Quantitative assessment of the role of male circumcision in HIV epidemiology at the population level

Comparison of Switching Between Antiretroviral Agents Versus Introducing Lipid-lowering Agents for HAART-induced Dyslipidemia

PURPOSE

Highly active antiretroviral therapy (HAART) has brought a significant reduction in HIV/AIDS-related morbidity and mortality. However, metabolic abnormalities (eg, dyslipidemias) have continued to pose significant challenges, warranting a switch between antiretroviral agents and/or the introduction of a statin. Hence, the purposes of this study was to compare the efficacy of switching between antiretroviral agents versus introducing a statin in the long-term management of HAART-induced dyslipidemia in people living with HIV, and to identify the most potent agent in switching therapies.

METHODS

A comprehensive literature search of PubMed and Medline identified articles published from the years 2000 to 2020 in the English language, resulting in 84 articles, 30 of which were selected based on inclusion and exclusion criteria. Information on primary and secondary outcomes was extracted. Statistical analysis was done on the variables, and the differences between groups were considered significant at P < 0.05.

FINDINGS

Statin use was associated with significant reductions in triglycerides and total cholesterol (TC) at 6 weeks (both, P < 0.01). A switch of antiretroviral agents was associated with gradual reductions in TC and triglycerides for up to 48 weeks (both, P < 0.01). Statin use was associated with a reduced CD4 count at 24 weeks (P < 0.01). A switch of antiretroviral agents was associated with an increased CD4 count at 48 weeks (P < 0.01).

IMPLICATIONS

Statins were as effective as switching antiretroviral therapies in the short-term management of TC and triglycerides in patients with HAART-induced dyslipidemia.

A potential transition from a concentrated to a generalized HIV epidemic: the case of Madagascar

BACKGROUND

HIV expansion is controlled by a range of interrelated factors, including the natural history of HIV infection and socio-economical and structural factors. However, how they dynamically interact in particular contexts to drive a transition from concentrated HIV epidemics in vulnerable groups to generalized epidemics is poorly understood. We aim to explore these mechanisms, using Madagascar as a case-study.

METHODS

We developed a compartmental dynamic model using available data from Madagascar, a country with a contrasting concentrated epidemic, to explore the interaction between these factors with special consideration of commercial and transactional sex as HIV-infection drivers.

RESULTS

The model predicts sigmoidal-like prevalence curves with turning points within years 2020-2022, and prevalence reaching stabilization by 2033 within 9 to 24% in the studied (10 out of 11) cities, similar to high-prevalence regions in Southern Africa. The late/slow introduction of HIV and  circumcision, a widespread traditional practice in Madagascar, could have slowed down HIV propagation, but, given the key interplay between risky behaviors associated to young women and acute infections prevalence, mediated by transactional sex, the protective effect of circumcision is currently insufficient to contain the expansion of the disease in Madagascar.

CONCLUSIONS

These results suggest that Madagascar may be experiencing a silent transition from a concentrated to a generalized HIV epidemic. This case-study model could help to understand how this HIV epidemic transition occurs.

Risk Compensation in Voluntary Medical Male Circumcision Programs

PURPOSE OF REVIEW

Evidence from clinical trials identified the effectiveness of voluntary medical male circumcision (VMMC) as an additional strategy to reduce the risk of HIV transmission from women to men. However, concerns about post-circumcision sexual risk compensation may hinder the scale-up of VMMC programs. We reviewed the evidence of changes in risky sexual behaviors after circumcision, including condomless sex, multiple sex partners, and early resumption of sex after surgery.

RECENT FINDINGS

Most clinical trial data indicate that condomless sex and multiple partners did not increase for men after circumcision, and early resumption of sex is rare. Only one post-trial surveillance reports that some circumcised men had more sex partners after surgery, but this did not offset the effect of VMMC. Conversely, qualitative studies report that a small number of circumcised men had increased risky sexual behaviors, and community-based research reports that more men resumed sex early after surgery. With the large-scale promotion and expansion of VMMC services, it may be challenging to maintain effective sexual health educations due to various restrictions. Misunderstandings of the effect of VMMC in preventing HIV infection are the main reason for increasing risky sexual behaviors after surgery. Systematic and practical sexual health counseling services should be in place on an ongoing basis to maximize the effect of VMMC.

Circumcision as an Intervening Strategy against HIV Acquisition in the Male Genital Tract

Unsafe sex with HIV-infected individuals remains a major route for HIV transmission, and protective strategies, such as the distribution of free condoms and pre-or post-prophylaxis medication, have failed to control the spread of HIV, particularly in resource-limited settings and high HIV prevalence areas. An additional key strategy for HIV prevention is voluntary male circumcision (MC). International health organizations (e.g., the World Health Organization, UNAIDS) have recommended this strategy on a larger scale, however, there is a general lack of public understanding about how MC effectively protects against HIV infection. This review aims to discuss the acquisition of HIV through the male genital tract and explain how and why circumcised men are more protected from HIV infection during sexual activity than uncircumcised men who are at higher risk of HIV acquisition.

Association between medical male circumcision and HIV risk compensation among heterosexual men: a systematic review and meta-analysis

Background

Medical male circumcision (MMC) reduces HIV infection among heterosexual men. There are concerns MMC might prompt higher-risk sexual behaviours because of lower self-perceived risk of HIV infection. We reviewed the published literature to examine associations between MMC and both condom use and number of sex partners among heterosexual men.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, and the Cochrane Library for studies published before Nov 15, 2020. Interventional and observational studies were included if they contained original quantitative data describing the association between MMC and condom use or number of sex partners among heterosexual men. We excluded data from men whose circumcisions were ritual or religious and data from men who have sex with men. We extracted odds ratios (ORs) and 95% CIs for the associations between MMC and condomless sex and MMC and multiple sex partners directly from the publications if available, selecting adjusted ORs when provided; when necessary, we calculated ORs and 95% CIs using original study data provided in the publication. We used the Mantel-Haenszel random effects model to calculate pooled ORs and 95% CIs.

Findings

Our search yielded 3035 results, of which 471 were duplicates and 2537 did not meet the inclusion criteria. From the remaining 27 eligible studies, we identified 99 292 men from 31 independent population samples. 24 studies were done in Africa. We found no statistically significant associations between MMC and condomless sex (OR 0·91, 95% CI 0·80–1·05; k=30; I²=88·7%) or multiple sex partners (1·02, 0·88–1·18; k=27; I²=90·1%). No associations between MMC and condomless sex or multiple sexual partners were found in any subgroup analyses by study design, income of country, age, recruitment setting, circumcision assessment, circumcision prevalence, and risk of publication bias.

Interpretation

The promotion of circumcision as an HIV preventive measure does not appear to increase higher-risk sexual behaviours in heterosexual men. Ongoing sexual health education should be maintained as a vital component of effective MMC programmes.

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.

METHODS

A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.

RESULTS

We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2-2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3-13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0-34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1-1.8%) in FSWs and 0.4% (95% CI = 0.1-0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).

CONCLUSIONS

HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."

Acceptability of a Pilot Intervention of Voluntary Medical Male Circumcision and HIV Education for Street-Connected Youth in Western Kenya

PURPOSE

Street-connected youth (SCY) in Kenya and elsewhere in sub-Saharan Africa are at high risk of HIV. Voluntary Male Medical Circumcision (VMMC) reduces the risk of female-to-male HIV transmission. Circumcision is also a traditional coming-of-age process in many Kenyan ethnic groups. This paper describes the acceptability of VMMC delivered as part of a ten-day healing, educational, and 'coming-of-age' retreat implemented as a pilot with SCY.

METHODS

Male SCY aged between 12 and 24 living on the street for more than 3 months were eligible to participate. The study took place over 10 days. After medical circumcision, youth participated in education modules. Data collected included qualitative semi-structured exit interviews featuring structured and open-ended questions about factors relevant to this intervention's acceptability.

RESULTS

There were 116 SCY (median age 14, IQR 13-15) who participated in the study. All were circumcised successfully, with no major complications. The majority of participants (81%) agreed that the circumcision procedure was uncomplicated, and 99% agreed the education was an important part of the initiation process. Thematic analysis of interview data highlighted four factors important to the program's acceptability: providing food, shelter, security; providing a safe place to heal; including traditional elements; and being with peers.

CONCLUSIONS

This novel implementation of VMMC was found to be acceptable to SCY participants and could likely be adapted and scaled for HIV prevention and education with SCY elsewhere in Kenya and sub-Saharan Africa where circumcision is part of traditional coming-of-age processes.

Couple serostatus patterns in sub-Saharan Africa illuminate the relative roles of transmission rates and sexual network characteristics in HIV epidemiology

HIV prevalence has surpassed 30% in some African countries while peaking at less than 1% in others. The extent to which this variation is driven by biological factors influencing the HIV transmission rate or by variation in sexual network characteristics remains widely debated. Here, we leverage couple serostatus patterns to address this question. HIV prevalence is strongly correlated with couple serostatus patterns across the continent; in particular, high prevalence countries tend to have a lower ratio of serodiscordancy to concordant positivity. To investigate the drivers of this continental pattern, we fit an HIV transmission model to Demographic and Health Survey data from 45,041 cohabiting couples in 25 countries. In doing so, we estimated country-specific HIV transmission rates and sexual network characteristics reflective of pre-couple and extra-couple sexual contact patterns. We found that variation in the transmission rate could parsimoniously explain between-country variation in both couple serostatus patterns and prevalence. In contrast, between-country variation in pre-couple or extra-couple sexual contact rates could not explain the observed patterns. Sensitivity analyses suggest that future work should examine the robustness of this result to between-country variation in how heterogeneous infection risk is within a country, or to assortativity, i.e. the extent to which individuals at higher risk are likely to partner with each other.

Cancer risks in Nairobi (2000-2014) by ethnic group

We investigated the ethnic differences in the risk of several cancers in the population of Nairobi, Kenya, using data from the Nairobi Cancer Registry. The registry records the variable "Tribe" for each case, a categorisation that includes, as well as 22 tribal groups, categories for Kenyans of European and of Asian origin, and non-Kenyan Africans. Tribes included in the final analysis were Kikuyu, Kamba, Kisii, Kalenjin, Luo, Luhya, Somalis, Asians, non-Kenyans, Caucasians, Other tribes and unknown. The largest group was taken as the reference category for the calculation of odds ratios; this was African Kenyans (for comparisons by race), and Kikuyus (the tribe with the largest numbers of cancer registrations (38% of the total)) for comparisons between the Kenyan tribes. P-values are obtained from the Wald test. Cancers that were more common among the white population than in black Kenyans were skin cancers and cancers of the bladder, while cancers that are more common in Kenyan Asians include colorectal, lung, breast, ovary, corpus uteri and non-Hodgkin lymphoma. Cancers that were less common among Asians and Caucasians were oesophagus, stomach and cervix cancer. Within the African population, there were marked differences in cancer risk by tribe. Among the tribes of Bantu ethnicity, the Kamba had higher risks of melanoma, Kaposi sarcoma, liver and cervix cancer, and lower risks of oesophagus, stomach, corpus uteri and nervous system cancers. Luo and Luhya had much higher odds of Kaposi sarcoma and Burkitt lymphoma.

Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis

Background

The epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example.

Methods and Findings

We used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010–2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up.

The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively.

Conclusion

Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.

Potential impact of multiple interventions on HIV incidence in a hyperendemic region in Western Kenya: a modelling study

BACKGROUND

Multiple prevention interventions, including early antiretroviral therapy initiation, may reduce HIV incidence in hyperendemic settings. Our aim was to predict the short-term impact of various single and combined interventions on HIV spreading in the adult population of Ndhiwa subcounty (Nyanza Province, Kenya).

METHODS

A mathematical model was used with data on adults (15-59 years) from the Ndhiwa HIV Impact in Population Survey to compare the impacts on HIV prevalence, HIV incidence rate, and population viral load suppression of various interventions. These interventions included: improving the cascade of care (use of three guidelines), increasing voluntary medical male circumcision (VMMC), and implementing pre-exposure prophylaxis (PrEP) use among HIV-uninfected women.

RESULTS

After four years, improving separately the cascade of care under the WHO 2013 guidelines and under the treat-all strategy would reduce the overall HIV incidence rate by 46 and 58 %, respectively, vs. the baseline rate, and by 35 and 49 %, respectively, vs. the implementation of the current Kenyan guidelines. With conservative and optimistic scenarios, VMMC and PrEP would reduce the HIV incidence rate by 15-25 % and 22-28 % vs. the baseline, respectively. Combining the WHO 2013 guidelines with VMMC would reduce the HIV incidence rate by 35-56 % and combining the treat-all strategy with VMMC would reduce it by 49-65 %. Combining the WHO 2013 guidelines, VMMC, and PrEP would reduce the HIV incidence rate by 46-67 %.

CONCLUSIONS

The impacts of the WHO 2013 guidelines and the treat-all strategy were relatively close; their implementation is desirable to reduce HIV spread. Combining several strategies is promising in adult populations of hyperendemic areas but requires regular, reliable, and costly monitoring.

Lymphatic Dissemination of Simian Immunodeficiency Virus after Penile Inoculation

The human immunodeficiency virus (HIV) is primarily transmitted by heterosexual contact, and approximately equal numbers of men and women worldwide are infected with the virus. Understanding the biology of HIV acquisition and dissemination in men exposed to the virus by insertive penile intercourse is likely to help with the rational design of vaccines that can limit or prevent HIV transmission. To characterize the target cells and dissemination pathways involved in establishing systemic simian immunodeficiency virus (SIV) infection, we necropsied male rhesus macaques at 1, 3, 7, and 14 days after penile SIV inoculation and quantified the levels of unspliced SIV RNA and spliced SIV RNA in tissue lysates and the number of SIV RNA-positive cells in tissue sections. We found that penile (glans, foreskin, coronal sulcus) T cells and, to a lesser extent, macrophages and dendritic cells are primary targets of infection and that SIV rapidly reaches the regional lymph nodes. At 7 days after inoculation, SIV had disseminated to the blood, systemic lymph nodes, and mucosal lymphoid tissues. Further, at 7 days postinoculation (p.i.), spliced SIV RNA levels were the highest in the genital lymph nodes, indicating that this is the site where the infection is initially amplified. By 14 days p.i., spliced SIV RNA levels were high in all tissues, but they were the highest in the gastrointestinal tract, indicating that the primary site of virus replication had shifted from the genital lymph nodes to the gut. The stepwise pattern of virus replication and dissemination described here suggests that vaccine-elicited immune responses in the genital lymph nodes could help prevent infection after penile SIV challenge.

IMPORTANCE

To be the most effective, vaccines should produce antiviral immune responses in the anatomic sites of virus replication. Thus, understanding the path taken by HIV from the mucosal surfaces, which are the site of virus exposure, to the deeper tissues where the virus replicates will provide insight into where AIDS vaccines should produce immunity to be the most effective. In this study, we determined that, by day 7 after penile inoculation, SIV has moved first to the inguinal lymph nodes and replicates to high levels. Although the virus is widely disseminated to other tissues by day 7, replication is largely limited to the inguinal lymph nodes. The step-by-step movement of SIV from penile mucosal surfaces to the draining lymph nodes may allow an HIV vaccine that produces immunity in these lymph nodes to block HIV from establishing an infection in an exposed person.

The when and how of male circumcision and the risk of HIV: a retrospective cross-sectional analysis of two HIV surveys from Guinea-Bissau

Introduction

Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa.

Methods

We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors.

Results

MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤12 years) and post-pubertal (≥13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12).

Conclusion

MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.

Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia

Background

Countries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.

Methods and Findings

A population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15–49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20–24 age-group) to 36 (45–49 age-group); cost-effectiveness ranged from $888 (20–24 age-group) to $3,300 (45–49 age-group). Circumcising 10–14, 15–19, or 20–24 year old achieved the largest incidence rate reduction; prioritizing 15–24, 15–29, or 15–34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9–12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.

Conclusion

Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

Male circumcision and HIV infection among sexually active men in Malawi

BACKGROUND

The HIV epidemic remains a major health challenge all over the world. In 2013, an estimated 35million people were living with HIV globally. Male circumcision is increasingly being adopted as a method of HIV prevention. WHO and UNAIDS have advised that male circumcision be added to current HIV interventions. Malawi is one of the countries hardest hit by HIV/AIDS with a prevalence rate of 11 % and male circumcision prevalence of 21.6 % in 2010. Prior to 2011, traditional male circumcision in Malawi was the dominant form of male circumcision, mainly for cultural and religious reasons. This paper looks at male circumcision as a prevention method against HIV by examining the relationship between male circumcision and HIV status among Malawian men.

METHODS

The data used were collected as part of the 2010 Malawi Demographic and Health Survey. The methodology used in the 2010 MDHS has been comprehensively described by the National Statistical Office of Malawi and ICF Macro. Our analysis is based on men aged 15-54 years who were tested for HIV and responded to questions on circumcision during the survey. Sixty one percent of the 7175 men interviewed in the MDHS, qualified for this analysis. The sample was weighted to ensure representativeness. Frequencies, cross-tabulations, univariate and multivariate logistic regressions were conducted. Differences in the prevalence of HIV infection among circumcised and uncircumcised men were determined with Chi-squared tests.

RESULTS

There is no significant difference in HIV prevalence between circumcised (12 %) and uncircumcised men (10 %). Among circumcised men, age and number of lifetime partners are the dominant correlates of HIV status. Additionally, circumcised men who have had ritual sex are two times more likely (OR = 2.399) to be HIV+ compared to circumcised men who have never had ritual sex.

CONCLUSION

This study has demonstrated that traditional male circumcision was not associated with HIV infection in pre-2010 Malawi. Among circumcised men, age and number of lifetime partners are correlates to HIV status while circumcised men who have had ritual sex are more likely to be diagnosed with HIV than circumcised men who have not had ritual sex.

Knowledge of HIV and benefits of male medical circumcision amongst clients in an urban area

BACKGROUND

Male medical circumcision (MMC) has been shown to reduce the risk of HIV transmission in circumcised men by up to 60%. Following recommendations from the World Health Organization, South Africa adopted MMC as a preventative strategy against HIV in 2010 and set up circumcision camps across the country. Concerns have been raised about condom avoidance following MMC because of a mistaken belief about the benefits of MMC.Aim and setting: The aim of this study was to describe the profile and knowledge about HIV and circumcision amongst men presenting for MMC in an urban area in KwaZulu-Natal.

METHODS

This was a cross-sectional descriptive study of 394 clients over the age of 18 years who presented to two MMC sites in Durban between November 2012 and March 2013. A validated questionnaire was used to collect data.

RESULTS

The mean age of clients presenting for MMC was 28 years. Most clients were black, single, unemployed and sexually active. The majority presented for MMC because they believed that MMC would reduce their risk of acquiring HIV infection. Knowledge about HIV transmission was very good and 86.3% of clients were aware that risky sexual behaviour such as condom avoidance could reverse the benefits of MMC.

CONCLUSION

The knowledge of HIV and benefits of MMC was very good amongst those presenting for MMC. However as MMC is primarily a preventative strategy, innovative methods to promote MMC prior to first sexual encounter need to be explored. Further research is needed to determine whether the benefits of MMC on the reduction of HIV transmission are sustained in routine practice.

Risk compensation following male circumcision: results from a two-year prospective cohort study of recently circumcised and uncircumcised men in Nyanza Province, Kenya

We present the results of the first study of longitudinal change in HIV-associated risk behaviors in men before and after circumcision in the context of a population-level voluntary medical male circumcision (VMMC) program. The behaviors of 1,588 newly circumcised men and 1,598 age-matched uncircumcised controls were assessed at baseline, 6, 12, 18 and 24 months of follow-up. Despite the precipitous decline in perception of high HIV risk among circumcised men (30-14 vs. 24-21 % in controls) and increased sexual activity among the youngest participants (18-24 years; p-time < 0.0001, p-group = 0.96), all specific risk behaviors decreased over time similarly in both groups. The proportion of men reporting condom use at last sex increased for both groups, with a greater increase among circumcised men (30 vs. 6 %). We found no evidence of risk compensation in men following circumcision. Concerns about risk compensation should not impede the widespread scale-up of VMMC initiatives.

Spatial variability in HIV prevalence declines in several countries in sub-Saharan Africa

Evidence suggests substantial declines in HIV prevalence in parts of sub-Saharan Africa. However, the observed aggregate declines at the national level may obscure local variations in the temporal dynamics of the infection. Using spatial scan statistics, we identified marked spatial variability in the within-country declines in HIV prevalence in Tanzania, Malawi, Kenya, and Zimbabwe. Our study suggests that the declines in the national HIV prevalence in some of the SSA countries may not be representative of downward trends in prevalence in areas of high HIV prevalence, as much as the result of sharp declines in prevalence in areas of already low HIV prevalence. Our findings provide insights for resource allocation and HIV prevention interventions in these countries.

"After my husband's circumcision, I know that I am safe from diseases": women's attitudes and risk perceptions towards male circumcision in Iringa, Tanzania

While male circumcision reduces the risk of female-to-male HIV transmission and certain sexually transmitted infections (STIs), there is little evidence that circumcision provides women with direct protection against HIV. This study used qualitative methods to assess women's perceptions of male circumcision in Iringa, Tanzania. Women in this study had strong preferences for circumcised men because of the low risk perception of HIV with circumcised men, social norms favoring circumcised men, and perceived increased sexual desirability of circumcised men. The health benefits of male circumcision were generally overstated; many respondents falsely believed that women are also directly protected against HIV and that the risk of all STIs is greatly reduced or eliminated in circumcised men. Efforts to engage women about the risks and limitations of male circumcision, in addition to the benefits, should be expanded so that women can accurately assess their risk of HIV or STIs during sexual intercourse with circumcised men.

Understanding the potential impact of a combination HIV prevention intervention in a hyper-endemic community

OBJECTIVES

Despite demonstrating only partial efficacy in preventing new infections, available HIV prevention interventions could offer a powerful strategy when combined. In anticipation of combination HIV prevention programs and research studies we estimated the population-level impact of combining effective scalable interventions at high population coverage, determined the factors that influence this impact, and estimated the synergy between the components.

METHODS

We used a mathematical model to investigate the effect on HIV incidence of a combination HIV prevention intervention comprised of high coverage of HIV testing and counselling, risk reduction following HIV diagnosis, male circumcision for HIV-uninfected men, and antiretroviral therapy (ART) for HIV-infected persons. The model was calibrated to data for KwaZulu-Natal, South Africa, where adult HIV prevalence is approximately 23%.

RESULTS

Compared to current levels of HIV testing, circumcision, and ART, the combined intervention with ART initiation according to current guidelines could reduce HIV incidence by 47%, from 2.3 new infections per 100 person-years (pyar) to 1.2 per 100 pyar within 4 years and by almost 60%, to 1 per 100 pyar, after 25 years. Short-term impact is driven primarily by uptake of testing and reductions in risk behaviour following testing while long-term effects are driven by periodic HIV testing and retention in ART programs. If the combination prevention program incorporated HIV treatment upon diagnosis, incidence could be reduced by 63% after 4 years and by 76% (to about 0.5 per 100 pyar) after 15 years. The full impact of the combination interventions accrues over 10-15 years. Synergy is demonstrated between the intervention components.

CONCLUSION

High coverage combination of evidence-based strategies could generate substantial reductions in population HIV incidence in an African generalized HIV epidemic setting. The full impact could be underestimated by the short assessment duration of typical evaluations.

Modeling the population-level effects of male circumcision as an HIV-preventive measure: a gendered perspective

Background

Evidence from biological, epidemiological, and controlled intervention studies has demonstrated that male circumcision (MC) protects males from HIV infection, and MC is now advocated as a public-health intervention against HIV. MC provides direct protection only to men, but is expected to provide indirect protection to women at risk of acquiring HIV from heterosexual transmission. How such indirect protection interacts with the possibility that MC campaigns will lead to behavior changes, however, is not yet well understood. Our objective here is to investigate the link between individual-level effects of MC campaigns and long-term population-level outcomes resulting from disease dynamics, looking at both genders separately, over a broad range of parameters.

Methods and Findings

We use simple mathematical models of heterosexual transmission to investigate the potential effects of a circumcision scale-up, combined with possible associated behavioral disinhibition. We examine patterns in expected long-term prevalence using a simple equilibrium model based on transmission factors, and validate our results with ODE-based simulations, focusing on the link between effects on females and those on males.We find that the long-term population-level effects on females and males are not strongly linked: there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females.

Conclusions

Since an intervention that reduces long-term male prevalence could nonetheless increase long-term female prevalence, MC campaigns should explicitly consider both the short-term and long-term effects of MC interventions on females. Our findings strongly underline the importance of pairing MC programs with education, support programs and HIV testing and counseling, together with other prevention measures.

Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions

BACKGROUND

Mathematical modelling has indicated that expansion of male circumcision services in high HIV prevalence settings can substantially reduce population-level HIV transmission. However, these projections need revision to incorporate new data on the effect of male circumcision on the risk of acquiring and transmitting HIV.

METHODS

Recent data on the effect of male circumcision during wound healing and the risk of HIV transmission to women were synthesised based on four trials of circumcision among adults and new observational data of HIV transmission rates in stable partnerships from men circumcised at younger ages. New estimates were generated for the impact of circumcision interventions in two mathematical models, representing the HIV epidemics in Zimbabwe and Kisumu, Kenya. The models did not capture the interaction between circumcision, HIV and other sexually transmitted infections.

RESULTS

An increase in the risk of HIV acquisition and transmission during wound healing is unlikely to have a major impact of circumcision interventions. However, it was estimated that circumcision confers a 46% reduction in the rate of male-to-female HIV transmission. If this reduction begins 2 years after the procedure, the impact of circumcision is substantially enhanced and accelerated compared with previous projections with no such effect-increasing by 40% the infections averted by the intervention overall and doubling the number of infections averted among women.

CONCLUSIONS

Communities, and especially women, may benefit much more from circumcision interventions than had previously been predicted, and these results provide an even greater imperative to increase scale-up of safe male circumcision services.