Author: John J. Potterat
Position: independent consultant
Institution: Colorado Springs, USA
E-mail: jjpotterat@earthlink.net
Additional Authors: Devon D. Brewer (Interdisciplinary Scientific Research & University of Washington, Seattle, USA); Stephen Q. Muth (Quintus-ential Solutions, Colorado Springs, USA); Stuart Brody (School of Social Sciences, University of Paisley, Paisley, Scotland, UK)
Submitted Date: November 04, 2005
Published Date: November 11, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Auvert and colleagues present preliminary evidence for the protective effect of male circumcision on HIV acquisition [1]. Their report also reveals several problems with the widely-held assumption that penile-vaginal sex accounts for the overwhelming majority of HIV transmission in sub-Saharan Africa.

We are baffled that the factor most strongly associated with incident HIV infection-- attendance at "a clinic for a health problem related to the genitals"(RR 5.7)--is neither highlighted nor specifically discussed. Given evidence for an increased risk of acquiring HIV from treatment for STD in sub-Saharan Africa (relative to untreated STD) [2], such a context for HIV acquisition should have been more assiduously explored, especially regarding nosocomial transmission.

Regrettably, the authors did not control for blood exposures (e.g., other types of medical or dental care, including "street doctors" and village injectionists, injections with syringes kept at home, ritualistic procedures, and injection drug use). Nor did they assess anal intercourse, the variable most strongly associated with sexual transmission of HIV. Anal intercourse is not uncommon in sub-Saharan Africa [3]. The authors also did not ask participants to specify the sex of their "non-spousal" partners, despite much evidence for bisexual behavior on the part of many "heterosexual" men in sub-Saharan Africa [3].

Furthermore, the authors did not report the relationship between level of condom use and HIV incidence. The need for more detailed investigation of sexual exposures is underlined by the negligible associations between such traditional measures of sexual risk as any unprotected sex, number of sexual exposures ("contacts"), and number of non-spousal partners, and HIV incidence [1]. Indeed, these results replicate the frequent lack of association between sexual behavior variables and HIV incidence or epidemic trajectories in sub-Saharan Africa [4]. (The authors should also report HIV incidence in persons reporting no sexual activity during specified study intervals.) Of concern as well is the high per coital act HIV transmission probability implied by the data presented. A high transmission probability would suggest that the HIV prevalence in their participants should be greater than the 4%-5% observed at baseline.

Until all modes of HIV transmission--by sex and by puncturing--are comprehensively investigated [5,6], the most effective means of preventing HIV transmission will remain shrouded. In light of the anomalies and lacunae in Auvert and colleagues' study, the protective effect of male circumcision they observed amounts to a faith lift for the empirically beleaguered paradigm of "heterosexual" HIV transmission in sub-Saharan Africa [7].

References
1 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2(11): e298.
2 Gisselquist D, Potterat JJ, Brody S, Vachon F (2003) Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 14: 148-161.
3 Brody S, Potterat JJ (2003) Assessing the role of anal intercourse in the epidemiology of AIDS in Africa. Int J STD AIDS 14: 431-436.
4 Potterat JJ, Gisselquist D, Brody S (2004) Still not understanding the uneven spread of HIV within Africa (Letter). Sex Transm Dis 31: 365.
5 Brody S, Potterat JJ (2004) Establishing valid AIDS monitoring and research in countries with generalized epidemics. Int J STD AIDS 15: 1-6.
6 Brewer DD, Rothenberg RB, Potterat JJ, Brody S, Gisselquist D (2004) HIV epidemiology in Africa: rich in conjecture, poor in data (reply to letter by Boily et al.) Int J STD AIDS 15: 63-65.
7 Brewer DD, Brody S, Drucker E, Gisselquist D, Minkin SF, et al (2003) Mounting anomalies in the epidemiology of HIV in Africa: Cry the beloved paradigm. Int J STD AIDS 14: 1