The utility of a diagnostic skin biopsy clinic within the genitourinary medicine clinic

HIV transmission – both sexual and blood-borne – in sub-Saharan Africa is insufficient to show just how HIV has been able to infect so many people. Hence, the current evidence is insufficient to inform efficient prevention efforts, though such lack of reliable information readily could be rectified by tracing HIV infections. Wamai and Morris seem to think that understanding Africa’s HIV epidemics requires only that one know the respective proportions of adult infections attributable to sexual and nonsexual exposures. That oversimplifies the case. Even if one were to ignore non-sexual transmission entirely – even if one thinks that 98% of transmission among adults is sexual – that still would leave an unanswered question: what is different about sexual behaviour and sexual exposures in some countries in sub-Saharan Africa that is so favourable for rapid HIV transmission (if, indeed, that is so)? And, to continue this same argument: even were one to uncritically accept the reported results from the three randomized controlled trials (RCTs) that circumcision significantly protects men from sexual acquisition of HIV, – 5 and to endorse programmes to circumcise African men, that would address only part of the problem. Even advocates for circumcision estimate that circumcising all African men by 2015 would reduce HIV incidence during the ensuing 2015–2035 period by a very modest 13%. Wamai and Morris charge us with speculating, rather than presenting, evidence about non-sexual (e.g. nosocomial) transmission. This criticism clearly missed the point of our article, which is that we are not satisfied with the available evidence for transmission by either mode, sexual and non-sexual, in sub-Saharan Africa. In any case, their charge overlooks the Malawi study we discussed, that documented a 77% population attributable fraction of HIV incidence associated with injections. Also, several of the undersigned have presented such evidence in other publications, including evidence from our own field-based research. – 11 Ignoring such field-based evidence, Wamai and Morris put undue faith in weaker ‘evidence’ from models. Wamai and Morris erroneously state that we ‘cite not a single study that questions the results of the [3 randomized controlled] trials’ of circumcision to inhibit HIV transmission. Actually, our original article cited several studies, including a vaccine trial that revealed higher HIV incidence among circumcised, than among uncircumcised, men. Yet the principal data we used to critique the circumcision trials come from the trials themselves, including data showing large percentages of incident infections in men who reported no unprotected sex during the relevant observation interval. Wamai and Morris claim that these three RCTs ‘used established scientific norms in providing evidence for major modes of HIV transmission’, but that is hardly the case. The trials failed to test the men’s sexual partners, or to warn partners when study subjects acquired HIV. One of the trials even failed to report sexual exposures in men with and without incident HIV infections, or to investigate unexplained HIV infections that were identified one month after circumcision. The trials failed to simultaneously and comprehensively assess both sexual and non-sexual exposures to HIV. Such trials cannot be considered to have followed ‘established scientific norms’. Although the trial results are promising, they do not provide carte blanche for circumcision campaigns, especially in the absence of guarantees that surgical procedures are safe.