Betting has been a popular activity for centuries, and with the rise of online gambling platforms, it has become more accessible than ever. One such platform that has gained immense popularity in recent years is 789bet. This article aims to serve as a comprehensive guide for those looking to make the most out of their betting experience on 789bet.
What is 789bet?
789bet is an online gambling platform that offers a wide range of betting options, including sports betting, casino games, and lottery. It was established in 2018 and has since become a go-to destination for bettors worldwide. The platform is known for its user-friendly interface, fast and secure transactions, and a diverse selection of games and sports events to bet on.
How to get started on 789bet?
Getting started on 789bet is simple and straightforward. Follow these steps to create an account and start betting:
Visit the official website of 789bet.
Click on the “Register” button located at the top right corner of the page.
Fill in the required information, including personal details and contact information.
Choose a username and password for your account.
Agree to the terms and conditions and click on “Register.”
You will receive a verification email, click on the link provided to activate your account.
Make a deposit using one of the secure payment methods available.
You are now ready to explore the various betting options on 789bet and place your bets.
Betting options on 789bet
One of the reasons for the popularity of 789bet is its extensive range of betting options. Here are the top categories available on the platform:
Sports Betting
789bet offers a wide selection of sports events to bet on, including football, basketball, tennis, cricket, and many others. The platform covers both local and international events, providing bettors with numerous opportunities to place their bets.
Casino Games
For those looking for a break from sports betting, 789bet offers a variety of casino games such as slots, blackjack, roulette, and baccarat. These games are powered by top-notch software providers, ensuring a seamless and enjoyable gaming experience.
Lottery
789bet also offers an online lottery service, allowing users to bet on various lotteries from around the world. The platform provides quick results and a high payout percentage, making it a popular choice among lottery enthusiasts.
Tips to Maximize Your Winnings on 789bet
While luck plays a significant role in betting, there are certain strategies one can follow to increase their chances of winning. Here are some tips that can help you make the most out of your bets on 789bet:
Do Your Research
Before placing any bets, it is essential to do your research on the teams or players involved. Look at their past performances, current form, and other factors that may affect the outcome of the event.
Set a Budget
It is crucial to set a budget for your betting activities and stick to it. Avoid chasing losses and know when to stop. This will prevent you from overspending and help maintain a healthy gambling habit.
Take Advantage of Bonuses and Promotions
789bet often offers bonuses and promotions to its users, which can significantly increase your winnings. Make sure to check the website regularly and take advantage of these offers whenever available.
Frequently Asked Questions (FAQs)
Q: Is it safe to bet on 789bet?
A: Yes, 789bet uses advanced security measures to protect its users’ personal and financial information, making it a safe and secure platform for betting.
Q: Can I access 789bet on my mobile phone?
A: Yes, 789bet is accessible on both desktop and mobile devices, allowing users to place bets anytime, anywhere.
Q: How long does it take to withdraw my winnings from 789bet?
A: Withdrawal times may vary depending on the chosen payment method. However, most withdrawals are processed within 24 hours.
Q: Are there any fees for depositing or withdrawing money on 789bet?
A: 789bet does not charge any fees for deposits or withdrawals. However, your chosen payment provider may have its own transaction fees.
Q: What should I do if I encounter a problem on 789bet?
A: 789bet has a dedicated customer support team available 24/7 to assist users with any issues they may face while using the platform.
Conclusion
789bet offers a diverse range of betting options, a user-friendly interface, and top-notch security, making it an ideal choice for all types of bettors. With the tips and tricks mentioned in this guide, you can increase your chances of winning and make the most out of your betting experience on 789bet. Remember to gamble responsibly and have fun!
Are you tired of losing money on bets? Do you want to learn how to make smarter bets and increase your chances of winning? Look no further, because we have all the tips and tricks you need to bet smartly and come out on top.
What is Smart Betting?
Before we delve into the strategies of smart betting, let’s first define what it means. Smart betting is not just about placing random bets and hoping for a win. It involves carefully analyzing the odds, understanding the game and players, and making informed decisions based on research and analysis.
Smart betting requires patience, discipline, and a systematic approach. It is not a get-rich-quick scheme, but rather a long-term investment that can reap great rewards if done correctly.
Now that we have a clear understanding of what smart betting is, let’s explore the different ways you can become a pro at it.
Understanding the Game and Players
The first step to making smart bets is to understand the game you are betting on. Whether it is sports, casino games, or horse racing, having a thorough knowledge of the rules, strategies, and player statistics can greatly improve your chances of winning.
Research and Analysis
To truly understand the game and make informed decisions, you need to do your homework. This means researching the teams, players, and their previous performances. Look at factors such as injuries, winning streaks, and even weather conditions. All of these can have a significant impact on the outcome of a game.
In addition to researching the teams and players, analyze the odds offered by different bookmakers. Compare them and choose the one that offers the best value for your bet. Remember, the goal is not to always bet on the favorite, but to find the best potential return on your investment.
Bankroll Management
One crucial aspect of smart betting is to manage your bankroll effectively. This means setting a budget for your bets and sticking to it. It may be tempting to keep betting until you win, but this can lead to significant losses in the long run. Set a limit on the amount you are willing to bet for each game or event, and do not exceed it.
Another useful tip is to avoid chasing losses. If you have a losing streak, do not try to recoup your losses by placing bigger bets. This can only result in more significant losses and put a strain on your bankroll.
Strategies for Smart Betting
Now that we have covered the basics, let’s explore some specific strategies you can use to make smart bets.
Value Betting
Value betting involves looking for discrepancies in odds offered by different bookmakers. By finding value in odds, you can bet on outcomes that have a higher probability of occurring than what the odds suggest. This strategy requires patience and careful research, but it can greatly increase your chances of winning.
Arbitrage Betting
Arbitrage betting is another popular strategy used by professional bettors. It involves placing bets on all possible outcomes of a game or event with different bookmakers to guarantee a profit regardless of the outcome. This strategy requires quick thinking and a keen eye for spotting arbitrage opportunities.
In-Play Betting
In-play or live betting allows you to place bets on a game while it is still in progress. This strategy requires you to watch the game closely and make quick decisions based on changing odds and performance. It can be risky, but if done correctly, it can result in significant profits.
Common Mistakes to Avoid
While we have explored several strategies for smart betting, it is essential to know what not to do as well. Here are some common mistakes to avoid when trying to bet smartly:
Betting with emotions instead of logic and research.
Placing bets without a clear understanding of the game or odds.
Chasing losses and exceeding your bankroll limit.
Not doing proper research and analysis before placing a bet.
Focusing on short-term gains instead of long-term investment.
Frequently Asked Questions
1. What is the best sport to bet on?
The best sport to bet on differs from person to person depending on their knowledge and interest. It is essential to choose a sport that you understand and can analyze effectively.
2. How much should I bet on each game?
It is recommended to bet no more than 5% of your total bankroll on each game. This way, even if you have a losing streak, you will not lose all of your money.
3. Is smart betting legal?
Yes, smart betting is legal as long as it is done through licensed and regulated bookmakers.
4. Can I become rich through smart betting?
While smart betting can result in significant profits, it is not a guaranteed way to get rich quick. It requires patience, discipline, and a systematic approach.
5. How do I know when to place a bet?
Knowing when to place a bet comes down to doing proper research and analysis. Keep an eye on team and player statistics, compare odds from different bookmakers, and look for value in the odds before placing a bet.
Conclusion: Bet Smart, Win Big
Smart betting is not about luck or guesswork; it is a calculated and strategic approach to gambling. By understanding the game, doing thorough research and analysis, and using appropriate strategies, you can increase your chances of winning and make smart bets. Remember to manage your bankroll effectively and avoid common mistakes, and you may just come out on top. So next time you’re feeling lucky, bet smart and watch your winnings grow.
Lottery players are always in search of ways to improve their chances of winning, and one strategy that has gained significant attention in recent years is Lo Gan. In this comprehensive blog post, we will dive deep into the world of Lo Gan and explore how 77WIN, a leading lottery platform, can help you unlock the secrets to playing the lottery effectively.
Understanding the Basics of Lo Gan
Lo Gan is a unique lottery strategy that involves analyzing the patterns and trends of past lottery draws to identify potential winning numbers. This approach is based on the belief that certain numbers or number combinations are more likely to appear in future draws, and by understanding these patterns, players can increase their chances of hitting the jackpot.
The History of Lo Gan
The origins of Lo Gan can be traced back to ancient Chinese divination practices, where practitioners used various methods to predict future events. Over time, this concept has evolved and been adapted to the world of lottery play, with players around the globe exploring its potential.
The Principles of Lo Gan
At the heart of Lo Gan is the idea that lottery numbers are not entirely random, and that there are underlying patterns and trends that can be identified and leveraged. By analyzing historical lottery data, players can identify hot and cold numbers, as well as number combinations that have a higher probability of appearing in future draws.
The Role of Statistical Analysis
Lo Gan relies heavily on statistical analysis to uncover these patterns and trends. Experienced lottery players and platforms like 77WIN use advanced data-driven techniques to analyze vast amounts of lottery data, identifying the most promising numbers and strategies for their players.
The Significance of Lo Gan in Lottery Play at 77 win
In the world of lottery, where the odds of winning can seem daunting, Lo Gan has emerged as a compelling approach for players seeking to improve their chances of success.
Enhancing Your Odds of Winning
By leveraging the insights and patterns revealed through Lo Gan, players can make more informed decisions about their lottery selections, potentially increasing their odds of winning.
Strategies for Consistent Winnings
Lo Gan is not just about hitting the jackpot; it’s also about consistently winning smaller prizes, which can add up over time. By identifying and focusing on numbers and number combinations with higher probabilities, players can develop a more sustainable and profitable lottery strategy.
The Psychological Aspect of Lo Gan
Engaging with Lo Gan can also have a positive psychological impact on players. The sense of empowerment and control that comes from understanding and applying these strategies can help alleviate the frustration and anxiety often associated with traditional lottery play.
77WIN: Unveiling the Secret to Lottery Success
77WIN, a renowned lottery platform, has positioned itself as a leader in the Lo Gan space, offering its players a comprehensive suite of tools and strategies to maximize their lottery success.
77WIN’s Expertise in Lo Gan Strategies
77WIN’s team of lottery experts has spent years studying and refining Lo Gan techniques, drawing on a wealth of data and analytics to develop proprietary algorithms and strategies that give their players a significant edge.
Key Factors
Description
Data-Driven Approach
77WIN’s strategies are built upon a deep understanding of lottery data, allowing them to identify the most promising patterns and trends.
Cutting-Edge Technology
77WIN leverages advanced technology, including machine learning and artificial intelligence, to analyze and interpret lottery data with unparalleled precision.
Continuous Improvement
77WIN’s team is constantly refining and improving their Lo Gan strategies, ensuring that their players always have access to the latest and most effective techniques.
Key Insights from 77WIN for Effective Lottery Play
Through their extensive experience and research, 77WIN has developed a wealth of insights that can help players navigate the world of lottery play more effectively. Some of these key insights include:
The importance of understanding the statistical distribution of lottery numbers
Techniques for identifying and capitalizing on hot and cold numbers
Strategies for optimizing your lottery ticket combinations
The role of luck and randomness in lottery play, and how to balance it with strategic thinking
Maximizing Your Chances of Winning with Lo Gan
Leveraging the power of Lo Gan, players can take concrete steps to improve their lottery success.
Developing a Systematic Approach
One of the keys to effective Lo Gan-based lottery play is to approach it with a systematic and disciplined mindset. This involves:
Regularly analyzing and keeping track of lottery data
Constantly refining and adjusting your strategies based on new insights
Maintaining a long-term perspective and avoiding the temptation of quick fixes
Utilizing 77WIN’s Lo Gan Tools and Resources
77WIN offers a range of tools and resources to help players seamlessly integrate Lo Gan into their lottery strategy, including:
Comprehensive lottery data analysis and visualization tools
Personalized recommendations and predictions based on your playing habits
Educational resources and tutorials on Lo Gan techniques and best practices
Staying Informed and Adaptable
Effective lottery play with Lo Gan requires a willingness to stay informed and adaptable. As the lottery landscape evolves and new insights emerge, players must be prepared to adjust their strategies accordingly.
The Power of Statistical Analysis in Lo Gan
At the heart of Lo Gan lies the power of statistical analysis, which enables players to identify and capitalize on the patterns and trends that govern lottery outcomes.
Understanding Probability and Distribution
One of the key aspects of statistical analysis in Lo Gan is the deep understanding of probability and the distribution of lottery numbers. By analyzing the historical data, players can gain insights into the likelihood of certain numbers or number combinations appearing in future draws.
Leveraging Regression Analysis
Regression analysis is a powerful tool used in Lo Gan to identify the relationships between different lottery variables, such as the frequency of number appearances and the timing of their occurrences. This information can be used to make more informed predictions and adjust strategies accordingly.
Incorporating Machine Learning and AI
In the modern era of lottery play, 77WIN has leveraged the power of machine learning and artificial intelligence to take statistical analysis to new heights. By training complex algorithms on vast amounts of lottery data, 77WIN can uncover insights and patterns that would be impossible for human analysts to detect.
77WIN’s Proven Methods for Lo Gan Success
77WIN has developed a comprehensive and proven approach to Lo Gan-based lottery play, drawing on their deep understanding of the underlying principles and their extensive experience in the field.
Comprehensive Data Analysis
At the core of 77WIN’s strategies is a meticulous and comprehensive analysis of lottery data, spanning historical draw results, player trends, and a multitude of other relevant factors.
Predictive Modeling and Forecasting
By applying advanced statistical techniques and machine learning algorithms, 77WIN is able to develop predictive models that forecast the likelihood of certain numbers or number combinations appearing in future draws.
Personalized Recommendations and Strategies
77WIN’s platform offers personalized recommendations and strategies tailored to each individual player’s preferences and playing habits, ensuring that their lottery approach is as effective and tailored as possible.
Continuous Improvement and Refinement
77WIN’s team of experts is constantly refining and improving their Lo Gan strategies, incorporating new data, insights, and technological advancements to ensure that their players always have access to the most cutting-edge and effective techniques.
The Future of Lottery Play: Embracing Lo Gan Strategies
As the world of lottery continues to evolve, the importance of Lo Gan-based strategies is only expected to grow, and platforms like 77WIN are at the forefront of this change.
Technological Advancements and Lo Gan
The rapid advancements in data processing, machine learning, and artificial intelligence are expected to drive significant improvements in Lo Gan-based lottery strategies, enabling players to make even more informed and accurate predictions.
The Increasing Popularity of Lo Gan
As more and more lottery players become aware of the potential benefits of Lo Gan, the demand for these strategies is likely to increase, with platforms like 77WIN playing a crucial role in meeting this growing need.
The Importance of Accessibility and Education
To truly unlock the power of Lo Gan, it will be essential for lottery platforms to prioritize the accessibility and education of these strategies, ensuring that players of all levels can understand and effectively apply them.
Conclusion
In the ever-evolving world of lottery play, the importance of Lo Gan-based strategies cannot be overstated. By leveraging the power of statistical analysis and cutting-edge technology, platforms like 77WIN are leading the charge in helping players maximize their chances of winning. Whether you’re a seasoned lottery player or just starting to explore the world of Lo Gan, 77WIN’s comprehensive suite of tools and resources can provide you with the insights and strategies you need to take your lottery success to new heights.
Rikvipct – Bí quy?t ch?i bài Rikvipct d? th?ng. Trong th? gi?i game online ngày nay, Rikvipct ?ã tr? thành m?t trong nh?ng trò ch?i ???c yêu thích nh?t. Nhi?u ng??i ch?i không ch? tìm ki?m ni?m vui mà còn mong mu?n có c? h?i th?ng l?n. Bài vi?t này s? cung c?p cho b?n nh?ng bí quy?t h?u ích ?? nâng cao kh? n?ng chi?n th?ng khi tham gia ch?i Rikvipct.
Tr??c khi b?t tay vào vi?c ch?i Rikvipct, ?i?u quan tr?ng là b?n c?n hi?u rõ v? trò ch?i này. Rikvipct không ch? ??n thu?n là m?t trò ch?i bài mà còn là m?t chi?n l??c tâm lý và k? n?ng.
B?n ch?t c?a Rikvipct
Rikvipct là m?t trò ch?i bài tr?c tuy?n, n?i ng??i ch?i c?nh tranh v?i nhau ?? tích l?y ?i?m s? cao h?n. Trò ch?i này ?òi h?i s? k?t h?p gi?a may m?n và k? n?ng, vì v?y vi?c n?m rõ lu?t ch?i là r?t quan tr?ng.
Rikvipct không gi?ng nh? các trò ch?i bài thông th??ng khác, nó mang l?i cho ng??i ch?i nhi?u c? h?i t??ng tác và trao ??i. Ng??i ch?i c?n ph?i xác ??nh các quy t?c và chi?n thu?t phù h?p ?? có l?i th? trong m?i ván bài.
Lu?t ch?i c? b?n
?? có th? tham gia vào trò ch?i Rikvipct m?t cách thu?n l?i, b?n c?n n?m v?ng các quy t?c c? b?n. M?i ván bài di?n ra theo m?t quy trình c? th?, bao g?m vi?c chia bài, ??t c??c và quy?t ??nh hành ??ng ti?p theo.
Vi?c hi?u rõ lu?t ch?i không ch? giúp b?n tránh sai sót mà còn t?o ra c? h?i t?t h?n ?? ??a ra quy?t ??nh chính xác trong t?ng tình hu?ng. B?n c?ng nên theo dõi các ván bài tr??c ?ó ?? phân tích và rút ra kinh nghi?m cho riêng mình.
Tâm lý trong trò ch?i
Tâm lý ng??i ch?i ?óng vai trò vô cùng quan tr?ng trong Rikvipct. S? t? tin và kiên nh?n s? giúp b?n ki?m soát c?m xúc và ??a ra nh?ng quy?t ??nh ?úng ??n.
Ng??i ch?i c?n h?c cách ??c tâm lý ??i th? ?? có th? d? ?oán hành ??ng c?a h?. ?i?u này không ch? t?o l?i th? cho b?n mà còn giúp b?n tránh nh?ng c?m b?y mà ??i th? có th? t?o ra.
Chi?n l??c ch?i Rikvipct hi?u qu?
?? có th? giành chi?n th?ng trong trò ch?i Rikvipct, vi?c áp d?ng các chi?n l??c ch?i là ?i?u c?n thi?t. M?t chi?n l??c t?t s? giúp b?n t?i ?u hóa t? l? th?ng c?a mình.
Tìm hi?u ??i th?
M?t trong nh?ng y?u t? quan tr?ng nh?t trong Rikvipct là vi?c hi?u rõ ??i th? c?a b?n. Quan sát cách h? ch?i và nh?n di?n phong cách c?a h? có th? giúp b?n ??a ra quy?t ??nh t?t h?n.
N?u ??i th? th??ng xuyên m?o hi?m, b?n có th? ch?n cách ch?i c?n th?n h?n ?? khai thác nh?ng sai sót c?a h?. Ng??c l?i, n?u h? ch?i an toàn, b?n có th? t?n d?ng ?i?u này ?? làm khó h? b?ng cách t?ng m?c c??c.
Qu?n lý v?n
Qu?n lý v?n là m?t ph?n thi?t y?u trong m?i trò ch?i cá c??c. Trong Rikvipct, b?n c?n ??t ra ngân sách c? th? cho m?i phiên ch?i ?? tránh vi?c tiêu t?n quá m?c.
Vi?c duy trì k? lu?t tài chính s? giúp b?n có th? ch?i lâu dài mà không b? ?nh h??ng b?i c?m xúc hay nh?ng bi?n ??ng t?m th?i. Hãy ch?c ch?n r?ng b?n luôn tuân th? ngân sách c?a mình, b?t k? th?ng hay thua.
??a ra quy?t ??nh ?úng lúc
Trong Rikvipct, timing là m?t y?u t? quy?t ??nh. ?ôi khi, vi?c ra quy?t ??nh t?i th?i ?i?m chính xác có th? mang l?i cho b?n l?i th? l?n.
Hãy chú ý ??n th?i ?i?m mà b?n nên ??t c??c l?n ho?c gi? im l?ng. Bi?t khi nào nên c??c và khi nào nên fold là m?t k? n?ng quan tr?ng mà b?n c?n phát tri?n.
Thay ??i chi?n thu?t
Không có m?t chi?n thu?t nào là hoàn h?o cho t?t c? tình hu?ng. Vì v?y, b?n c?n linh ho?t trong cách ch?i và ?i?u ch?nh chi?n thu?t c?a mình d?a trên di?n bi?n c?a ván bài.
N?u b?n th?y r?ng chi?n thu?t hi?n t?i ?ang không mang l?i k?t qu?, hãy nghiêm túc xem xét vi?c thay ??i h??ng ?i. S? linh ho?t trong cách ti?p c?n s? giúp b?n d? dàng thích nghi v?i nh?ng thay ??i trong trò ch?i.
Tâm lý và c?m xúc trong Rikvipct
S? qu?n lý tâm lý trong Rikvipct là m?t y?u t? c?c k? quan tr?ng. C?m xúc c?a b?n có th? ?nh h??ng l?n ??n quy?t ??nh và kh? n?ng ch?i c?a b?n.
Ki?m soát c?m xúc
M?t trong nh?ng thách th?c l?n nh?t mà ng??i ch?i ph?i ??i m?t là vi?c ki?m soát c?m xúc c?a mình. Khi th?ng, b?n có th? tr? nên kiêu ng?o; khi thua, b?n có th? c?m th?y chán n?n.
Vi?c duy trì s? bình t?nh s? giúp b?n t?p trung vào trò ch?i và ??a ra quy?t ??nh sáng su?t. B?n c?n h?c cách không ?? c?m xúc chi ph?i hành ??ng c?a mình, và luôn gi? v?ng tinh th?n.
??c tâm lý ??i th?
Bi?t cách ??c tâm lý ??i th? c?ng là m?t k? n?ng quan tr?ng. N?u b?n có th? hi?u ???c tr?ng thái tâm lý c?a ??i th?, b?n có th? ?i?u ch?nh chi?n thu?t c?a mình cho phù h?p.
Hãy quan sát các bi?u hi?n trên khuôn m?t và hành ??ng c?a ??i th? ?? phán ?oán xem h? có ?ang c?m th?y t? tin hay lo l?ng không. S? quan sát k? càng s? giúp b?n ??a ra nh?ng quy?t ??nh thông minh h?n.
G?n g?i v?i c?ng ??ng
Tham gia vào c?ng ??ng ng??i ch?i Rikvipct c?ng là m?t cách hi?u qu? ?? c?i thi?n tâm lý c?a b?n. Chia s? tr?i nghi?m và h?c h?i t? nh?ng ng??i khác s? giúp b?n c?m th?y t? tin h?n.
C?ng ??ng s? h? tr? b?n trong nh?ng lúc c?n thi?t và cho b?n nh?ng g?i ý quý giá. Hãy tích c?c tham gia các di?n ?àn, nhóm chat ho?c kênh truy?n thông xã h?i ?? m? r?ng m?ng l??i k?t n?i c?a b?n.
FAQs
Ch?i Rikvipct có h?p pháp không?
Vi?c ch?i Rikvipct ph? thu?c vào quy ??nh pháp lu?t c?a t?ng qu?c gia. B?n nên tìm hi?u k? tr??c khi tham gia ?? tránh g?p r?c r?i pháp lý.
Có th? ch?i Rikvipct mi?n phí không?
Nhi?u n?n t?ng cung c?p phiên b?n ch?i th? mi?n phí. ?i?u này cho phép b?n làm quen v?i lu?t ch?i mà không m?t ti?n.
Làm th? nào ?? nâng cao k? n?ng ch?i Rikvipct?
B?n có th? tham gia các khóa h?c tr?c tuy?n, ??c sách ho?c theo dõi các video h??ng d?n t? nh?ng ng??i ch?i chuyên nghi?p.
Có m?o nào ?? t?ng t? l? th?ng khi ch?i Rikvipct không?
?i?u quan tr?ng là n?m b?t lu?t ch?i, qu?n lý v?n t?t và làm ch? tâm lý c?a chính mình. Vi?c th?c hành th??ng xuyên c?ng giúp b?n c?i thi?n k? n?ng.
Rikvipct có th? ch?i trên ?i?n tho?i không?
Có, nhi?u nhà phát tri?n ?ã t?i ?u hóa trò ch?i Rikvipct cho các thi?t b? di ??ng, cho phép b?n ch?i m?i lúc, m?i n?i.
K?t lu?n
Rikvipct – Bí quy?t ch?i bài Rikvipct d? th?ng ???c xây d?ng d?a trên vi?c hi?u bi?t sâu s?c v? trò ch?i, áp d?ng các chi?n l??c hi?u qu? và qu?n lý tâm lý m?t cách khéo léo. V?i nh?ng bí quy?t mà bài vi?t ?ã cung c?p, hy v?ng b?n s? có th? nâng cao kh? n?ng th?ng c??c và tr?i nghi?m nh?ng giây phút thú v? trong trò ch?i này. Hãy luôn nh? r?ng, chi?n th?ng không ch? ??n t? may m?n mà còn t? s? chu?n b? và ki?n th?c b?n có!
Rikvip CT – C?ng game bài Rikvip CT an toàn và uy tín
Rikvip CT – C?ng game bài Rikvip CT an toàn và uy tín. Trong th?i ??i s? hi?n nay, vi?c ch?i game bài tr?c tuy?n ?ang tr? thành m?t thú vui ph? bi?n c?a nhi?u ng??i. N?i b?t trong s? ?ó là c?ng game Rikvip CT, n?i mang ??n cho ng??i ch?i nh?ng tr?i nghi?m thú v? v?i tính n?ng b?o m?t cao và d?ch v? khách hàng t?n tâm. Bài vi?t này s? ?i sâu vào các khía c?nh n?i b?t c?a Rikvip CT, t? cách th?c ho?t ??ng ??n s? uy tín mà nó mang l?i.
Khi nh?c ??n Rikvip CT, ?i?u ??u tiên xu?t hi?n trong tâm trí ng??i ch?i chính là s? an toàn và uy tín. C?ng game này không ch? ??n thu?n là n?i ?? gi?i trí mà còn là m?t n?n t?ng ???c xây d?ng v?i m?c tiêu mang ??n tr?i nghi?m t?t nh?t cho ng??i dùng.
L?ch s? hình thành và phát tri?n
Rikvip CT ra ??i trong b?i c?nh nhu c?u gi?i trí tr?c tuy?n t?ng cao. V?i s? gia t?ng nhanh chóng c?a các trò ch?i ?i?n t? và s? phát tri?n v??t b?c c?a công ngh? thông tin, Rikvip CT ?ã nhanh chóng chi?m l?nh th? tr??ng game bài t?i Vi?t Nam.
C?ng game này không ng?ng nâng c?p, ??i m?i ?? ?áp ?ng nhu c?u ngày càng cao c?a ng??i ch?i. T? các game truy?n th?ng ??n nh?ng trò ch?i hi?n ??i, Rikvip CT mang ??n ?a d?ng l?a ch?n cho m?i l?a tu?i và s? thích.
Các lo?i trò ch?i t?i Rikvip CT
Rikvip CT không ch? cung c?p m?t vài trò ch?i ??n ?i?u mà còn có m?t kho tàng phong phú các th? lo?i game bài. Ng??i ch?i có th? d? dàng tìm th?y các trò ch?i nh? Ti?n lên mi?n Nam, Xì t?, Bo?ng ba?n, hay các trò ch?i slot h?p d?n.
Các trò ch?i này ???c thi?t k? giao di?n ??p m?t, d? s? d?ng, t?o c?m giác tho?i mái cho ng??i ch?i. H?n n?a, m?i trò ch?i ??u có lu?t ch?i rõ ràng, giúp ng??i ch?i m?i có th? tham gia d? dàng mà không g?p khó kh?n nào.
Công ngh? và b?o m?t
?? làm nên tên tu?i c?a mình, Rikvip CT ?ã áp d?ng công ngh? tiên ti?n nh?m ??m b?o an toàn thông tin cho ng??i ch?i. H? th?ng mã hóa d? li?u hi?n ??i b?o v? thông tin cá nhân c?ng nh? tài kho?n c?a ng??i dùng kh?i các m?i ?e d?a t? bên ngoài.
Ngoài ra, ??i ng? k? thu?t viên c?a Rikvip CT luôn theo dõi h? th?ng 24/7 ?? k?p th?i phát hi?n và x? lý các v?n ?? phát sinh. ?i?u này giúp t?ng c??ng ni?m tin c?a ng??i ch?i ??i v?i c?ng game, kh?ng ??nh ?ây là n?i gi?i trí an toàn và ?áng tin c?y.
Tr?i nghi?m ng??i ch?i t?i Rikvip CT
M?t c?ng game không ch? c?n có ch?t l??ng trò ch?i t?t mà còn c?n mang ??n tr?i nghi?m tuy?t v?i cho ng??i ch?i. Rikvip CT hi?u rõ ?i?u này và không ng?ng c?i thi?n các y?u t? liên quan ??n tr?i nghi?m ng??i dùng.
Giao di?n ng??i dùng thân thi?n
Rikvip CT ???c thi?t k? v?i giao di?n thân thi?n, d? nhìn và d? s? d?ng. Ngay c? nh?ng ng??i ch?a có kinh nghi?m c?ng có th? d? dàng t??ng tác v?i các ch?c n?ng trên trang web.
?i?u này giúp ng??i ch?i không m?t quá nhi?u th?i gian ?? làm quen v?i n?n t?ng. H?n th? n?a, vi?c truy c?p vào các trò ch?i yêu thích c?ng tr? nên nhanh chóng và thu?n ti?n h?n bao gi? h?t.
D?ch v? ch?m sóc khách hàng
D?ch v? khách hàng t?i Rikvip CT là m?t ?i?m m?nh l?n. ??i ng? h? tr? khách hàng c?a h? luôn s?n sàng 24/7 v?i nh?ng ng??i t? v?n giàu kinh nghi?m, nhi?t tình và chuyên nghi?p.
Ng??i ch?i có th? d? dàng liên h? qua nhi?u kênh khác nhau nh? chat tr?c ti?p, email ho?c ?i?n tho?i. M?i th?c m?c c?a ng??i ch?i ??u ???c gi?i quy?t nhanh chóng, giúp h? yên tâm h?n khi tham gia các trò ch?i.
Ch??ng trình khuy?n mãi h?p d?n
Rikvip CT th??ng xuyên t? ch?c các ch??ng trình khuy?n mãi h?p d?n dành cho ng??i ch?i m?i c?ng nh? ng??i ch?i trung thành. Nh?ng ?u ?ãi này không ch? giúp ng??i ch?i ti?t ki?m chi phí mà còn t?ng thêm h?ng thú khi tham gia các trò ch?i.
Ch??ng trình khuy?n mãi ?a d?ng, t? th??ng ??ng ký cho ng??i ch?i m?i ??n các s? ki?n ??c bi?t trong game. ?i?u này giúp ng??i ch?i c?m th?y ???c trân tr?ng và khuy?n khích h? tham gia nhi?u h?n.
Rikvip CT và c?ng ??ng ng??i ch?i
C?ng ??ng là m?t ph?n quan tr?ng c?a b?t k? c?ng game nào. Rikvip CT không ch? t?o ra m?t n?n t?ng ch?i game mà còn xây d?ng m?t c?ng ??ng m?nh m? gi?a nh?ng ng??i ch?i.
Di?n ?àn và m?ng xã h?i
Rikvip CT t?o ra các di?n ?àn và nhóm trên m?ng xã h?i ?? ng??i ch?i có th? k?t n?i, chia s? kinh nghi?m và trao ??i chi?n thu?t ch?i game. Nh?ng di?n ?àn này c?ng là n?i ng??i ch?i có th? g?i ph?n h?i v? s?n ph?m và d?ch v? c?a c?ng game.
S? t??ng tác gi?a ng??i ch?i không ch? giúp h? c?m th?y g?n bó h?n mà còn góp ph?n làm phong phú thêm tr?i nghi?m ch?i game c?a m?i ng??i.
Các s? ki?n offline
Th?nh tho?ng, Rikvip CT c?ng t? ch?c các s? ki?n offline ?? k?t n?i ng??i ch?i th?c t?. ?ây là c? h?i ?? ng??i ch?i g?p g?, giao l?u và thi ??u v?i nhau, t?o thêm nh?ng m?i quan h? thú v? trong c?ng ??ng game.
Nh?ng s? ki?n này không ch? mang l?i ni?m vui mà còn t?o ra s? c?nh tranh lành m?nh, giúp ng??i ch?i nâng cao k? n?ng và tìm ki?m nh?ng ??i th? x?ng t?m.
?i?u này không ch? làm t?ng tính thân thi?n c?a c?ng ??ng mà còn giúp m?i ng??i cùng nhau phát tri?n và tr??ng thành trong th? gi?i game bài.
FAQs
Rikvip CT có an toàn không?
Rikvip CT cam k?t b?o m?t thông tin và tài kho?n c?a ng??i ch?i b?ng công ngh? mã hóa hi?n ??i. B?n hoàn toàn có th? yên tâm khi tham gia vào c?ng game này.
Có th? ch?i Rikvip CT trên ?i?n tho?i không?
Có, Rikvip CT h? tr? ch?i trên c? máy tính và ?i?n tho?i di ??ng. B?n có th? t?i ?ng d?ng v? ?? ch?i m?i lúc m?i n?i.
Tôi c?n ph?i n?p ti?n nh? th? nào ?? tham gia ch?i?
B?n có th? n?p ti?n vào tài kho?n Rikvip CT qua nhi?u ph??ng th?c khác nhau nh? chuy?n kho?n ngân hàng, ví ?i?n t?, ho?c th? cào. Quy trình n?p ti?n r?t ??n gi?n và nhanh chóng.
Rikvip CT có ch??ng trình khuy?n mãi nào không?
Có, Rikvip CT th??ng xuyên t? ch?c các ch??ng trình khuy?n mãi dành cho ng??i m?i và ng??i ch?i trung thành. B?n có th? tham kh?o thông tin khuy?n mãi trên trang ch? ?? không b? l?.
Tôi có th? liên h? v?i b? ph?n h? tr? khách hàng khi g?p v?n ?? không?
Có, b?n có th? liên h? v?i b? ph?n h? tr? khách hàng qua chat tr?c ti?p, email ho?c ?i?n tho?i. ??i ng? h? tr? luôn s?n sàng giúp ?? b?n m?i lúc.
K?t lu?n
Rikvip CT – C?ng game bài Rikvip CT an toàn và uy tín ?ã kh?ng ??nh ???c v? th? c?a mình trên th? tr??ng game online. V?i s? ?a d?ng trong trò ch?i, d?ch v? ch?m sóc khách hàng t?n tâm cùng v?i h? th?ng b?o m?t ch?t ch?, ?ây th?c s? là m?t ??a ch? ?áng tin c?y cho nh?ng ai yêu thích game bài. Hy v?ng r?ng v?i nh?ng thông tin trên, b?n s? có cái nhìn t?ng quan và chi ti?t h?n v? Rikvip CT, t? ?ó ??a ra nh?ng quy?t ??nh ?úng ??n khi tham gia.
(Reuters) – Jewish and Muslim groups protested on Wednesday after a German court banned the circumcision of young boys for religious reasons in the first ruling of its kind in the country.
The court in the western city of Cologne handed down the decision on Tuesday in the case of a doctor prosecuted for circumcising a four-year-old Muslim boy who had to be treated two days later for post-operative bleeding.
It ruled involuntary religious circumcision should be made illegal because it could inflict serious bodily harm on people who had not consented to it.
However the ruling, which applies only to the Cologne area, said boys who consciously decided to be circumcised could have the operation. No age restriction was given, or any more specific details.
The doctor, who was prosecuted after the hospital doctor who treated the boy for bleeding called police, was acquitted as there was no law banning religious circumcision at the time.
The Central Council of Jews in Germany called the ruling an “unprecedented and dramatic intrusion” of the right to religious freedom and an “outrageous and insensitive” act.
“Circumcision for young boys is a solid component of the Jewish religion and has been practiced worldwide for millennia. This religious right is respected in every country around the world,” President Dieter Graumann said in a statement.
“INTERFERENCE”
The Central Council of Muslims in Germany called the sentence a “blatant and inadmissible interference” in the rights of parents.
“Freedom of religion is highly valued in our constitution and cannot be the play-thing of a one-dimensional case law which, furthermore, consolidates existing prejudices and stereotypes,” it said in a statement.
According to the court ruling, “the fundamental right of the child to bodily integrity outweighs the fundamental rights of the parents”.
“The child’s body is permanently and irreparably changed by the circumcision. This change runs counter to the interests of the child, who can decide his religious affiliation himself later in life,” it said.
Germany is home to about 4 million Muslims and 120,000 Jews. In Judaism, eight-day-old male infants are circumcised to recall the covenant established between God and the Hebrew patriarch Abraham.
The time for Muslim circumcision varies according to family, region and country.
Concerned the ruling could be followed in other parts of the country and that it could prevent doctors carrying out circumcisions for fear of prosecution, the Central Council of Jews urged the German parliament “to provide legal clarity in order to prevent attacks on religious freedom”.
The World Health Organisation estimates 30 percent of men worldwide are circumcised.
In countries including the United States, many parents cite health reasons for having boys circumcised, saying it improves hygiene and can cut the risk of the spread of disease.
Female genital mutilation is forbidden across Germany.
(Reporting By Elisa Oddone; Editing by Tom Heneghan and Pravin Char)
In a response letter to NOCIRC-SA, the South African Medical Association denounces the circumcision of male infants for HIV prevention as “unethical” and “illegal.”
(The South African Medical Association sent a letter response last week to NOCIRC-SA—the South African chapter of the National Organization of Circumcision Information Resource Centers— denouncing male infant circumcision as “unethical”and “illegal.” The letter was signed by Ms. Ulundia Berhtel, head of the Human Rights, Law & Ethics unit, and Obo Chairperson of the Human Rights, Law & Ethics Committee.
The South Africa Medical Association (SAMA) letter was in response to a February letter sent from NOCIRC-SA to the Kwa-Zulu Natal Health Department to try and stop the new mass infant circumcision programs. The NOCIRC-SA letter pointed out the legal and ethical consequences of rolling out mass infant circumcision programs for HIV prevention. According to the Children’s Act, children can only be circumcised for “medical reasons” directly related to problems with the foreskin. Circumcision is a serious surgery that is traumatic for the infant, irreversible, and results in a significant loss of sexual sensation and capability. A healthy foreskin is important for normal sexual functioning when the child becomes an adult. Circumcising children for HIV prevention is therefore illegal under the Children’s Act, and children could sue their doctors as adults for the violation of their right to a complete body.
In their February letter to SAMA, NOCIRC-SA highlighted the fact that while there are studies on HIV prevention for circumcised adult males, there are currently no studies in existence on HIV prevention for circumcised infants. NOCIRC-SA holds that it is “unreasonable” and “inhumane” to perform a radical genital surgery on infants 12-14 years before they will become sexually active. These children can be educated on condom use—which provide the best protection against HIV for each time of use, over 99% if used correctly—and in 12-14 years a vaccine for HIV might exist. Any circumcised man having regular unprotected sex over time will ultimately carry the same risk of HIV exposure and increase the risk of his partner, especially if he falls prey to the belief that he is protected from HIV. Already, throughout Africa, men are beginning to believe that they do not need to wear a condom because they are circumcised.
The response letter from the South African Medical Association:
CIRCUMCISION OF BABIES FOR PROPOSED HIV PREVENTION
We refer to the above matter and your email correspondence of 16 February 2011.
The matter was discussed by the members of the Human Rights, Law & Ethics Committee at their previous meeting and they agreed with the content of the letter by NOCIRC SA. The Committee stated that it was unethical and illegal to perform circumcision on infant boys in this instance. In particular, the Committee expressed serious concern that not enough scientifically-based evidence was available to confirm that circumcisions prevented HIV contraction and that the public at large was influenced by incorrect and misrepresented information. The Committee reiterated its view that it did not support circumcision to prevent HIV transmission.
How the circumcision solution in Africa will increase HIV infections
Robert S. Van Howe, Michelle R. Storms
Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Marquette, MI, USA
Correspondence: Dr. Robert S. Van Howe, Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, 413 E. Ohio Street, Marquette, MI 49855, USA.
Tel. +1.906.2287454 – Fax: +1.906.4852726. E-mail: [email protected], [email protected]
Key words: circumcision, HIV infection, risk compensation.
Conflict of interest: the authors report no conflicts of interest.
Received for publication: 25 October 2010.
Accepted for publication: 9 December 2010.
This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0).
The World Health Organization and UNAIDS have supported circumcision as a preventive for HIV infections in regions with high rates of heterosexually transmitted HIV; however, the circumcision solution has several fundamental flaws that undermine its potential for success. This article explores, in detail, the data on which this recommendation is based, the difficulty in translating results from high risk adults in a research setting to the general public, the impact of risk compensation, and how circumcision compares to existing alternatives. Based on our analysis it is concluded that the circumcision solution is a wasteful distraction that takes resources away from more effective, less expensive, less invasive alternatives. By diverting attention away from more effective interventions, circumcision programs will likely increase the number of HIV infections.
Introduction
At the XVIII International AIDS conference held in Vienna, there was a strong push to gather funding to circumcise 38 million men in sub-Saharan Africa within the next five years. The belief is that male circumcision provides the best hope of decreasing the spread of HIV infection there. We believe these efforts are misguided.
Although the World Health Organization (WHO) and UNAIDS have supported circumcision as an HIV preventive in regions with high rates of heterosexually transmitted HIV, the circumcision solution has several fundamental flaws that have been glossed over by its proponents within these organizations. These proponents, who have been touting the “benefits” of circumcision for decades, have developed plans to circumcise Africa on behalf of WHO and UNAIDS.1 If their goal is to prevent the spread of HIV in Africa, circumcision will only serve to divert resources away from effective measures.
In this paper, we will expose the lack of scientific evidence, biological plausibility, and epidemiological evidence that provides the foundation for the circumcision solution. We will demonstrate how circumcision will likely increase the number of heterosexually transmitted HIV infections. Finally, we will discuss how poorly circumcision compares with other interventions.
Lack of scientific evidence
The results of three randomized clinical trials (RCTs) are often presented as proof beyond a reasonable doubt that male circumcision prevents HIV infection.2 After all, RCTs are the gold standard of medical experimentation. However, such accolades only apply to well-designed, well-executed trials. The three RCTs were neither.
The trials were nearly identical in their methodology and in the number of men in each arm of the trial who became infected. The trials shared the same biases, which led to nearly identical results. All had expectation bias (both researcher and participant), selection bias, lead-time bias, attrition bias, duration bias, and early termination that favored the treatment effect the investigators were hoping for.3 All three studies were overpowered such that the biases alone could have provided a statistically significant difference.
The common hypothesis for these trials was that male circumcision would decrease the rate of heterosexually transmitted HIV infections. A basic assumption adopted by the investigators was that all HIV infections resulted from heterosexual transmission, so no effort was made to determine the source of the infections discovered during the trial. There is strong evidence that this assumption was not valid.
In the South African trial, men who reported at least one episode of unprotected sex accounted for 2498 person-years and 46 HIV infections during the trial. Among the remaining men, who accounted for 2076 person-years, 23 become infected although they either had no sexual contact or always used a condom. These men, who had infection rate of 1.11/100 person-years (95%CI=0.74-1.67), presumably became infected through non-sexual means. The men at sexual risk of infection had an infection rate of 1.84/100 person-years (95%CI=1.38-2.46). It would be expected that all men in the trial shared the same baseline risk of non-sexual transmission and any additional risk could be attributed to sexual transmission. The infections attributed to sexual contact would be the difference between the total rate and the non-sexually transmitted rate (0.73/100 person-years). Consequently, only 18 (0.0073 infections per person-year * 2498 person-years) of the 69 infections in the South African trial can be attributed to sexual transmission.4
Similarly, in the Ugandan trial, men who consistently used condoms had the same rate of infection as those who never used condoms (Consistent condom use: 1.03/100 person-years; No condom use 0.91/100 person-years; RR=1.13, 95%CI=0.54-2.38, P=0.74). Men who reported no sexual partners for the duration of the trial accounted for 1252.1 patient-years and 6 infections (0.48/100 persons-years, 95%CI=0.22-1.07). If this rate is subtracted from the rate in sexually active men, at most 35 of the 67 infections in the Ugandan trial can be attributed to sexual transmission.5
Finally, in the first three months of the Kenyan trial, five men became HIV-positive who reported no sexual activity in the period before the seroconversion (0.73/100 person-years, 95%CI=0.30-1.76). If this rate is subtracted from the overall rate of infection in the trial, at most 36 of the 69 infections in the Ugandan trial can be attributed to sexual transmission.6 Conservatively for the three trials, 89 of the 205 infections (43.1%) were sexually transmitted. Without knowing which infections were sexually transmitted, it is impossible to test the hypothesis of whether circumcision reduces the rate of sexually transmitted HIV. Basing policy on studies that were unable to answer their own research question is unwarranted.
Lack of biologic plausibility
How does cutting off the foreskin prevent the transmission of HIV? This question remains unanswered. Proponents of the circumcision solution have speculated that the interior mucosa of the prepuce is thinner and more prone to tearing, but mucosa of the inner and outer prepuce have been shown to be of the same thickness.7 Proponents also speculate that HIV is more likely to be transmitted through the foreskin because it has a high concentration of Langerhans cells, which they believe are the entry point for HIV. Research has shown that Langerhans cells are quite efficient in repelling HIV and explains why the transmission rate of HIV is one per 1000 unprotected coital acts.8 The inner foreskin secretes langerin, which kills viruses.9 Langerhans cells also protect against other sexually transmitted infections (STIs), which may explain why circumcised men are at greater risk for getting an STI (unpublished data). In general, mucosal immunity provides a stronger barrier to infection than the skin. Finally, to support their plausibility argument, circumcision proponents have identified the sub-preputial space as a harbor for sexually transmitted viruses. Meta-analyses assessing the susceptibility to genital infections with herpes simplex virus and human papilloma virus have not shown an association with circumcision status.10,11,12 Unfortunately, these speculations have been repeated so often in the medical literature that many physicians and public health officials consider them factual. There is, however, no direct scientific evidence to support the hypothesis that the foreskin is a predisposing factor for infection.
Lack of consistent epidemiological evidence
If the RCTs are to be believed and circumcision provides 50% to 60% protection from sexually transmitted HIV infection, then the impact of circumcision should be readily apparent in the general population. This is not the case. In Africa, there are several countries where circumcised men are more likely to be HIV infected than intact men, including Malawi, Rwanda, Cameroon, Ghana, Zimbabwe, Lesotho, Swaziland, and Tanzania.13,14,15 Even in South Africa, where one RCT was undertaken, 12.3% of circumcised men were HIV-positive, while 12.0% of intact men were HIV-positive.16 If the national survey data that are available from 19 countries are combined in a meta-analysis (Table 1) the random-effects model summary effect for the risk of a genitally intact man having HIV is an odds ratio of 1.10 (95%CI=0.83-1.46), indicating that on a general population level, circumcision has no association with risk of HIV infection. Among developed nations, the United States has the highest rate of circumcision and the highest rate of heterosexually transmitted HIV.17 Within the United States, blacks have the highest rate of circumcision18,19,20,21 and the highest rate of heterosexually transmitted HIV.22 Among English-speaking developed nations there is a significant positive association between neonatal circumcision rates and HIV prevalence (data currently under submission, Scot Anderson). On a population level, circumcision has not been found to be an effective measure and may be associated with an increase in HIV risk.
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Table 1. Meta-analysis of population survey results from 19 countries15,16 comparing HIV prevalence based on circumcision status using fixed-effects and random-effects models on exact odds ratios and confidence intervals.11
Risk compensation
Risk compensation occurs when people believe they have been provided additional protection (wearing safety belts) they will engage in higher risk behavior (driving faster). As a consequence of the increase in higher risk behavior, the number of targeted events (traffic fatalities) either remains unchanged or increases.23,24 When modeling HIV infections in San Francisco, Blower and McLean found that if an HIV-vaccine offered 50% protection, but reduced condom usage, or increased other risky behaviors, it would likely result in higher HIV infection rates.21
Risk compensation will accompany the circumcision solution in Africa. Circumcision has been promoted as a natural condom,25 and African men have reported having undergone circumcision in order not to have to continually use condoms. Such a message has been adopted by public health researchers. A recent South African study assessing determinants of demand for circumcision listed “It means that men don’t have [to] use a condom” as a circumcision advantage in the materials they presented to the men they surveyed.26 If circumcision results in lower condom use, the number of HIV infections will increase.
African men, on average, have coitus once a week,27 and use condoms in 48% of their sexual encounters with women.5 Assume that 20% of sexually active women are HIV-positive, partners were contacted randomly, condoms are 98% effective when used, the baseline circumcision rate is 5%, and circumcision reduced the transmission rate of HIV infection by 50%. Since the transmission rate of HIV from females to males is one per 1000 unprotected coital acts, the HIV infection rate in men in this scenario would be 0.537 per 100 person-years (which is far below the rate reported in the three RCTs). If the circumcision rate increases from 5% up to 75%, the infection rate would decrease to 0.344 per 100 person-years. If in the baseline scenario with a 5% circumcision rate condom use increased from 48% up to 67.9% of sexual encounters, the infection rate would be 0.344 per 100 person-years. Consequently, the impact of a fifteen-fold increase in the rate of circumcision could be accomplished by a relative 41% increase in the use of condoms.
The leap of faith
Interventions and medications that demonstrate efficacy in a research setting are often failures in a clinical setting. Circumcision will provide another example of this. The results from the RCTs are of questionable value, and it is unknown how they will translate to the real world. Numbers gathered from general populations are outside the 95% confidence intervals generated by the RCTs.
Research results often fail to translate to other settings because the research population differs considerably from the targeted population. For example, to save money in a trial of a new antihypertensive medication, participants with the highest blood pressure will be recruited for the trial, because it is easier to show effectiveness in those with more severe disease. The new medication may do well with the participants, but when the medication is released for general use, it may not be beneficial for those with mild hypertension, let alone those who are normotensive.
The men attracted by a free circumcision to enroll in the RCTs are not representative of the general population. The RCT participants were required to want to be circumcised. A faithful monogamous man with a faithful spouse would have little motivation to seek a free circumcision. This selection bias may have resulted in enrollment of men more likely to engage in high-risk behaviors. The free circumcision and financial inducements may have added to the selection bias.
If the selection bias resulted in more men at high risk of infection being in the trial, then the results would apply only to men who engage in high-risk behaviors. This would be consistent with the observational studies finding that the association between circumcision status and HIV infection was present primarily in studies of high-risk men.
Instead of targeting sexually active men at high risk of HIV infection, the circumcision solution proposes circumcising all males (of all ages), which would be equivalent to recommending the above antihypertensive medication to everyone regardless of their blood pressure. In addition to the national survey data (Table 1), observational studies of general populations have for the most part failed to show an association between circumcision status and HIV infection.28,29,30 There is no scientific reason to believe that the RCT results would necessarily apply to the general population. It is quite likely that applying research results from a high risk population to the general population will lead to failure. Using the scenario above, if it is assumed that circumcision has only a 10% protective in the general population then increasing the circumcision rate from 5% up to 75% would decrease the infection rate from 0.548 to 0.509 per 100 person-years. Increasing condom use from 48% up to 51.8% would result in the same gains. So a fifteen-fold increase in the circumcision rate would have the same impact as a 3.8% absolute increase in the use in condoms.
Attractive, less invasive, less expensive, more effective alternatives
Before Africans address sexually transmitted HIV, a concerted effort to eliminate the iatrogenic spread of the virus is needed. As the numbers from the RCTs indicate, most infections can be attributed to non-sexual transmission. While this indictment of the medical system is unsettling, ignoring iatrogenic sources of infection will only allow the African epidemic to flourish.31
When it comes to sexually transmitted HIV infections, proponents of circumcision have consistently failed to compare the effectiveness and cost of circumcision to currently available alternatives, which include condoms, aggressive surveillance and treatment of STIs, and antiretroviral therapy (ART).
ART is a secondary preventive measure. When those infected with HIV are treated with ART, the viral counts can decrease to where the patient is no longer contagious. HIV-infected patients on ART with no currently active STI no longer need to use condoms to protect their partners.32 A recent model predicted that a “test and treat” model in a sub-Saharan setting could reduce the number of new HIV infections by 55-73.2%,33 making this approach attractive in Africa, San Francisco, and Washington, DC.34 This intervention directs prevention at those most likely to benefit: those exposed to the virus. With the circumcision solution, the vast majority of men who are circumcised will not benefit from the procedure (Figure 1). Secondary prevention is a more efficient use of resources and many HIV experts consider primary prevention extremely wasteful and ineffective.8 The “test and treat” approach is effective regardless of whether the infection was sexually or iatrogenically transmitted. Such an approach would not be limited to ART, as the use of other medications proven to decrease viral counts, such as decitabine and gemcitabine, may also become available.35
Aggressive surveillance and treatment of STIs has been shown to reduce the number of HIV infections by 40%36 at a cost of $217.62 per HIV-1 infection averted.37 This is more cost-effective than models for circumcision, which extrapolate the data collected from the 21 to 24 months of the RCTs to over 20 years, have predicted. These models, which incorporated major assumptions of questionable validity, presented circumcision as favorably as possible. In addition to being more cost-effective, aggressive surveillance and treatment of STIs have the advantage of treating and preventing the spread of STIs and avoiding the damage caused by removing the most sensitive portion of penis.38 Part of the success of STI treatment research may be due to a reduction of iatrogenically transmitted HIV, as the STIs were treated in research facilities.
In studies of discordant couples, condoms have been shown to be more than 99% effective in preventing infection.39 Condoms, in a public health setting, cost 2.5¢ each.40 A safe circumcision performed under sterile conditions in Africa using local anesthetic costs approximately $75,41 so for the cost of an adult circumcision, 3000 condoms, at 2.5¢ per condom, can be purchased. The nearly complete protection provided by condoms is a bargain compared with circumcision. In the first hypothetical scenario outlined above, the 0.193 infections per 100 person-years decrease in HIV infection rate brought by circumcision costs $52.50 per person. The cost per person of the additional condoms (at 2.5¢ each) for one year to achieve the same impact on the infection rate would total 25.87¢. To have the same effect for one year, circumcision costs 202.9 times more than condoms. Proponents for circumcision would argue that circumcision is a one-time expenditure, while condoms would be an ongoing expense. Using the scenario above with 3% discounting and assuming an average of weekly sexual contact over 45 years, the lifetime difference in the cost of condoms would be $6.13 per person. With 5% discounting the lifetime difference in cost would be $4.83. If circumcision is only 10% effective, with a 3% discount, the lifetime difference in cost of condoms would be $1.25.
One complaint has been that the 2.5¢ condoms are not attractive, which may explain why they are underused. Based on this analysis, if a man is having sex weekly for 45 years, an upgrade to condoms that cost ten times as much would be cost neutral (assuming a discount rate of 3%). Of course, if sexual contact was less frequent or a man was in a mutual monogamous relationship, further condom upgrades could be justified.
This is, however, a false comparison because, unlike circumcision, condoms can provide nearly complete protection.
Circumcision proponents believe that circumcision is the only proven effective preventive tool for HIV infection and have argued that condoms are ineffective.42,43 Condoms would be expected to be ineffective in regions where the majority of infections are from non-sexual transmission. Abstinence, be faithful, and condoms (ABC) should remain the focus of primary prevention for sexually transmitted HIV, but more resources need to be focused on the non-sexually transmitted infections, which is a much more efficient means of transmission.31
How rational is it to tell men that they must be circumcised to prevent HIV, but after circumcision they still need to use a condom to be protected from sexually transmitted HIV? Condoms provide near complete protection, so why would additional protection be needed? It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection). The argument that men don’t want to use condoms needs to be addressed with more attractive condom options and further education that sex without a condom and without a foreskin is potentially fatal, while sex with a condom and a foreskin is safe. No nuance is needed. Offering less effective alternatives can only lead to higher rates of infection.
Rather than wasting resources on circumcision, which is less effective, more expensive, and more invasive, focusing on iatrogenic sources and secondary prevention should be the priority, since it provides the most impact for the resources expended. The second tier would be primary prevention that focuses on the ABCs.
Resources are not unlimited. With the push for circumcision, public health workers in Africa are finding that resources that previously paid for condoms are now being redirected to circumcision. With every circumcision performed, 3000 condoms will not be available. For every circumcision performed, a health care provider is prevented from caring for someone in need of medical care. With trained medical providers busy performing circumcisions, patients will be forced to seek medical care provided in settings where sterility of equipment is less likely and HIV is more likely to be spread iatrogenically. For every circumcision performed, there are fewer resources that can be put into ART and other chemotherapies. Male circumcision is an unnecessary distraction that depletes the limited resources available to address the HIV epidemic. It also fails to address the underlying causes for the epidemic in Africa.
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Figure 1. Cumulative HIV infections over time using the combined data from three randomized clinical trials with early circumcision represented with the solid line and delayed circumcision (control group) in the dashed line. Nearly all of the men in the trial remained infection free.
References
1.World Health Organization, UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability. 2007. Available at: http://www.malecircumcision.org/media/documents/MC_Global_Trends_Determinants.pdf
2. World Health Organization, UNAIDS. New data on male circumcision and HIV prevention: policy and programme implications. 2007. Available at: http://www. unaids.org/en/media/unaids/contentassets/dataimport/pub/report/2007/mc_recommendations_en.pdf
3. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999; 354:1813-5.
4. Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2005;2:e298.
5. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-66.
6. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369:643-56.
7. Dinh MH, McRaven MD, Kelley Z, et al. Keratinization of the adult male foreskin and implications for male circumcision. AIDS 2010;24:899-906.
8. Chin J. The AIDS pandemic: the collision of epidemiology with political correctness. 2007. Radcliffe Publ., Abingdon, OX,UK
9. de Witte L, Nabatov A, Pion M, , et al. Langerin as a natural barrier to HIV-1 transmission by Langerhans cells. Nat Med 2007;13:367-71.
10. Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006;82:101-10.
11. Van Howe RS. Human papillomavirus and circumcision: A meta-analysis. J Infect 2007;54:490-6.
12. Van Howe RS, Storms MR. Circumcision to prevent HPV infection. Lancet Oncol 2009;10:746-7.
13. Garenne M. Long-term population effect of male circumcision in generalised HIV epidemics in sub-Saharan Africa. Afr J AIDS Res 2008;7:1-8.
14. Demographic and Health Surveys. HIV Prevalence and Associated Factors (Chapter 15). In: Rwanda National Health and Demographic Survey for 2005. Available at: http://www.measuredhs.com/ pubs/pdf/FR183/15Chapter15.pdf
15. Mishra V, Medley A, Hong Ret al. Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. 2009. DHS Comparative Reports No. 22. Macro International Inc., Calverton, MD, USA.
16. Connolly C, Shanmugam R, Simbayi LC, Nqeketo A. Male circumcision and its relationship to HIV infection in South Africa: Results of a national survey in 2002. S Afr Med J 2008;98:789-94.
17. UNAIDS, World Health Organization. Global HIV/AIDS and STD Surveillance Project: Report on the global HIV/AIDS epidemic 1998. Available at: http://www. unaids.org/hivaidsinfo/statistics/june98/global_report/index.html.
18. O’Brien TR, Calle EE, Poole WK. Incidence of neonatal circumcision in Atlanta, 1985-1986. South Med J 1995;88:411-5.
19. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis 2007;34:479-84.
20. 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:e861.
21. Mansfield CJ, Hueston WJ, Rudy M. Neonatal circumcision: associated factors and length of hospital stay. J Fam Pract 1995;41:370-6.
22. US Centers for Disease Control and Prevention. Racial/ethnic disparities in diagnoses of HIV/AIDS – 33 states, 2001-2005. MMWR Morb Mort Wkly Rep 2007;56:189-93.
23. Blower SM, McLean AR. Prophylactic vaccines, risk behaviour change, and the probability of eradicating HIV in San Francisco. Science 1994;265:1451-4.
24. Richens J, Imrie J, Copas A. Condoms and seat belts: the parallels and the lessons. Lancet 2000;355:400-3.
25. Bonner K. Male circumcision as an HIV control strategy: not a ‘natural condom’. Reprod Health Matters 2001;9:143-55.
26. Bridges JFP, Selck FW, Gray GE, et al. Condom avoidance and determinants of demand for male circumcision in Johannesburg, South Africa. Health Policy Planning 2010; e-pub ahead of print.
27. Sawers L, Stillwaggon E. Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence. J Int AIDS Soc 2010; 13: 34.
28. Grosskurth H, Mosha F, Todd J, et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS 1995;9:927-34.
29. O’Farrell N, Egger M. Circumcision in men and the prevention of HIV infection: a “meta-analysis” revisited. Int J STD AIDS 2000;11: 137-42.
30. Van Howe RS. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS 1999;10:8-16.
31. Gisselquist D. Points to consider: responses to HIV/AIDS in Africa, Asia and Caribbean. 2008. Adonis & Abbey Publ. Ltd, London, UK.
32. Vernazza P. La prévention du sida devient plus simpl, mais aussi plus complexe! Bull Med Suisses 2008;89:163-4.
33. Bendavid E, Brandeau ML, Wood R, Owens DK. Comparative effectiveness of HIV testing and treatment in highly endemic regions. Arch Int Med 2010;170:1357-54.
34. Charlebois ED, Havlir DV. “A Bird in the Hand…”: a commentary on the test and treat approach for HIV. Arch Int Med 2010;170:1354-6.
35. Clouser CL, Patterson SE, Mansky LM. Exploiting drug repositioning for discovery of a novel HIV combination therapy. J Virol 2010;84:9301-9.
36 Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995;346:530-6.
37. Gilson L, Mkanje R, Grosskurth H, et al. Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania. Lancet 1997;350:1805-9.
38. Sorrells ML, Snyder JL, Reiss MD, et al. Fine-touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.
39. de Vincenzi I. A longitudinal study of human immunodeficiency virus transmission by heterosexual partners. European Study Group on Heterosexual Transmission of HIV. N Engl J Med 1994;331:341-6.
40. Shelton JD, Johnston B. Condom gap in Africa: evidence from donor agencies and key informants. Br Med J 2001;323:139.
41. Krieger JN, Bailey RC, Opeya J, et al. Adult male circumcision: results of a standardized procedure in Kisumu District, Kenya. BJU Int 2005;96:1109-13.
42. Potts M, Halperin DT, Kirby D, et al. Reassessing HIV prevention. Science 2008;320:749-50.
43. Klausner JD, Wamai RG, Bowa K, et al. Is male circumcision as good as the HIV vaccine we’ve been waiting for? Future HIV Ther 2008;2:1-7.
More and more reports are coming through of African men who abandon condoms in favour of circumcision.
Exactly what anti-circumcision activists have been warning all along:
“One man boasts that he got circumcised because it is “nice to have sex without condoms” — drawing a furious reaction from the recruiters.”
Circumcision does not prevent HIV, sends out the wrong message for safe sex, and puts women and men at more risk as they adopt riskier behaviour.