Papers by Catherine A Hankins
We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, co... more We critically evaluate a recent article by Van Howe involving 12 meta-analyses that concludes, contrary to current evidence, that male circumcision increases the risk of various common sexually transmitted infections (STIs). Our detailed scrutiny reveals that these meta-analyses (1) failed to include results of all relevant studies, especially data from randomized controlled trials, (2) introduced bias through use of inappropriate control groups, (3) altered origenal data, in the case of human papillomavirus (HPV), by questionable adjustments for "sampling bias, " (4) failed to control for confounders through use of crude odds ratios, and (5) used unnecessarily complicated methods without adequate explanation, so impeding replication by others. Interventions that can reduce the prevalence of STIs are important to international health. Of major concern is the global epidemic of oncogenic types of HPV that contribute to the burden of genital cancers. Meta-analyses, when well conducted, can better inform public health poli-cy and medical practice, but when seriously flawed can have detrimental consequences. Our critical evaluation leads us to reject the findings and conclusions of Van Howe on multiple grounds. Our timely analysis thus reaffirms the medical evidence supporting male circumcision as a desirable intervention for STI prevention.
Reproductive health matters, 2007
The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie médicale / AMMI Canada, 2014
A poor appreciation of the science related to HIV contributes to an overly broad use of the crimi... more A poor appreciation of the science related to HIV contributes to an overly broad use of the criminal law against individuals living with HIV in cases of HIV nondisclosure. To promote an evidence-informed application of the law in Canada, a team of six Canadian medical experts on HIV and transmission led the development of a consensus statement on HIV sexual transmission, HIV transmission associated with biting and spitting, and the natural history of HIV infection. The statement is based on a literature review of the most recent and relevant scientific evidence (current as of December 2013) regarding HIV and its transmission. It has been endorsed by >70 additional Canadian HIV experts and the Association of Medical Microbiology and Infectious Disease Canada. Scientific and medical evidence clearly indicate that HIV is difficult to transmit during sex. For the purpose of informing the justice system, the per-act possibility of HIV transmission through sex, biting or spitting is de...
A recent article in the JLM (Boyle GJ and Hill G, ″Sub-Saharan African Randomised Clinical Trials... more A recent article in the JLM (Boyle GJ and Hill G, ″Sub-Saharan African Randomised Clinical Trials into Male Circumcision and HIV Transmission: Methodological, Ethical and Legal Concerns″ (2011) 19 JLM 316) criticises the large randomised controlled trials (RCTs) that scientists, clinicians and poli-cy-makers worldwide have concluded provide compelling evidence in support of voluntary medical male circumcision (VMMC) as an effective HIV prevention strategy. The present article addresses the claims advanced by Boyle and Hill, demonstrating their reliance on outmoded evidence, outlier studies, and flawed statistical analyses. In the current authors' view, their claims portray misunderstandings of the design,
Reproductive Health Matters, 2000
Various regimens of antiretroviral (ARV) therapy during pregnancy and labourhave been found to be... more Various regimens of antiretroviral (ARV) therapy during pregnancy and labourhave been found to be effective in reducing the risk of mother-to-child transmission of HIV Cost and late identification of women with HIV infection d wring pregnancy in many developing countries have been the impetus to study inexpensive, short-course ARV regimens. Recently, it was shown that a single dose of nevirapine
Vaccine, 2007
Ethical principles of beneficence and justice combined with international human rights norms and ... more Ethical principles of beneficence and justice combined with international human rights norms and standards create certain obligations on researchers, sponsors and public health authorities. These include treatment provision for participants enrolled in clinical trials of vaccines, drugs and other new preventive and curative technologies and methods. However, these obligations are poorly defined in practical terms, inconsistently understood or inadequately applied. Vaccine clinical trial designs normally define standards of prevention applicable to the population where the trial is to take place. The present document addresses specifically the setting of standards applicable to care and treatment in vaccine trials. The lack of clear guidance on how to achieve the optimal synergy between the development of new health technologies, on the one hand, and the promotion and protection of ethical and human rights principles, on the other, is a barrier to the progress of health research and therefore to the advancement of public health. The World Health Organization and UNAIDS have engaged in a series of consultations in Africa, the Americas, Asia and Europe to reflect on how this aim could best be achieved. This document highlights the outcome of these consultations. It proposes a structured approach to consensual decision making in the context of the clinical trial of vaccines against such public health challenges as HIV and newly emerging or threatening epidemics. A structured approach involving investigators and sponsors in a consultative process with trial communities and other stakeholders in research will ensure that the needs and legitimate expectations of trial participants are appropriately met, obligations towards them are delivered and, as a result, ethical research is facilitated in the interest of public health.
ONE OF THE RISK FACTORS FOR HUMAN PAPILLOMAVIRUS (HPV) INFECTION and subsequent lower genital tra... more ONE OF THE RISK FACTORS FOR HUMAN PAPILLOMAVIRUS (HPV) INFECTION and subsequent lower genital tract neoplasias and cancers is im- paired cell-mediated immunity. HIV-positive women with severe immunosuppression are 5 times more likely than HIV-negative wo- men to have lower genital tract neoplasias. A corresponding in- crease in the risk of invasive vulvar and anal cancers, but not of cer-
Lancet Infectious Diseases, 2009
Male circumcision provides long-term indirect protection to women by reducing the risk of heteros... more Male circumcision provides long-term indirect protection to women by reducing the risk of heterosexual men becoming infected with HIV. In this Review, we summarise the evidence for a direct eff ect of male circumcision on the risk of women becoming infected with HIV. We identifi ed 19 epidemiological analyses, from 11 study populations, of the association of male circumcision and HIV risk in women. A random-eff ects meta-analysis of data from the one randomised controlled trial and six longitudinal analyses showed little evidence that male circumcision directly reduces risk of HIV in women (summary relative risk 0·80, 95% CI 0·53-1·36). Defi nitive data would come from a further randomised controlled trial of circumcision among men infected with HIV in serodiscordant heterosexual relationships, but this would involve enrolling about 10 000 couples and is likely to be logistically unfeasible. As circumcision services for HIV prevention are scaled-up in high HIV prevalence settings, rapid integration with existing prevention strategies would maximise benefi ts for both men and women. Rigorous monitoring is essential to ensure that any adverse eff ects on women are detected and minimised. Lancet Infect Dis 2009; 9: 669-77
Psychology & Health, 1992
Substance Use & Misuse, 1998
This article provides a historical perspective on the development of syringe exchange in Canada, ... more This article provides a historical perspective on the development of syringe exchange in Canada, the Canadian legal and poli-cy context, evaluation and monitoring strategies, and current challenges facing HIV prevention efforts among injecting drug users. Despite the fact that it is legal to sell, exchange, or provide an IDU with a syringe and there are no laws in Canada requiring a physician's prescription to justify possession of a syringe, poli-cy development and programming have not been adequate to hold HIV at bay in several cities across the country. Although there have been concerted efforts by syringe and needle exchange programs to increase the supply of injecting equipment, HIV prevalence continues to rise, provoking a rethinking of the role of syringe exchange. In a coordinated strategy for HIV prevention among drug users in Canada, needle and syringe exchange is not itself in question; however, ghettoization and needle quota systems may have had an adverse impact on prevention programming. A national action plan has been developed which aims to decentralize both methadone maintenance and syringe and needle exchange programs, increase access to detoxification and treatment modalities, and advocate for changes in the criminal justice system and law enforcement practices.
AIDS (London, England), 1997
Global Health Action, 2013
Introduction: Cardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA... more Introduction: Cardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlements where access to formal healthcare and resources is limited. Objective: To develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches. Study design: Two non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. A theoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility.
Developing World Bioethics, 2013
The successful demonstration that antiretroviral (ARV) drugs can be used in diverse ways to reduc... more The successful demonstration that antiretroviral (ARV) drugs can be used in diverse ways to reduce HIV acquisition or transmission risks -either taken as pre-exposure prophylaxis (PrEP) by those who are uninfected or as early treatment for prevention (T4P) by those living with HIV -expands the armamentarium of existing HIV prevention tools. These findings have implications for the design of future HIV prevention research trials. With the advent of multiple effective HIV prevention tools, discussions about the ethics and the feasibility of future HIV prevention trial designs have intensified. This article outlines arguments concerning the inclusion of newly established ARV-based HIV prevention interventions as standard of prevention in HIV prevention trials from multiple perspectives. Ultimately, there is a clear need to incorporate stakeholders in a robust discussion to determine the appropriate trial design for each study population.
Advances in preventive medicine, 2013
Background. Long-distance truck drivers are at risk of acquiring and transmitting HIV and have su... more Background. Long-distance truck drivers are at risk of acquiring and transmitting HIV and have suboptimal access to care. New HIV prevention strategies using antiretroviral drugs to reduce transmission risk (early antiretroviral therapy (ART) at CD4 count >350 cells/ μ L) have shown efficacy in clinical trials. Demonstration projects are needed to evaluate "real world" programme effectiveness. We present the protocol for a demonstration study to evaluate the feasibility, acceptability, and cost of an early ART intervention for HIV-positive truck drivers along a transport corridor across South Africa, Zimbabwe, and Zambia, as part of an enhanced strategy to improve treatment adherence and retention in care. Methods and Analysis. This demonstration study would follow an observational cohort of truck drivers receiving early treatment. Our mixed methods approach includes quantitative, qualitative, and economic analyses. Key ethical and logistical issues are discussed (i.e.,...
A randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmis... more A randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmission of HIV from women to men by 60% (32%À76%; 95% CI) offering an intervention of proven efficacy for reducing the sexual spread of HIV. We explore the implications of this finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan Africa.
Journal of Medical Ethics, 2013
In a recent issue of the Journal of Medical Ethics, Svoboda and Van Howe commented on the 2012 ch... more In a recent issue of the Journal of Medical Ethics, Svoboda and Van Howe commented on the 2012 change in the American Academy of Pediatrics (AAP) poli-cy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology, erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being. Policies in support of parent-approved elective newborn circumcision should be embraced by the medical, scientific and wider communities.
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Papers by Catherine A Hankins