Male circumcision for HIV prevention: current research and programmatic issues

HIV-Host Cell Interactions

The development of antiretroviral drugs (ARVs) was a great milestone in the management of HIV infection. ARVs suppress viral activity in the host cell, thus minimizing injury to the cells and prolonging life. However, an effective treatment has remained elusive for four decades due to the successful immune evasion mechanisms of the virus. A thorough understanding of the molecular interaction of HIV with the host cell is essential in the development of both preventive and curative therapies for HIV infection. This review highlights several inherent mechanisms of HIV that promote its survival and propagation, such as the targeting of CD4⁺ lymphocytes, the downregulation of MHC class I and II, antigenic variation and an envelope complex that minimizes antibody access, and how they collaboratively render the immune system unable to mount an effective response.

Does receiving a SARS-CoV-2 antibody test result change COVID-19 protective behaviors? Testing risk compensation in undergraduate students with a randomized controlled trial

BACKGROUND

Risk compensation, or matching behavior to a perceived level of acceptable risk, can blunt the effectiveness of public health interventions. One area of possible risk compensation during the SARS-CoV-2 pandemic is antibody testing. While antibody tests are imperfect measures of immunity, results may influence risk perception and individual preventive actions. We conducted a randomized control trial to assess whether receiving antibody test results changed SARS-CoV-2 protective behaviors.

PURPOSE

Assess whether objective information about antibody status, particularly for those who are antibody negative and likely still susceptible to SARS-CoV-2 infection, increases protective behaviors. Secondarily, assess whether a positive antibody test results in decreased protective behaviors.

METHODS

In September 2020, we enrolled 1076 undergraduate students, used fingerstick tests for SARS-CoV-2 antibodies, and randomized participants to receive their results immediately or delayed by 4 weeks. Two weeks later, participants completed a survey about their engagement in 4 protective behaviors (mask use, social event avoidance, staying home from work/school, ensuring physical distancing). We estimated differences between conditions for each of these behaviors, stratified by antibody status. For negative participants at baseline, we also estimated the difference between conditions for seroconversion over 8 weeks of follow-up.

RESULTS

For the antibody negative participants (n = 1029) and antibody positive participants (n = 47), we observed no significant differences in protective behavior engagement between those who were randomized to receive test results immediately or after 4 weeks. For the baseline antibody negative participants, we also observed no difference in seroconversion outcomes between conditions.

CONCLUSIONS

We found that receiving antibody test results did not lead to significant behavior change in undergraduate students whether the SARS-CoV-2 antibody result was positive or negative.

"Getting to Zero New HIV Infections in the Caribbean": Knowledge and Attitudes Toward Male Circumcision Among Adolescent Males in The Bahamas

Male circumcision (MC) plays a significant role in reducing new HIV infections, particularly in high prevalence countries. This cross-sectional study assesses the prevalence of MC and attitudes toward MC among youth aged 15-18 years in The Bahamas, a medium HIV prevalence country. The survey included 797 young men who completed a questionnaire on MC. Data analyses included chi-squared tests. The self-reported prevalence of MC among youth was 16.7% (121/759). Most of the circumcised youth were circumcised as infants, 84% (107/121) were pleased with their circumcision, and 71% would recommend it to others. For uncircumcised youth, 35% (189/533) would consider voluntary male circumcision (VMC) and 26% would recommend MC to others. In all scenarios, circumcised youth were more likely to be positive about MC. Among uncircumcised young men, being older (17-18 years compared to 15-16 years) was the only variable statistically associated with considering MC or recommending MC. After being presented with information on the benefits of MC for HIV prevention, the number of men who were positive about MC increased. Most of the young men in this cohort would consider VMC for reducing HIV incidence. Also, many stated that, if they had a male child, they would have him circumcised. The attitudes of these youth emphasize the need to provide information on HIV in addition to general health benefits of MC if there were to be a sustainable MC program within this population.

Voluntary medical male circumcision (VMMC) for prevention of heterosexual transmission of HIV and risk compensation in adult males in Soweto: Findings from a programmatic setting

BACKGROUND

Clinical trials have clearly shown a reduction in HIV acquisition through voluntary medical male circumcision (VMMC). However, data assessing risk compensation under programmatic conditions is limited.

METHODS

This was a prospective cohort of HIV seronegative males aged 18-40 years receiving VMMC between November 2012 and July 2014. HIV serostatus was determined pre and post VMMC. Risk compensation was defined as a decrease in condom use at last sex act and/or an increase in concurrent sexual relationships, both measured twelve months post-circumcision.

RESULTS

A total of 233 males were enrolled and underwent voluntary medical male circumcision (VMMC) for prevention against HIV. There was no evidence of risk compensation post-circumcision as defined in this study. Significant increases in proportion of participants in the 18-24 years age group who knew the HIV status of their sexual partner (39% to 56%, p = 0.0019), self-reported condom use at last sex act (21% to 34%, p = 0.0106) and those reporting vaginal sexual intercourse in the past 12 months (67% to 79%, p-value = <0.0001) were found. In both 18-24 and 25-40 years age groups, there was a significant increase in perception of being at risk of contracting HIV (70% to 84%, p-value = <0.0001).

CONCLUSION

No significant risk compensation was observed in this study on comparing pre-and post-circumcision behaviour. An increase in proportion of participants in the 18-24 years age group who had vaginal intercourse in the first 12 months post-circumcision as a possibility of risk compensation was minimal and negated by an increase in proportion of those reporting using a condom at the last sex act, increase in knowledge of partner's HIV status and lack of increase in alcohol post-circumcision.

High risk exposure to HIV among sexually active individuals who tested negative on rapid HIV Tests in the Tshwane District of South Africa-The importance of behavioural prevention measures

OBJECTIVE

To assess the prevalence of HIV risk behaviour among sexually active HIV sero-negative individuals in the Tshwane district of South Africa (SA).

METHODS

Demographic and HIV risk behaviour data were collected on a questionnaire from participants of a cross-sectional study that screened for early HIV infection using pooled nucleic acid amplification testing (NAAT). The study enrolled individuals who tested negative on rapid HIV tests performed at five HIV counseling and testing (HCT) clinics, which included four antenatal clinics and one general HCT clinic.

RESULTS

The study enrolled 9547 predominantly black participants (96.6%) with a median age of 27 years (interquartile range [IQR]: 23-31). There were 1661 non-pregnant and 7886 pregnant participants largely enrolled from the general and antenatal HCT clinics, respectively. NAAT detected HIV infection in 61 participants (0.6%; 95% confidence interval [CI]: 0.4-0.8) in the whole study. A high proportion of study participants, 62.8% and 63.0%, were unaware of their partner's HIV status; and also had high prevalence, 88.5% and 99.5%, of recent unprotected sex in the general and pregnant population, respectively. Consistent use of condoms was associated with protection against HIV infection in the general population. Trends of higher odds for HIV infection were observed with most demographic and HIV risk factors at univariate analysis, however, multivariate analysis did not show statistical significance for almost all these factors. A significantly lower risk of HIV infection was observed in circumcised men (p <0.001).

CONCLUSIONS

These data show that a large segment of sexually active people in the Tshwane district of SA have high risk exposure to HIV. The detection of newly diagnosed HIV infections in all study clinics reflects a wide distribution of individuals who are capable of sustaining HIV transmission in the setting where HIV risk behaviour is highly prevalent. A questionnaire that captures HIV risk behaviour would be useful during HIV counselling and testing to ensure that there is a systematic way of identifying HIV risk factors and that counselling is optimised for each individual. HIV risk behaviour surveillance could be used to inform relevant HIV prevention interventions that could be implemented at a community or population level.

Release of HIV-1 sequestered in the vesicles of oral and genital mucosal epithelial cells by epithelial-lymphocyte interaction

Oropharyngeal mucosal epithelia of fetuses/neonates/infants and the genital epithelia of adults play a critical role in HIV-1 mother-to-child transmission and sexual transmission of virus, respectively. To study the mechanisms of HIV-1 transmission through mucosal epithelium, we established polarized tonsil, cervical and foreskin epithelial cells. Analysis of HIV-1 transmission through epithelial cells showed that approximately 0.05% of initially inoculated virions transmigrated via epithelium. More than 90% of internalized virions were sequestered in the endosomes of epithelial cells, including multivesicular bodies (MVBs) and vacuoles. Intraepithelial HIV-1 remained infectious for 9 days without viral release. Release of sequestered intraepithelial HIV-1 was induced by the calcium ionophore ionomycin and by cytochalasin D, which increase intracellular calcium and disrupt the cortical actin of epithelial cells, respectively. Cocultivation of epithelial cells containing HIV-1 with activated peripheral blood mononuclear cells and CD4+ T lymphocytes led to the disruption of epithelial cortical actin and spread of virus from epithelial cells to lymphocytes. Treatment of epithelial cells with proinflammatory cytokines tumor necrosis factor-alpha and interferon gamma also induced reorganization of cortical actin and release of virus. Inhibition of MVB formation by small interfering RNA (siRNA)-mediated silencing of its critical protein hepatocyte growth factor-regulated tyrosine kinase substrate (Hrs) expression reduced viral sequestration in epithelial cells and its transmission from epithelial cells to lymphocytes by ~60-70%. Furthermore, inhibition of vacuole formation of epithelial cells by siRNA-inactivated rabankyrin-5 expression also significantly reduced HIV-1 sequestration in epithelial cells and spread of virus from epithelial cells to lymphocytes. Interaction of the intercellular adhesion molecule-1 of epithelial cells with the function-associated antigen-1 of lymphocytes was important for inducing the release of sequestered HIV-1 from epithelial cells and facilitating cell-to-cell spread of virus from epithelial cells to lymphocytes. This mechanism may serve as a pathway of HIV-1 mucosal transmission.

“Please Don’t Send Us Spam!” A Participative, Theory-Based Methodology for Developing an mHealth Intervention

Background

Mobile health solutions have the potential of reducing burdens on health systems and empowering patients with important information. However, there is a lack of theory-based mHealth interventions.

Objective

The purpose of our study was to develop a participative, theory-based, mobile phone, audio messaging intervention attractive to recently circumcised men at voluntary medical male circumcision (VMMC) clinics in the Cape Town area in South Africa. We aimed to shift some of the tasks related to postoperative counselling on wound management and goal setting on safe sex. We place an emphasis on describing the full method of message generation to allow for replication.

Methods

We developed an mHealth intervention using a staggered qualitative methodology: (1) focus group discussions with 52 recently circumcised men and their partners to develop initial voice messages they felt were relevant and appropriate, (2) thematic analysis and expert consultation to select the final messages for pilot testing, and (3) cognitive interviews with 12 recent VMMC patients to judge message comprehension and rank the messages. Message content and phasing were guided by the theory of planned behavior and the health action process approach.

Results

Patients and their partners came up with 245 messages they thought would help men during the wound-healing period. Thematic analysis revealed 42 different themes. Expert review and cognitive interviews with more patients resulted in 42 messages with a clear division in terms of needs and expectations between the initial wound-healing recovery phase (weeks 1–3) and the adjustment phase (weeks 4–6). Discussions with patients also revealed potential barriers to voice messaging, such as lack of technical knowledge of mobile phones and concerns about the invasive nature of the intervention. Patients’ own suggested messages confirmed Ajzen’s theory of planned behavior that if a health promotion intervention can build trust and be relevant to the recipient’s needs in the first contacts, then the same recipients will perceive subsequent motivational messages more favorably. The health action process approach was also a useful tool for guiding the phasing of the messages. Participants were more positive and salutogenic than public health experts.

Conclusions

The system showed how a process of consultation can work with a set of potential recipients of an mHealth service to ensure that their needs are included. Classic behavioral theories can and should be used to design modern mHealth interventions. We also believe that patients are the best source of messaging, ensuring that messages are culturally relevant and interesting to the recipient.

Assessment of Different Intervention Models of Male Circumcision and Their Preliminary Effectiveness in Reducing HIV Incidence Among Drug Users in Western China

World Health Organization (WHO) and Joint United Nations Program on AIDS (UNAIDS) recommend male circumcision (MC) as an additional HIV prevention measure. This study aimed to assess three models of promoting MC and their effects on preventing HIV infection among drug users in western China. We carried out a cohort study in three provinces of western China. HIV seronegative male drug users were recruited from methadone maintenance therapy clinics and cluster randomized into three intervention models. At baseline, 6, and 9 months of follow-up, changes in MC knowledge, the acceptability of MC, MC surgery uptake, and the costs of model implementation were analyzed. Of 1,304 male drug users who were screened, 1,218 were enrolled in the study. The participants' knowledge about MC was significantly increased after interventions by all three models. The one-stage model led to the highest increase in MC acceptability and the greatest increase in MC uptake. Multivariable Cox regression analysis showed that the one-stage model was also the most effective method to promote MC uptake, compared with the two-stage model [rate ratio (RR) = 0.602; 95% confidence interval (CI), 0.420-0.862] and three-stage model (RR = 0.555; 95% CI, 0.382-0.807). The HIV incidence rate in the MC group was lower than that in the non-MC group (RR = 0.234; 95% CI, 0.056-0.974). Moreover, the one-stage model required the lowest cost per circumcision. The one-stage model is the most effective and the most cost-effective intervention to increase MC uptake among male drug users in western China and could decrease the HIV incidence rate, based on a short follow-up investigation.

Uptake of antiretroviral therapy and male circumcision after community-based HIV testing and strategies for linkage to care versus standard clinic referral: a multisite, open-label, randomised controlled trial in South Africa and Uganda

BACKGROUND

Male circumcision decreases HIV acquisition by 60%, and antiretroviral therapy (ART) almost eliminates HIV transmission from HIV-positive people who are virally suppressed; however, coverage of these interventions has lagged behind targets. We aimed to assess whether community-based HIV testing with counsellor support and point-of-care CD4 cell count testing would increase uptake of ART and male circumcision.

METHODS

We did this multisite, open-label, randomised controlled trial in six research-naive communities in rural South Africa and Uganda. Eligible HIV-positive participants (aged ≥16 years) were randomly assigned (1:1:1) in a factorial design to receive lay counsellor clinic linkage facilitation, lay counsellor follow-up home visits, or standard-of-care clinic referral, and then (1:1) either point-of-care CD4 cell count testing or referral for CD4 testing. HIV-negative uncircumcised men (aged 16-49 years) who could receive secure mobile phone text messages were randomly assigned (1:1:1) to receive text message reminders, lay counsellor visits, or standard clinic referral. The study biostatistician generated the randomisation schedule via a computer-generated random number program with varying block sizes (multiples of six or three) stratified by country. Primary outcomes for HIV-positive people were obtaining a CD4 cell count, linkage to an HIV clinic, ART initiation, and viral suppression at 9 months, and for HIV-negative uncircumcised men were visiting a circumcision facility and uptake of male circumcision at 3 months. We assessed social harms as a safety outcome throughout the study. We did the primary analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02038582.

FINDINGS

Between June 6, 2013, and March 11, 2015, 15 332 participants were tested. 2339 (15%) participants tested HIV positive, of whom 1325 (57%) were randomly assigned to receive lay counsellor clinic linkage facilitation (n=437), lay counsellor follow-up home visits (n=449), or standard clinic referral (n=439), and then point-of-care CD4 cell testing (n=206, n=220, and n=213, respectively) or referral for CD4 testing (n=231, n=229, and n=226, respectively). 12 993 (85%) participants tested HIV negative, of whom 750 (6%) uncircumcised men were randomly assigned to receive clinic referral (n=230), text message reminders (n=288), or lay counsellor follow-up visits (n=232). 1218 (93%) of 1303 HIV-positive participants were linked to care, but only 488 (37%) participants initiated ART. Overall, 635 (50%) of 1272 HIV-positive individuals achieved viral suppression at 9 months: 219 (52%) of 419 participants in the clinic facilitation group, 202 (47%) of 431 participants in the lay counsellor follow-up group, and 214 (51%) of 422 participants in the clinic referral group, with no significant differences between groups (p=0·668 for clinic facilitation and p=0·273 for lay counsellor follow-up vs clinic referral). 523 (72%) of 734 HIV-negative men visited a circumcision facility, with no difference between groups. 62 (28%) of 224 men were circumcised in the male circumcision clinic referral group compared with 137 (48%) of 284 men in the text message reminder group (relative risk 1·72, 95% CI 1·36-2·17; p<0·0001) and 106 (47%) of 226 men in the lay counsellor follow-up group (1·67, 1·29-2·14; p=0·0001). No cases of study-related social harm were reported, including probing about partnership separation, unintended disclosure, gender-based violence, and stigma.

INTERPRETATION

All the community-based strategies achieved high rates of linkage of HIV-positive people to HIV clinics, roughly a third of whom initiated ART, and of those more than 80% were virally suppressed at 9 months. Uptake of male circumcision was almost two-times higher in men who received text message reminders or lay counsellor visits than in those who received standard-of-care clinic referral. Clinic barriers to ART initiation should be addressed in future strategies to increase the proportion of HIV-positive people accessing treatment and achieving viral suppression.

FUNDING

National Institute of Allergy and Infectious Diseases, National Institutes of Health.

"What do You Mean I've Got to Wait for Six Weeks?!" Understanding the Sexual Behaviour of Men and Their Female Partners after Voluntary Medical Male Circumcision in the Western Cape

Background

Several studies have shown that voluntary male medical circumcision (VMMC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) in heterosexual men by up to 60%. However, there is an increased risk of transmission of STIs, including HIV, in the immediate post-operative period after receiving VMMC. This study is to understand sexual practices of couples in the post-operative period in a Coloured population in the Western Cape Province of South Africa.

Methods

Coloured Males who had undergone VMMC in the previous six months in the Cape Town area and their partners participated in eight single-gender focus group discussions. The groups explored why the men decided to undergo VMMC, what kind of counselling they received, and how they experienced the 6-week post-operative period, including sexually.

Results

The primary motivation to VMMC uptake included religious injunction and hygiene reasons and protection against sexually transmitted infections not necessarily HIV. There was some exploration of alternative sexual practices. During the period immediately post operation the respondents spoke of pain and fear of any sexual arousal, but towards the end of the six week period, sexual desire returned. Both men and women felt that sex was important to maintain the relationship. Gaps were identified in the pre- and post-MC procedure counselling.

Conclusions

There is a real risk that men in this population may begin sex before complete healing has occurred. VMMC counselling to encourage men to stay sexually safe in the wound-healing period, needs to take into account the real-life factors of the circumcised men. It is essential from a public health, and gender perspective that effective counselling strategies for the VMMC post-operative period, and the longer term, are developed and tested.

Male circumcision for protection against HIV infection in sub-Saharan Africa: the evidence in favour justifies the implementation now in progress

This article responds to a recent 'controversy study' in Global Public Health by de Camargo et al. directed at three randomised controlled trials (RCTs) of male circumcision (MC) for HIV prevention. These trials were conducted in three countries in sub-Saharan Africa (SSA) and published in 2005 and 2007. The RCTs confirmed observational data that had accumulated over the preceding two decades showing that MC reduces by 60% the risk of HIV infection in heterosexual men. Based on the RCT results, MC was adopted by global and national HIV policy-makers as an additional intervention for HIV prevention. Voluntary medical MC (VMMC) is now being implemented in 14 SSA countries. Thus referring to MC for HIV prevention as 'debate' and viewing MC through a lens of controversy seems mistaken. In their criticism, de Camargo et al. misrepresent and misinterpret current science supporting MC for HIV prevention, omit previous denunciations of arguments similar to theirs, and ignore evidence from ongoing scientific research. Here we point out the flaws in three areas de Camargo et al. find contentious. In doing so, we direct readers to growing evidence of MC as an efficacious, safe, acceptable, relatively low-cost one-off biomedical intervention for HIV prevention.

Ritual male infant circumcision and human rights

Opponents of male circumcision have increasingly used human rights positions to articulate their viewpoint. We characterize the meaning of the term "human rights." We discuss these human rights arguments with special attention to the claims of rights to an open future and to bodily integrity. We offer a three-part test under which a parental decision might be considered an unacceptable violation of a child's right. The test considers the impact of the practice on society, the impact of the practice on the individual, and the likelihood of adverse impact. Infant circumcision is permissible under this test. We conclude that infant circumcision may be proscribed as violating local norms, even though it does not violate human rights.

Correlates of prevalent HIV infection among adults and adolescents in the Kisumu incidence cohort study, Kisumu, Kenya

We estimated HIV prevalence and identified correlates of HIV infection among 1106 men and women aged 16-34 years residing in Kisumu, Kenya. Demographic, sexual, and other behavioural data were collected using audio computer-assisted self-interview in conjunction with a medical examination, real-time parallel rapid HIV testing, and laboratory testing for pregnancy, gonorrhoea, chlamydia, syphilis, and herpes simplex virus type 2. Multivariate logistic regression was used to identify variables associated with prevalent HIV infection by gender. Overall HIV prevalence was 12.1%. HIV prevalence among women (17.1%) was approximately two-and-one-half times the prevalence among men (6.6%). Odds of HIV infection in men increased with age (aOR associated with one-year increase in age = 1.21, CI = 1.07-1.35) and were greater among those who were uncircumcised (aOR = 4.42, CI = 1.41-13.89) and those who had an herpes simplex virus type 2-positive (aOR = 3.13, CI = 1.12-8.73) test result. Odds of prevalent HIV infection among women also increased with age (aOR associated with one-year increase in age = 1.16, CI = 1.04-1.29). Women who tested herpes simplex virus type 2 positive had more than three times the odds (aOR = 3.85, CI = 1.38-10.46) of prevalent HIV infection compared with those who tested herpes simplex virus type 2 negative. Tailored sexual health interventions and programs may help mitigate HIV age and gender disparities.

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.

Understanding partial protection and HIV risk and behavior following voluntary medical male circumcision rollout in Kenya

In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men's understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18-39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a '60 percent protection' or 'not 100 percent protection', and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC.

HIV knowledge, risk perception and avoidant behaviour change among Sierra Leonean refugees in Guinea

A common assumption underpinning health communications design in humanitarian settings is that increasing knowledge and risk perception will lead to appropriate behaviour change. This study compares associations of HIV knowledge and perceived risk with reported HIV-avoidant behaviour changes and sexual health choices from a community survey of 698 sexually experienced male and female Sierra Leonean refugees in Guinea. HIV knowledge was not significantly associated with reported HIV-avoidant changes (OR 1.25; adjusted for gender; 95%CI 0.76-2.04), while perceived HIV risk was negatively associated (OR 0.38, adjusted for age at sexual debut; 95%CI 0.22-0.66). Trying to conceive was the main reason reported for not using condoms or other contraception (28%; 138/498), followed by current pregnancy/lactation (19%; 93/498). Results suggest contextual factors (e.g. desire for children) can be as important as knowledge and risk-perception, and HIV prevention initiatives in stable and chronic humanitarian settings should account for these.

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

BACKGROUND

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

METHODS

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

RESULTS

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

CONCLUSIONS

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

Male circumcision and HIV: a controversy study on facts and values

We present a controversy study on the association between male circumcision (MC) and HIV. Our general goal is to shed light on the issue, unravelling and comparing different conceptions of scientific evidence and their respective world views. We seek to reconstruct, based on an analysis of the literature on the topic, key moments in the history of the controversy about the association between MC and HIV prevention, analysing more closely three recent randomised studies, given their relevance to the argumentative strategy employed by those who defend circumcision as a prevention method. Following this, we present a synthesis of the main arguments against the three referred studies. In conclusion, it seems that reasonable arguments for a more cautious approach are not being adequately considered.

Translation of biomedical prevention strategies for HIV: prospects and pitfalls

Early achievements in biomedical approaches for HIV prevention included physical barriers (condoms), clean injection equipment (both for medical use and for injection drug users), blood and blood product safety, and prevention of mother-to-child transmission. In recent years, antiretroviral drugs to reduce the risk of transmission (when the infected person takes the medicines; treatment as prevention) or reduce the risk of acquisition (when the seronegative person takes them; preexposure prophylaxis) have proven to be efficacious. Circumcision of men has also been a major tool relevant for higher prevalence regions such as sub-Saharan Africa. Well-established prevention strategies in the control of sexually transmitted diseases and tuberculosis are highly relevant for HIV (ie, screening, linkage to care, early treatment, and contact tracing). Unfortunately, only slow progress is being made in some available HIV-prevention strategies such as family planning for HIV-infected women who do not want more children and prevention of mother-to-child HIV transmission. Current studies seek to integrate strategies into approaches that combine biomedical, behavioral, and structural methods to achieve prevention synergies. This review identifies the major biomedical approaches demonstrated to be efficacious that are now available. We also highlight the need for behavioral risk reduction and adherence as essential components of any biomedical approach.

Trichomoniasis and HIV interactions: a review

OBJECTIVE

To discuss the epidemiology of Trichomonas vaginalis (TV) and HIV co-infections, the role of TV in acquisition and transmission of HIV, special treatment considerations for TV among women with HIV and the prevention of TV among HIV-infected persons.

DESIGN

Systematic review.

DATA SOURCE

Review of literature of EMBASE and PubMed databases from January 1990 to February 2013. Search keywords included TV, HIV co-infections, HIV acquisition, HIV transmission, HIV shedding, TV treatment, HIV and couples studies.

REVIEW METHOD

We included studies of any design that contained the selected search words and were published during the specified time frame. We then searched the reference lists of included papers for additional papers and included these when relevant.

RESULTS

There is strong evidence that TV increases both transmission and acquisition of HIV among women, and that successful treatment for TV can reduce HIV genital shedding. Single dose metronidazole (MTZ) should no longer be used for HIV+ women with TV given the high rates of asymptomatic bacterial vaginosis co-infections and other factors that may render MTZ less effective in HIV+ women. Prevention of TV among HIV+ persons is similar to among HIV, including promotion of condoms as well as regular screening and prompt treatment. There may be a role for expedited partner treatment for the prevention of repeat infections, but most repeat infections are clinical treatment failures. Diligence in screening and treating TV among both HIV- susceptible and HIV+ persons is an important public health strategy.

A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia

OBJECTIVE

Neonatal male circumcision (NMC) is not routinely practiced in Zambia, but it is a promising long-term HIV prevention strategy. We studied the feasibility and safety of three different NMC methods.

METHODS

We enrolled healthy newborns in a controlled trial of the Mogen, Gomco, and Plastibell devices. Doctors, nurses, and clinical officers were trained to perform Mogen, Gomco, and Plastibell techniques. Each provider performed at least 10 circumcisions using each device. Neonates were reviewed at 1 and 6 weeks after circumcision for adverse events.

RESULTS

Between October 2009 and March 2011, 17 providers (5 physicians, 9 nurse midwives, and 3 clinical officers) without previous NMC experience were trained, and 640 circumcisions were performed. The median infant birth weight was 3.2 kg (interquartile range: 2.9-3.5 kg), and median age at the time of procedure was 11 days (interquartile range: 7-18 days); 149 babies (23.3%) were exposed to HIV. The overall adverse event rate was 4.9% (n = 31/630), and the moderate-severe adverse event rate was 4.1% (n = 26/630). Rates did not significantly differ by method. Most providers (65%) preferred Mogen clamp over Gomco and Plastibell.

CONCLUSIONS

Doctors, nurses, and clinical officers can be trained to safely provide NMC in a programmatic setting. The 3 studied techniques had comparable safety profiles. Mogen clamp was the preferred device for most providers.

Biomedical Strategies for Human Immunodeficiency Virus (HIV) Prevention? A New Paradigm

Introduction: This article presents recent developments in biomedical interventions for prevention of sexual transmission of the human immunodeficiency virus (HIV) infection. Materials and Methods: A review of results from randomised clinical trials on the use of antiretroviral (ARV) medications and other biomedical methods to prevent the transmission and acquisition of HIV infection. Results: Pre-exposure prophylaxis (PrEP) refers to the provision of ARV medications to uninfected persons at high risk of HIV infection either in the form of topical agents, e.g. vaginal microbicide gels, or orally administered tablets. The Caprissa study demonstrated the efficacy of vaginal microbicides, the Vaginal and Oral Interventions to Control the Epidemic (VOICE) study however was not able to confirm these results. Oral PrEP was found to be efficacious in the iPrEx study on men who have sex with men (MSM), and among heterosexual couples in the Partners-PrEP and the TDF2 studies in Africa. The HPTN 052 trial demonstrated that the provision of early ARV treatment was able to prevent transmission of HIV by 92% compared with delayed treatment. This has led to enthusiasm to roll out treatment as prevention (TasP) programmes. Encouraging results from studies on male circumcision to prevent HIV acquisition have resulted in several implementation projects in Africa. Another encouraging result has been the success, albeit modest, of the prime-boost combination RV144 vaccine trial in Thailand. Conclusion: New advances in prevention strategies are urgently needed to slow down the HIV pandemic. Recent developments particularly in the form of PrEP and TasP have given new hope that we will be able to achieve this goal. Key words: Biomedical, HIV infection, Prevention

Assessment of changes in risk behaviors during 3 years of posttrial follow-up of male circumcision trial participants uncircumcised at trial closure in Rakai, Uganda

Risk compensation associated with male circumcision has been a concern for male circumcision scale-up programs. Using posttrial data collected during 2007-2011 on 2,137 male circumcision trial participants who were uncircumcised at trial closure in Rakai, Uganda, the authors evaluated their sexual behavioral changes during approximately 3 years' follow-up after trial closure. Eighty-one percent of the men self-selected for male circumcision during the period, and their sociodemographic and risk profiles were comparable to those of men remaining uncircumcised. Linear models for marginal probabilities of repeated outcomes estimate that 3.3% (P < 0.0001) of the male circumcision acceptors reduced their engagement in nonmarital relations, whereas there was no significant change among men remaining uncircumcised. Significant decreases in condom use occurred in both male circumcision acceptors (-9.2% with all partners and -7.0% with nonmarital partners) and nonacceptors (-12.4% and -13.5%, respectively), and these were predominantly among younger men. However, the magnitudes of decrease in condom use were not significantly different between the 2 groups. Additionally, significant decreases in sex-related alcohol consumption were observed in both groups (-7.8% in male circumcision acceptors and -6.1% in nonacceptors), mainly among older men. In summary, there was no evidence of risk compensation associated with male circumcision among this cohort of men during 3 years of posttrial follow-up.

Safety of over twelve hundred infant male circumcisions using the Mogen clamp in Kenya

Background

Several sub-Saharan African countries plan to scale-up infant male circumcision (IMC) for cost-efficient HIV prevention. Little data exist about the safety of IMC in East and southern Africa. We calculated adverse event (AE) rate and risks for AEs associated with introduction of IMC services at five government health facilities in western Kenya.

Methods

AE data were analyzed for IMC procedures performed between September, 2009 and November, 2011. Healthy infants aged ≤2 months and weighing ≥2.5 kg were eligible for IMC. Following parental consent, trained clinicians provided IMC services free of charge under local anesthesia using the Mogen clamp. Odds ratios and 95% confidence intervals were used to explore AE risk factors.

Findings

A total of 1,239 IMC procedures were performed. Median age of infants was 4 days (IQR = 1, 16). The overall AE rate among infants reviewed post-operatively was 2.7% (18/678; 95%CI: 1.4, 3.9). There was one severe AE involving excision of a small piece of the lateral aspect of the glans penis. Other AEs were mild or moderate and were treated conservatively. Babies one month of age or older were more likely to have an AE (OR 3.20; 95%CI: 1.23, 8.36). AE rate did not differ by nurse versus clinical officer or number of previous procedures performed.

Conclusion

IMC services provided in Kenyan Government hospitals in the context of routine IMC programming have AE rates comparable to those in developed countries. The optimal time for IMC is within the first month of life.

Factors associated with uptake of infant male circumcision for HIV prevention in western Kenya

BACKGROUND AND OBJECTIVES

Three randomized trials demonstrated male circumcision decreases female-to-male HIV incidence by 60%. Male circumcision research in sub-Saharan Africa has focused on adolescents and adults. Modeling suggests infant male circumcision (IMC) will be cost saving for HIV prevention in high to moderate seroprevalent regions. This study examined parental decision-making and differences in characteristics of parents accepting and declining IMC services in western Kenya.

METHODS

This case-control study was conducted in 2010 at 5 government hospitals in Nyanza Province, Kenya. Cases were mothers and fathers accepting circumcision for their son. Controls were parents who declined IMC services. A questionnaire comprising 41 questions was administered.

RESULTS

A total of 627 mothers and 493 fathers enrolled. In multivariable logistic regression modeling, factors associated with accepting IMC among mothers were the following: father circumcised (odds ratio [OR] = 2.30, P < .001) and agreeing with the father about the IMC decision (OR = 4.38, P < .001). Among fathers, factors associated with accepting IMC were the following: being circumcised (OR = 1.77, P = .016) and agreeing with the mother about IMC (OR = 11.0, P < .001). Fathers were the primary decision makers in most instances (66%). Few parents (3%) reported they would prefer a future son to remain uncircumcised.

CONCLUSIONS

Fathers are important in the IMC decision-making process. Fathers, as well as mothers, should be targeted for optimal scale-up of IMC services. Circumcision programs should offer services for males of all ages, as male circumcision at some age is highly acceptable to both men and women.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

A 'snip' in time: what is the best age to circumcise?

BACKGROUND

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.

DISCUSSION

We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.

SUMMARY

Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

Transformations in the medicalization of sex: HIV prevention between discipline and biopolitics

This article examines transformations in HIV prevention strategies from the 1980s to the present. Drawing on the concepts of medicalization (Conrad, 2007 ), discipline and biopolitics (Foucault, 1976/ 1988 ), and biomedicalization (Clarke, Fishman, Fosket, Mamo, & Shim, 2003 ), it explores the shift from behavioral to biomedical and surgical prevention techniques-a shift symbolic of a more general trend toward the biomedicalization of sexuality. It argues that, although biomedical and surgical approaches (chemoprevention and male circumcision) have certain benefits, their efficacy is limited and uncertain. They do not guarantee individual protection. The aim is no longer the modification of sexual behavior through disciplinary strategies aimed at the development of subjective and sexual awareness, but the modification of health behavior as a positive response to biomedical recommendations. Through the use of preventative or curative drugs, the same type of sexual awareness is seen as no longer required.

Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up

Scaling up voluntary medical male circumcision (VMMC) for HIV prevention is cost saving and creates fiscal space in the future that otherwise would have been encumbered by antiretroviral treatment costs. An investment of US$1,500,000,000 between 2011 and 2015 to achieve 80% coverage in 13 priority countries in southern and eastern Africa will result in net savings of US$16,500,000,000. Strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilisation, and human resource deployment, are essential. This collection of articles on determining the cost and impact of VMMC for HIV prevention signposts the way forward to scaling up VMMC service delivery safely and efficiently to reap individual- and population-level benefits.

The HIV/AIDS epidemic in sub-Saharan Africa: thinking ahead on programmatic tasks and related operational research

Until now, we have all been desperately trying to run behind the HIV/AIDS epidemic and catch up with it, but despite all our efforts, the epidemic remains well ahead of us. In 2010, the antiretroviral treatment (ART) gap was about 60%, AIDS-related deaths were almost two million a year, and on top of these figures, for every one person started on ART, there were two new HIV infections. What is needed to change this situation is to think ahead of the epidemic in terms of the programmatic tasks we will be faced with and try to act boldly in trying to implement those tasks. From a programmatic perspective, we: a) highlight what needs to fundamentally change in our thinking and overall approach to the epidemic; and b) outline a number of key task areas for implementation and related operational research.

Targeting strategies and behavior change to combat the HIV epidemic in southern Africa

Behavior change remains a cornerstone of effective HIV prevention, whether interventions aim to reduce primary HIV acquisition or in the context of ‘prevention for positives’, the likelihood of onward transmission. However, to optimize the growing number of biomedical interventions, both prevention and implementation science will need to take a broader view of what they consider to be behavior change, move away from a narrow focus on risk behaviors and give greater consideration to health-seeking behaviors, social practices, cultural and social norms. These have been largely excluded from primary prevention thinking in southern Africa. Exciting developments in other areas of HIV research science, for example viral genetics, molecular and spatial epidemiology, can also be part of this process as they are able to help us to identify sub-populations at greatest risk, even in severe generalized epidemics. A number of biomedical interventions are already being rolled out, and attempts to bring them to scale will peak in the next few years. Much needs to be done to support these efforts, but equally much can be learned from the challenges that can have wider value in other resource-poor contexts. With better understanding and more accurate targeting of sub-populations, communities and behaviors, it will be possible to strengthen biomedical intervention strategies and improve allocation of prevention resources.

The potential impact of an HIV vaccine with limited protection on HIV incidence in Thailand: a modeling study

BACKGROUND

The RV144 trial on the ALVAC/AIDSVAX candidate HIV vaccine, carried out in Thailand, showed short-lived protection against infection.

METHODS

Using a deterministic compartmental model we explored the potential impact of this vaccine on heterosexual HIV transmission in Thailand. Both one-off vaccination strategies, as well as strategies with regular boosting, either annually or every two years, were explored. Both targeting the general adult population and prioritizing sex workers were modeled. The impact of risk compensation among high risk groups, as well as whether higher levels of safe sex in high risk groups could be an alternative to vaccination, was studied.

RESULTS

One-off vaccination campaigns had only transient effects, and boosting appears to be a key component of successful vaccination campaigns. Intensive vaccination campaigns may reduce HIV incidence by up to 75% after 10 years of vaccination. Targeting only sex workers has a smaller impact but has a more favorable cost-benefit ratio. Risk compensation has the potential of undoing much of the benefits of a vaccination program and may even increase incidence. In contrast, higher levels of safe sex among sex workers would provide a viable alternative to vaccinating this group.

DISCUSSION

The new vaccine holds promise for controlling HIV in Thailand and similar countries. In view of the short lived protection of the vaccine, regular boosting of immunity as well as avoidance of risk compensation are essential. Targeting sex workers would achieve the greatest reduction in incidence per vaccination and may be considered for expensive vaccines but its cost-effectiveness has to be compared to alternatives.

Acute HIV-1 Infection

In 2009, the United Nations Estimated that 33.2 Million People worldwide were living with human immunodeficiency virus type 1 (HIV-1) infection and that 2.6 million people had been newly infected. The need for effective HIV-1 prevention has never been greater. In this review, we address recent critical advances in our understanding of HIV-1 transmission and acute HIV-1 infection. Fourth-generation HIV-1 testing, now available worldwide,^, will allow the diagnosis of infection in many patients and may lead to new treatments and opportunities for prevention.

HIV prevention research: taking stock and the way forward

Previous papers in this supplement have reviewed the evidence of the effectiveness of alternative HIV prevention methods from randomized controlled trials and other studies. This paper draws together the main conclusions from these reviews. A conceptual framework is presented that maps the proximal and distal determinants of sexual HIV transmission and helps to identify the stages in the causal pathway at which each intervention approach acts. The advances, gaps and challenges emerging from the reviews of individual intervention methods are summarized and cross-cutting themes identified. Approximately 90% of HIV prevention trials have found no effect on HIV incidence and we explore the alternative explanations for the large number of 'flat' trials. We conclude that there is no single explanation for these flat results, which may be due to interventions that are ineffective or inappropriately targeted or implemented, or to factors related to the design or conduct of trials. We examine the lessons from these flat results and provide recommendations on what should be done differently in future trials. HIV prevention remains of critical importance in an era of expanded delivery of antiretroviral therapy. In future HIV prevention research, it is important that resources are used as efficiently as possible to provide rigorous evidence of the effectiveness of a wider array of complementary prevention tools.