. Demographic and Health Surveys 2006: 225-41.

3. Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg 2007; 17: 266-9.

4. Bailey RC, Neema S, Othieno R. Sexual behaviours and other HIV risk factors in circumcised and uncircumcised men in Uganda. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 22: 294-301.

5. Montori VM, Devereaux PJ, Adhikari NK, Burns KE, Eggert CH, Briel M, et al. Randomized trial stopped early for benefit: a systematic review. JAMA 2005; 294: 2203-9.

6. Mor Z, Kent CK, Kohn RP, Klausner JD. Declining rates in male circumcision amidst increasing evidence of its public health benefit. PLoS ONE 2007; 2(9): e861.

No competing interests declared.