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Gao Y, Zhan Y, Sun Y, Zheng W, Zhang W, Fu L, Guo Z, Lin YF, Li Y, Zheng L, Zhan Y, Zhu Z, Duan J, Zhang G, Huang T, Su B, Yu M, Wu G, Ouyang L, Zhao J, Wang G, Zhou Y, Qian HZ, Fitzpatrick T, Vermund SH, Zou H. Efficacy of Voluntary Medical Male Circumcision to Prevent HIV Infection Among Men Who Have Sex With Men : A Randomized Controlled Trial. Ann Intern Med 2024; 177:719-728. [PMID: 38801778 DOI: 10.7326/m23-3317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Observational studies suggest that voluntary medical male circumcision (VMMC) may lower HIV risk among men who have sex with men (MSM). A randomized controlled trial (RCT) is needed to confirm this. OBJECTIVE To assess the efficacy of VMMC in preventing incident HIV infection among MSM. DESIGN An RCT with up to 12 months of follow-up. (Chinese Clinical Trial Registry: ChiCTR2000039436). SETTING 8 cities in China. PARTICIPANTS Uncircumcised, HIV-seronegative men aged 18 to 49 years who self-reported predominantly practicing insertive anal intercourse and had 2 or more male sex partners in the past 6 months. INTERVENTION VMMC. MEASUREMENTS Rapid testing for HIV was done at baseline and at 3, 6, 9, and 12 months. Behavioral questionnaires and other tests for sexually transmitted infections were done at baseline, 6 months, and 12 months. The primary outcome was HIV seroconversion using an intention-to-treat analysis. RESULTS The study enrolled 124 men in the intervention group and 123 in the control group, who contributed 120.7 and 123.1 person-years of observation, respectively. There were 0 seroconversions in the intervention group (0 infections [95% CI, 0.0 to 3.1 infections] per 100 person-years) and 5 seroconversions in the control group (4.1 infections [CI, 1.3 to 9.5 infections] per 100 person-years). The HIV hazard ratio was 0.09 (CI, 0.00 to 0.81; P = 0.029), and the HIV incidence was lower in the intervention group (log-rank P = 0.025). The incidence rates of syphilis, herpes simplex virus type 2, and penile human papillomavirus were not statistically significantly different between the 2 groups. There was no evidence of HIV risk compensation. LIMITATION Few HIV seroconversions and limited follow-up period. CONCLUSION Among MSM who predominantly practice insertive anal intercourse, VMMC is efficacious in preventing incident HIV infection; MSM should be included in VMMC guidelines. PRIMARY FUNDING SOURCE The National Science and Technology Major Project of China.
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Affiliation(s)
- Yanxiao Gao
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, and School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (Y.G.)
| | - Yuewei Zhan
- Discipline Development Office, Shenzhen People's Hospital, Shenzhen, China (YueweiZhan)
| | - Yinghui Sun
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China (Y.S.)
| | - Weiran Zheng
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Weijie Zhang
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Leiwen Fu
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Zhihui Guo
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Yi-Fan Lin
- Department of Spine Surgery/Orthopaedics, the First Affiliated Hospital, Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China (Y.-F.L.)
| | - Yuwei Li
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Lingling Zheng
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China (L.Z.)
| | - Yiqiang Zhan
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China (W.Zheng, W.Zhang, L.F., Z.G., Y.L., YiqiangZhan)
| | - Zhiqiang Zhu
- Beijing Youan Hospital, Capital Medical University, Beijing, China (Z.Z., J.D., G.Z., T.H., B.S.)
| | - Junyi Duan
- Beijing Youan Hospital, Capital Medical University, Beijing, China (Z.Z., J.D., G.Z., T.H., B.S.)
| | - Guanghui Zhang
- Beijing Youan Hospital, Capital Medical University, Beijing, China (Z.Z., J.D., G.Z., T.H., B.S.)
| | - Tao Huang
- Beijing Youan Hospital, Capital Medical University, Beijing, China (Z.Z., J.D., G.Z., T.H., B.S.)
| | - Bin Su
- Beijing Youan Hospital, Capital Medical University, Beijing, China (Z.Z., J.D., G.Z., T.H., B.S.)
| | - Maohe Yu
- Tianjin Center for Disease Control and Prevention, Tianjin, China (M.Y.)
| | - Guohui Wu
- Chongqing Center for Disease Control and Prevention, Chongqing, China (G.Wu, L.O.)
| | - Lin Ouyang
- Chongqing Center for Disease Control and Prevention, Chongqing, China (G.Wu, L.O.)
| | - Jin Zhao
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China (J.Z.)
| | - Guanghui Wang
- Qingdao Qingtong AIDS Prevention Volunteer Service Center, Qingdao, China (G.Wang)
| | - Yepeng Zhou
- Foshan Friend Care Center for AIDS/HIV Control, Foshan, China (Y.Zhou)
| | - Han-Zhu Qian
- Departments of Biostatistics and Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut (H.-Z.Q.)
| | - Thomas Fitzpatrick
- Department of Internal Medicine, University of Washington, Seattle, Washington (T.F.)
| | - Sten H Vermund
- Departments of Biostatistics and Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, and Global Virus Network, Baltimore, Maryland (S.H.V.)
| | - Huachun Zou
- School of Public Health, Fudan University, Shanghai, China, and Shenzhen Campus, Sun Yat-sen University, Shenzhen, China (H.Z.)
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Zhang X, Li J, Tang G, Wang Z, Guo Q, Guo Q, Qin Q, Fan Y. The prevalence and factors of willingness to accept circumcision among MSM in Maanshan City, China. AIDS Care 2024; 36:752-761. [PMID: 38266488 DOI: 10.1080/09540121.2023.2299664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024]
Abstract
To investigate the prevalence of male circumcision and the willingness to undergo male circumcision and influencing factors among MSM in Maanshan City, we conducted a cross-sectional study from June 2016 to December 2019. Respondent-driven sampling (RDS) was used to recruit participants. Influential factors of willingness to accept circumcision were identified by a multivariable logistic regression model. The multivariable logistic regression model revealed that five variables were independent influential factors for willingness to participate. The factors include that used condoms during last anal intercourse (OR = 1.87, 95% CI:1.03-3.41, P = 0.04), sex with female sex partners (OR = 0.499, 95% CI:0.298-0.860, P = 0.012, level of education (junior college: OR = 0.413, 95% CI:0.200-0.854, P = 0.017; bachelor's degree or higher: OR = 0.442, 95% CI:0.208-0.938, P = 0.033), condom use during oral sex in the last six months (OR = 4.20, 95% CI:1.47-12.0, P = 0.007) and level of knowledge of PrEP (OR = 5.09, 95% CI:1.39-18.7, P = 0.014). Given the willingness of MSM to accept circumcision was low in China, establishing a proper understanding of circumcision is essential if it is to be used as a strategy to prevent HIV infection among MSM. Therefore, publicity and education on the operation should be strengthened to increase the willingness to undergo male circumcision.
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Affiliation(s)
- Xinhong Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
| | - Jianwei Li
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
| | - Gan Tang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
| | - Ziwei Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
| | - Qian Guo
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
| | - Qisheng Guo
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
| | - Qirong Qin
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Ma'anshan Center for Disease Control and Prevention, Ma'anshan, People's Republic of China
| | - Yinguang Fan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, People's Republic of China
- Anhui Province Key Laboratory of Major Autoimmune Diseases, Anhui Medical University, Hefei, People's Republic of China
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3
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Morris BJ, Banerjee J. Comment on 'Changing relationships between HIV prevalence and circumcision in Lesotho', and 'Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa'. J Biosoc Sci 2024:1-4. [PMID: 38766849 DOI: 10.1017/s0021932024000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Two articles by Garenne (2023a,b) argue that voluntary medical male circumcision does not reduce human immunodeficiency virus transmission in Africa. Here we point out key evidence and analytical flaws that call into question this conclusion.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW, Australia
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4
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Nuvunga S, Langa DC, Sacarlal J, Rossetto E, Baltazar CS. HIV prevalence and associated factors among married women, Mozambique, 2015: analysis of the 2015 National AIDS Indicator Survey (IMASIDA). Pan Afr Med J 2024; 47:94. [PMID: 38799187 PMCID: PMC11126754 DOI: 10.11604/pamj.2024.47.94.42781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/19/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction epidemiological estimates from the 2021 Joint United Nations Program on HIV/AIDS (UNAIDS) emphasize the existing gender disparities, where women face a higher risk of HIV/AIDS exposure. In Mozambique, as of 2021, the HIV prevalence rate among the adult population stood at 12.5%, with an even more concerning rate of 15.4% among women of reproductive age. Methods a cross-sectional study was carried out with secondary data from the Survey on National Indicators of Vaccination, Malaria, and HIV/AIDS (IMASIDA 2015), where we included married women, both civil marriage and common law marriage of reproductive age 15-49 years. Statistical analyses, including chi-squared tests and logistic regression models, accounting for survey design, were employed to assess associations. Results the study findings showed that HIV prevalence was higher among married women aged 35-49 years (aOR=2.5; 95% CI: 1.3-4.6; p=0.005), those without formal education (aOR=7.7; 95% CI: 1.1-52.9; p=0.038) and those with primary education (aOR=9.8; 95% CI: 1.6-60.1; p=0.014), those who experienced domestic violence (aOR=1.8; 95% CI: 1.0-3.2; p=0.04), had an uncircumcised partner (aOR=1.9; 95% CI: 1.2-3.1; p=0.008), and had three or more lifetime sex partners (aOR=3.6; 95% CI: 2.9-7.3; p<0.001). Women who were in one lifelong union had a lower risk of HIV positivity (aOR=0.5; 96%CI: 0.3-0.8, p=0.005). Conclusion the findings of this study highlight sociodemographic, behavioral, and violent factors associated with HIV prevalence among women. These findings underscore the importance of targeted interventions and education programs aimed at reducing HIV transmission among females and promoting safer sexual practices.
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Affiliation(s)
- Samuel Nuvunga
- Mozambique Field Epidemiology Training Program, National Institute of Health, Maputo, Mozambique
| | | | - Jahit Sacarlal
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Erika Rossetto
- MassGenics, assigned to Mozambique Centers for Disease Control Prevention, Maputo, Mozambique
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Morris B, Rivin BE, Sheldon M, Krieger JN. Neonatal Male Circumcision: Clearly Beneficial for Public Health or an Ethical Dilemma? A Systematic Review. Cureus 2024; 16:e54772. [PMID: 38405642 PMCID: PMC10889534 DOI: 10.7759/cureus.54772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Contrasting ethical and legal arguments have been made concerning neonatal male circumcision (NMC) that merit the first systematic review on this topic. We performed PRISMA-compliant keyword searches of PubMed, EMBASE, SCOPUS, LexisNexis, and other databases and identified 61 articles that met the inclusion criteria. In the bibliographies of these articles, we identified 58 more relevant articles and 28 internet items. We found high-quality evidence that NMC is a low-risk procedure that provides immediate and lifetime medical and health benefits and only rarely leads to later adverse effects on sexual function or pleasure. Given this evidence, we conclude that discouraging or denying NMC is unethical from the perspective of the United Nations Convention on the Rights of the Child, which emphasizes the right to health. Further, case law supports the legality of NMC. We found, conversely, that the ethical arguments against NMC rely on distortions of the medical evidence. Thus, NMC, by experienced operators using available safety precautions, appears to be both legal and ethical. Consistent with this conclusion, all of the evidence-based pediatric policies that we reviewed describe NMC as low-risk and beneficial to public health. We calculated that a reduction in NMC in the United States from 80% to 10% would substantially increase the cases of adverse medical conditions. The present findings thus support the evidence-based NMC policy statements and are inconsistent with the non-evidence-based policies that discourage NMC. On balance, the arguments and evidence reviewed here indicate that NMC is a medically beneficial and ethical public health intervention early in life because it reduces suffering, deaths, cases, and costs of treating adverse medical conditions throughout the lifetimes of circumcised individuals.
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Affiliation(s)
- Brian Morris
- Faculty of Medicine and Health, The University of Sydney, Sydney, AUS
| | - Beth E Rivin
- Schools of Medicine and Public Health, Department of Global Health, University of Washington, Seattle, USA
- Bioethics, Uplift International, Seattle, USA
| | - Mark Sheldon
- Medical Humanities and Bioethics Program, Feinberg School of Medicine, Chicago, USA
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Moreton S, Cox G, Sheldon M, Bailis SA, Klausner JD, Morris BJ. Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health. World J Clin Pediatr 2023; 12:244-262. [PMID: 38178933 PMCID: PMC10762604 DOI: 10.5409/wjcp.v12.i5.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 12/08/2023] Open
Abstract
The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.
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Affiliation(s)
| | - Guy Cox
- Australian Centre for Microscopy & Microanalysis and School of Aeronautical, Mechanical and Mechatronic Engineering, University of Sydney, Sydney 2006, New South Wales, Australia
| | - Mark Sheldon
- Medical Humanities and Bioethics Program, Feinberg School of Medicine, Northwestern University, Chicago, IL 60661, United States
| | - Stefan A Bailis
- Cornerstone Therapy & Recovery Center, St. Paul, MN 55101, United States
| | - Jeffrey D Klausner
- Department of Medicine, Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States
| | - Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney 2006, New South Wales, Australia
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Alonso D, Vallès X. A potential transition from a concentrated to a generalized HIV epidemic: the case of Madagascar. Infect Dis Poverty 2023; 12:112. [PMID: 38057918 DOI: 10.1186/s40249-023-01164-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023] Open
Abstract
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.
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Affiliation(s)
- David Alonso
- Computational and Theoretical Ecology, Spanish Council for Scientific Research (CEAB-CSI)C, C/Access Cala Francesc, 14, 17300, Blanes, Spain
| | - Xavier Vallès
- International Health Program (PROSICS), North Metropolitan Health Area From Barcelona, Hospital Universitari Germans Trias i Pujol, Passatge dels Encants, s/n, 08914, Badalona, Catalonia, Spain.
- Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, C/Canyet s/n, 08916, Badalona, Spain.
- Fundació Lluita contra les Infeccions, C/Canyet s/n, 08916, Badalona, Spain.
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8
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Stojanovski K, King EJ, O'Connell S, Gallagher KS, Theall KP, Geronimus AT. Spiraling Risk: Visualizing the multilevel factors that socially pattern HIV risk among gay, bisexual & other men who have sex with men using Complex Systems Theory. Curr HIV/AIDS Rep 2023; 20:206-217. [PMID: 37486568 PMCID: PMC10403445 DOI: 10.1007/s11904-023-00664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE OF REVIEW Global disparities in HIV infection, particularly among gay, bisexual, and other men who have sex with men (GBMSM), indicate the importance of exploring the multi-level processes that shape HIV's spread. We used Complex Systems Theory and the PRISMA guidelines to conduct a systematic review of 63 global reviews to understand how HIV is socially patterned among GBMSM. The purpose was to conduct a thematic analysis of the reviews to (1) synthesize the multi-level risk factors of HIV risk, (2) categorize risk across the socioecological model, and (3) develop a conceptual model that visualizes the interrelated factors that shape GBMSMS's HIV "risk." RECENT FINDINGS We included 49 studies of high and moderate quality studies. Results indicated that GBMSM's HIV risk stems from the individual, interpersonal, and structural levels of the socioecological model. We identified a few themes that shape GBMSM's risk of HIV infection related to biomedical prevention methods; sexual and sex-seeking behaviors; behavioral prevention methods; individual-level characteristics and syndemic infections; lived experiences and interpersonal relationships; country-level income; country-level HIV prevalence; and structural stigma. The multi-level factors, in tandem, serve to perpetuate GBMSM's risk of HIV infection globally. The amalgamation of our thematic analyses from our systematic reviews of reviews suggests that the risk of HIV infection operates in an emergent, dynamic, and complex nature across multiple levels of the socioecological model. Applying complex systems theory indicates how multilevel factors create a dynamic and reinforcing system of HIV risk among GBMSM.
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Affiliation(s)
- K Stojanovski
- Department of Social, Behavioral and Population Sciences, Tulane School of Public Health & Tropical Medicine, New Orleans, USA.
| | - E J King
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, USA
| | - S O'Connell
- Department of Epidemiology, Tulane School of Public Health & Tropical Medicine, New Orleans, USA
| | - K S Gallagher
- Department of Health Policy and Management, Tulane School of Public Health & Tropical Medicine, New Orleans, USA
| | - K P Theall
- Department of Social, Behavioral and Population Sciences, Tulane School of Public Health & Tropical Medicine, New Orleans, USA
- Department of Epidemiology, Tulane School of Public Health & Tropical Medicine, New Orleans, USA
| | - A T Geronimus
- Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, USA
- Institute for Social Research, University of Michigan, Ann Arbor, USA
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9
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Gao Y, Zheng W, Sun Y, Yang L, Guo Z, Li Y, Lin YF, Lu Z, Yuan T, Zhan Y, Qian HZ, Su B, Zhu Z, Duan J, Wang G, Cui X, Ouyang L, Sheng G, Zhou Y, Long A, Yao Y, Fitzpatrick T, Yu M, Wu G, Zou H. Voluntary Medical Male Circumcision and Incident HIV Infection Among Men Who Have Sex With Men in China (The CoM Study): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e47160. [PMID: 37247211 PMCID: PMC10262017 DOI: 10.2196/47160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/30/2023] [Accepted: 05/05/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Systematic reviews and meta-analyses based on observational studies have shown voluntary medical male circumcision (VMMC) may reduce HIV risk among men who have sex with men (MSM). There is a lack of randomized controlled trial (RCT) data assessing the efficacy of VMMC. OBJECTIVE The primary objective of this study was to assess the efficacy of VMMC for preventing HIV acquisition among MSM who primarily engage in insertive anal sex. METHODS A multicenter RCT will be conducted among MSM in 8 cities in China. Eligible participants are men aged 18-49 years who self-report ≥2 male sex partners in the past 6 months, predominantly practice insertive anal sex, and are willing to undergo circumcision. Interested men who satisfy inclusion criteria will be tested for HIV 1 month before enrollment and at enrollment, and only those who are HIV negative will be enrolled. At baseline, all enrolled participants will be asked to report sociodemographic characteristics and sexual behaviors; provide a blood sample for HIV, syphilis, and herpes simplex virus type 2 testing; and provide a penile swab for human papillomavirus testing. Participants will be randomly assigned to the intervention or control group. Those in the intervention group will receive VMMC and undergo a web-based weekly follow-up assessment of postsurgery healing for 6 consecutive weeks. All participants will be tested for HIV at 3-, 6-, 9-, and 12-month follow-ups. All participants will also be asked to report sexual behaviors and undergo repeat herpes simplex virus type 2 and human papillomavirus testing at 6- and 12-month follow-ups. The primary end point is HIV seroconversion. Secondary end points are the safety and satisfaction with VMMC and the changes in sexual behaviors after VMMC. The grouped censored data will be analyzed by intention-to-treat approach. RESULTS Recruitment for the RCT began in August 2020 and continued through July 2022. Data collection is expected to be completed by July 2023, and full data analysis is going to be completed by September 2023. CONCLUSIONS This study will be the first RCT to assess the efficacy of VMMC in preventing HIV infection among MSM. Results from this trial will provide preliminary evidence for the potential efficacy of VMMC to reduce incident HIV infection among MSM. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2000039436; https://www.chictr.org.cn/showproj.html?proj=63369. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/47160.
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Affiliation(s)
- Yanxiao Gao
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Weiran Zheng
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Yinghui Sun
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Luoyao Yang
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Zhihui Guo
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Yuwei Li
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Yi-Fan Lin
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Zhen Lu
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Tanwei Yuan
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Yuewei Zhan
- School of Public Health, Sun Yat-sen University, Shenzhen, China
| | - Han-Zhu Qian
- GlaxoSmithKline plc, Rockville, MD, United States
| | - Bin Su
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Zhiqiang Zhu
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Junyi Duan
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Guanghui Wang
- Qingdao Qingtong AIDS Prevention Volunteer Service Center, Qingdao, China
| | - Xin Cui
- Qingdao Qingtong AIDS Prevention Volunteer Service Center, Qingdao, China
| | - Lin Ouyang
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Genshen Sheng
- Shenzhen Rainbow 258 Centre for Men, Shenzhen, China
| | - Yepeng Zhou
- Foshan Pengyou Care and Rescue Center for AIDS Prevention, Foshan, China
| | - Ao Long
- Luzhou Red Ribbon Heart Association, Luzhou, China
| | - Yuming Yao
- Zhitong LGBT Service Center, Guangzhou, China
| | - Thomas Fitzpatrick
- Department of Internal Medicine, University of Washington, Seattle, WA, United States
| | - Maohe Yu
- Tianjin Municipal Center for Disease Control and Prevention, Tianjin, China
| | - Guohui Wu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Huachun Zou
- School of Public Health, Sun Yat-sen University, Shenzhen, China
- Kirby Institute, University of New South Wales, Sydney, Australia
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10
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Asa GA, Fauk NK, Ward PR. Traditional male circumcision and the risk for HIV transmission among men: a systematic review. BMJ Open 2023; 13:e072118. [PMID: 37208134 DOI: 10.1136/bmjopen-2023-072118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVES To synthesise evidence to determine whether, in contrast to medical male circumcision, traditional male circumcision (TMC) practices may contribute to HIV transmission and what the impacts of TMC are on the initiates, their families and societies. DESIGN Systematic review. DATA SOURCE PubMed, CINHAL, SCOPUS, ProQuest, Cochrane database and Medline were searched between 15 and 30 October 2022. ELIGIBILITY CRITERIA (1) Studies involving young men, young male adults, male adults and mixed male and female participants; (2) studies on TMC involving men living with HIV (married and non-married); (3) studies on TMC, HIV transmission and impact in low-income and middle-income countries; (4) qualitative, quantitative and mixed-method studies and (5) studies aimed at exploring TMC and how it contributes to HIV transmission and the impacts of HIV on circumcised men and their families. DATA EXTRACTION Data were extracted based on study details, study design, characteristics of participants and results. RESULT A total of 18 studies were included: 11 were qualitative studies, five were quantitative studies and two were mixed-method studies. All the studies included were conducted in areas where TMC was performed (17 in Africa and one in Papua New Guinea). The review's findings were categorised into themes: TMC as a cultural practice, consequences of not being traditionally circumcised on men and their families and TMC-related risk of HIV transmission. CONCLUSION This systematic review highlights that TMC practice and HIV risk could negatively impact men and their families. Existing evidence suggests that little attention has been paid to men and their families experiencing the impacts of TMC and HIV risk factors. The findings recommend the need for health intervention programmes such as safe circumcision and safe sexual behaviours following TMC and efforts to address psychological and social challenges in communities practising TMC. PROSPERO REGISTRATION NUMBER CRD42022357788.
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Affiliation(s)
- Gregorius Abanit Asa
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
| | - Nelsensius Klau Fauk
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
| | - Paul Russell Ward
- Research Centre for Public Health, Equity and Human Flourishing (PHEHF), Torrens University Australia, Adelaide, South Australia, Australia
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11
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Lin Y, Gao Y, Sun Y, Turner D, Zou H, Vermund SH, Qian HZ. Does Voluntary Medical Male Circumcision Reduce HIV Risk in Men Who Have Sex with Men? Curr HIV/AIDS Rep 2022; 19:522-525. [PMID: 36520379 DOI: 10.1007/s11904-022-00637-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To review the evidence on the effect of voluntary medical male circumcision (VMMC) on reducing HIV risk among men who have sex with men (MSM) and assess the limitations of available evidence. RECENT FINDINGS Individual studies have shown conflicting results, but recent meta-analyses have consistently suggested that VMMC was associated with 7 to 23% reductions in HIV prevalence or incidence in MSM, particularly among a subgroup of men who predominantly practice insertive role in anal sex. Mathematical models have also suggested a moderate population-level impact of VMMC intervention. All original studies have been observational and are subject to confounding and bias. Randomized clinical trials (RCTs) are needed to provide strong evidence of assessing the efficacy of VMMC on HIV risk among MSM. VMMC is a promising HIV risk reduction tool for MSM. RCTs are needed to evaluate the efficacy of VMMC intervention.
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Affiliation(s)
- Yidie Lin
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yanxiao Gao
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, China
| | - Yue Sun
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - DeAnne Turner
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, China
| | - Sten H Vermund
- School of Public Health, Yale University, Suite 501, 300 George Street, New Haven, CT, USA
| | - Han-Zhu Qian
- School of Public Health, Yale University, Suite 501, 300 George Street, New Haven, CT, USA.
- GlaxoSmithKline Plc, Rockville, MD, USA.
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12
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Morris BJ, Moreton S, Krieger JN, Klausner JD. Infant Circumcision for Sexually Transmitted Infection Risk Reduction Globally. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00811. [PMID: 36041835 PMCID: PMC9426975 DOI: 10.9745/ghsp-d-21-00811] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/21/2022] [Indexed: 12/26/2022]
Abstract
Population-based studies in high-income countries have failed to find that male circumcision protects against sexually transmitted infections. Using evidence from several sources, we show that male circumcision does protect against HIV during insertive intercourse for men who have sex with men.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, Australia.
| | | | - John N Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jeffrey D Klausner
- Department of Medicine, Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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13
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Kommentar zu Verringert eine Beschneidung das HIV-Ansteckungsrisiko? Aktuelle Urol 2022; 53:307. [DOI: 10.1055/a-1783-4291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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14
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Mbita G, Komba AN, Casalini C, Bazant E, Curran K, Christensen A, Nyato D, Kim YM, Reed J, Makyao N, Kategile U, Conserve DF, Faini D, van Roosmalen J, van den Akker T. Predictors of HIV Among 1 Million Clients in High-Risk Male Populations in Tanzania. AIDS Behav 2022; 26:3185-3198. [PMID: 35362905 PMCID: PMC9474353 DOI: 10.1007/s10461-022-03667-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 12/01/2022]
Abstract
The World Health Organization identified men as an essential group to target with HIV testing and treatment strategies;: men who have sex with men (MSM) and male clients of female sex workers (CFSW) account for 35% of new HIV infections globally. Using a cross-sectional design from a community-based HIV prevention project in Tanzania (October 2015-September 2018) and multivariable logistic regression, we identified predictors of HIV seropositivity among men. Of 1,041,343 men on their initial visit to the project, 36,905 (3.5%) were MSM; 567,005 (54.5%) were CFSW; and 437,343 (42.0%) were other men living near hotspots (OMHA). Three predictors of HIV seropositivity emerged across all three groups: being uncircumcised, having sexually transmitted infection symptoms, and harmful drinking of alcohol before sex. Any reported form of gender-based violence among MSM and OMHA and inconsistent condom use among CFSW were associated with HIV seropositivity. These findings may inform community HIV strategies like self-testing, delivery of pre-exposure prophylaxis and antiretroviral therapy, and behavioral change communication targeting men at higher risk of infection.
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Affiliation(s)
- Gaspar Mbita
- Jhpiego, Dar-es-Salaam, Tanzania.
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania.
- Jhpiego, Monrovia, Liberia.
| | | | | | - Eva Bazant
- The Task Force for Global Health, Decatur, GA, USA
| | | | | | - Daniel Nyato
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | | | | | - Neema Makyao
- Ministry of Health Community Development, Gender, Elderly, and Children, National AIDS Control Program, Dodoma, Tanzania
| | | | - Donaldson F Conserve
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Diana Faini
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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15
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Bershteyn A, Mudimu E, Platais I, Mwalili S, Zulu JE, Mwanza WN, Kripke K. Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges. Curr HIV/AIDS Rep 2022; 19:526-536. [PMID: 36459306 PMCID: PMC9759505 DOI: 10.1007/s11904-022-00639-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE OF REVIEW Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations. RECENT FINDINGS Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Edinah Mudimu
- Department of Decision Sciences, College of Economic and Management Sciences, University of South Africa, Pretoria, Gauteng South Africa
| | - Ingrida Platais
- Department of Population Health, New York University Grossman School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Samuel Mwalili
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, Kenya
| | - James E. Zulu
- Zambia Field Epidemiology Training Program, Workforce Development Cluster, Zambia National Public Health Institute, Lusaka, Zambia
| | - Wiza N. Mwanza
- Directorate of Public Health and Research, Ministry of Health, Lusaka, Zambia
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16
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Iyemosolo BM, Chivese T, Esterhuizen TM. A comparison of the prevalence of sexually transmitted infections among circumcised and uncircumcised adult males in Rustenburg, South Africa: a cross-sectional study. BMC Public Health 2021; 21:656. [PMID: 33823828 PMCID: PMC8022379 DOI: 10.1186/s12889-021-10509-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa has a persistent burden of sexually transmitted infections (STIs). Male circumcision has been shown to be effective in preventing HIV and STIs, but data are scarce on the protective effect of circumcision in high-risk populations such as migrant miners. The objective of this study was to assess the effect of medical and traditional circumcision on the prevalence of STIs after adjusting for other risk factors in Rustenburg, a mining town in North West Province, South Africa. METHODS This cross-sectional study used baseline data collected from a cohort study. Adult males in a mining town were assessed for STIs (gonorrhea, chlamydia, and trichomoniasis) using syndromic assessment. Data on circumcision status and other risk factors for STI syndromes were collected using an interviewer-administered questionnaire. The following symptoms were assessed; penile discharge, painful urination, dyspareunia or penile sores. These symptoms indicate sexually transmitted infection in general since laboratory tests were not performed. Multivariable log binomial regression was used to assess the independent effect of circumcision on STI presence after adjusting for confounders. RESULTS A total of 339 participants with a median age of 25 years (IQR 22-29) were included in the study, of whom 116 (34.2%) were circumcised. The overall STIs prevalence was 27.4% (95% CI 22.8 to 32.6%) and was lower in the circumcised participants compared with those who were uncircumcised (15.5% vs 33.6%, respectively, p < 0.001). Both medical (OR 0.57, 95% CI 0.34-0.95, p = 0.030) and traditional circumcision (OR 0.34, 95% CI 0.13-0.86, p = 0.022) were strongly associated with a lower risk of STIs after adjustment for employment and condom use. CONCLUSION In this high-risk population in a mining town in South Africa, with a relatively high prevalence of STIs, and where one third of males are circumcised, both medical and traditional circumcision appear to be protective against STIs.
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Affiliation(s)
- Blanchard Mbay Iyemosolo
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tonya M. Esterhuizen
- Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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17
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Merzouki A, Estill J, Orel E, Tal K, Keiser O. Clusters of sub-Saharan African countries based on sociobehavioural characteristics and associated HIV incidence. PeerJ 2021; 9:e10660. [PMID: 33520455 PMCID: PMC7812934 DOI: 10.7717/peerj.10660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 12/07/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction HIV incidence varies widely between sub-Saharan African (SSA) countries. This variation coincides with a substantial sociobehavioural heterogeneity, which complicates the design of effective interventions. In this study, we investigated how sociobehavioural heterogeneity in sub-Saharan Africa could account for the variance of HIV incidence between countries. Methods We analysed aggregated data, at the national-level, from the most recent Demographic and Health Surveys of 29 SSA countries (2010–2017), which included 594,644 persons (183,310 men and 411,334 women). We preselected 48 demographic, socio-economic, behavioural and HIV-related attributes to describe each country. We used Principal Component Analysis to visualize sociobehavioural similarity between countries, and to identify the variables that accounted for most sociobehavioural variance in SSA. We used hierarchical clustering to identify groups of countries with similar sociobehavioural profiles, and we compared the distribution of HIV incidence (estimates from UNAIDS) and sociobehavioural variables within each cluster. Results The most important characteristics, which explained 69% of sociobehavioural variance across SSA among the variables we assessed were: religion; male circumcision; number of sexual partners; literacy; uptake of HIV testing; women’s empowerment; accepting attitude toward people living with HIV/AIDS; rurality; ART coverage; and, knowledge about AIDS. Our model revealed three groups of countries, each with characteristic sociobehavioural profiles. HIV incidence was mostly similar within each cluster and different between clusters (median (IQR); 0.5/1000 (0.6/1000), 1.8/1000 (1.3/1000) and 5.0/1000 (4.2/1000)). Conclusions Our findings suggest that the combination of sociobehavioural factors play a key role in determining the course of the HIV epidemic, and that similar techniques can help to predict the effects of behavioural change on the HIV epidemic and to design targeted interventions to impede HIV transmission in SSA.
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Affiliation(s)
- Aziza Merzouki
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Erol Orel
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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18
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Korenromp EL, Bershteyn A, Mudimu E, Weiner R, Bonecwe C, Loykissoonlal D, Manuhwa C, Pretorius C, Teng Y, Stover J, Johnson LF. The impact of the program for medical male circumcision on HIV in South Africa: analysis using three epidemiological models. Gates Open Res 2021; 5:15. [PMID: 33615145 PMCID: PMC7878969 DOI: 10.12688/gatesopenres.13220.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.
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Affiliation(s)
| | - Anna Bershteyn
- Department of Population and Health, NYU Langone Medical Center, New York, NY, 11016, USA
| | - Edina Mudimu
- Department of Decision Sciences, University of South Africa (UNISA), Pretoria, 0003, South Africa
| | - Renay Weiner
- Research and Training for Health and Development, Johannesburg, 2196, South Africa
| | | | | | - Clarence Manuhwa
- FHI 360, Pretoria, 0083, South Africa
- Independent Consultant, Pretoria, 0083, South Africa
| | - Carel Pretorius
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Yu Teng
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - John Stover
- Center for Modeling and Analysis, Avenir Health, Glastonbury, CT, 06033, USA
| | - Leigh F. Johnson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
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19
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Morris BJ. Voluntary Medical Male Circumcision Proves Robust for Mitigating Heterosexual Human Immunodeficiency Virus Infection. Clin Infect Dis 2020; 73:e1954-e1956. [DOI: 10.1093/cid/ciaa1542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
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20
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George C, Roberts R, Deveaux L, Brennen DFP, Read SE. "Getting to Zero New HIV Infections in the Caribbean": Knowledge and Attitudes Toward Male Circumcision Among Adolescent Males in The Bahamas. Am J Mens Health 2020; 13:1557988319872074. [PMID: 31431104 PMCID: PMC6704421 DOI: 10.1177/1557988319872074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Clemon George
- 1 University of Ontario Institute of Technology, Oshawa, ON, Canada.,5 Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados
| | - Robin Roberts
- 2 UWI School of Clinical Medicine and Research, Nassau, Bahamas
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21
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Comprehensive HIV risk reduction interventions for 2020 and beyond: product choices and effective service-delivery platforms for individual needs and population-level impact. Curr Opin HIV AIDS 2020; 14:423-432. [PMID: 31261158 DOI: 10.1097/coh.0000000000000567] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW This review summarizes key HIV prevention strategies in the 2020 toolkit and discusses opportunities to maximize the public health impact of these prevention interventions at a population level. RECENT FINDINGS HIV prevention has relied on counseling, HIV testing, and condom distribution for the past three decades. Recent exciting work has provided evidence on effective HIV prevention interventions, including antiretroviral therapy for HIV prevention, expanding preexposure prophylaxis modalities, and voluntary medical male circumcision which all reduce individual-level HIV risk. Efficient service-delivery approaches are necessary to deliver these products at scale while addressing population-specific needs. These approaches include: making it easier to get individuals HIV tested and linked to prevention services; de-medicalization to increase access to prevention products; creating welcoming clinic service-delivery environments; and integrating HIV prevention products into existing clinical platforms to support ongoing care engagement. SUMMARY The 2020 HIV prevention toolkit includes powerful HIV prevention options, and product choice will be increasingly imperative. Meeting ambitious global HIV reduction targets in the next decade will require improved service-delivery platforms to get prevention choices to persons at risk while layering prevention coverage to achieve population-level impact.
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22
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Farley TMM, Samuelson J, Grabowski MK, Ameyan W, Gray RH, Baggaley R. Impact of male circumcision on risk of HIV infection in men in a changing epidemic context - systematic review and meta-analysis. J Int AIDS Soc 2020; 23:e25490. [PMID: 32558344 PMCID: PMC7303540 DOI: 10.1002/jia2.25490] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 03/17/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION WHO/UNAIDS recommended Voluntary Medical Male Circumcision in 2007 based on systematic review of observational studies prior to 1999 and three randomized controlled trials (RCTs). To inform updated WHO guidance, we conducted a systematic review and meta-analysis of impact of circumcision on the risk of HIV infection among heterosexual men. METHODS Studies in PubMed of HIV incidence and changes in prevalence in heterosexual men by circumcision status were identified. Pooled incidence rate ratios were computed using fixed- and random-effects meta-analysis and risk of bias was assessed using the ROBINS-I tool. RESULTS AND DISCUSSION In three RCTs, the pooled incidence ratio was 0.41 (95% CI 0.30 to 0.56), with risk difference 10 (8 to 12) fewer infections per 1000 person-years (py). Pooled incidence ratios were 0.34 (0.24 to 0.49) in two post-RCT follow-up studies, 0.29 (0.19 to 0.43) in men at high HIV risk (five cohorts), 0.48 (0.33 to 0.70) in four community-based cohorts before circumcision scale-up, and 0.56 (0.49 to 0.64) (7 [6 to 8] fewer per 1000 py) in six community-based cohorts during circumcision and antiretroviral treatment scale-up. Heterogeneity between studies was low except in men at high HIV risk. We estimated 520,000 (425,000 to 605,000) fewer infections occurred in men by end of 2018 from 22.7 million circumcisions performed since 2008 and increasing by 155,000 (125,000 to 180,000) annually if epidemic conditions remain similar. After exclusion of studies with high risk of bias and those conducted outside Africa, pooled incidence ratios were similar. There was no evidence of confounding nor changes in risk behaviour following circumcision. In post-hoc exploratory analyses we observed a trend of decreasing effectiveness of circumcision in cohorts with lower HIV incidence. CONCLUSIONS Efficacy of medical male circumcision on HIV incidence from randomized controlled trials was supported by effectiveness from observational studies in populations with diverse HIV risk and changing epidemic contexts. Voluntary Medical Male Circumcision remains an important evidence-based intervention for control of generalized HIV epidemics.
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Affiliation(s)
| | - Julia Samuelson
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - M Kate Grabowski
- Department of PathologyJohns Hopkins School of MedicineBaltimoreMDUSA
| | - Wole Ameyan
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
| | - Ronald H Gray
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
- Rakai Health Sciences ProgramKalisizoUganda
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs ProgrammesWorld Health OrganizationGenevaSwitzerland
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Yuan T, Fitzpatrick T, Ko NY, Cai Y, Chen Y, Zhao J, Li L, Xu J, Gu J, Li J, Hao C, Yang Z, Cai W, Cheng CY, Luo Z, Zhang K, Wu G, Meng X, Grulich AE, Hao Y, Zou H. Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data. LANCET GLOBAL HEALTH 2020; 7:e436-e447. [PMID: 30879508 DOI: 10.1016/s2214-109x(18)30567-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. Previous reviews investigating the role of circumcision in preventing HIV and other STIs among MSM were inconclusive. Many new studies have emerged in the past decade. To inform global prevention strategies for HIV and other STIs among MSM, we reviewed all available evidence on the associations between circumcision and HIV and other STIs among MSM. METHODS In this systematic review and meta-analysis, we searched PubMed, Web of Science, BioMed Central, Scopus, ResearchGate, Cochrane Library, Embase, PsycINFO, Google Scholar, and websites of international HIV and STI conferences for studies published before March 8, 2018. Interventional or observational studies containing original quantitative data describing associations between circumcision and incident or prevalent infection of HIV and other STIs among MSM were included. Studies were excluded if MSM could not be distinguished from men who have sex with women only. We calculated pooled odds ratios (ORs) and their 95% CIs using random-effect models. We assessed risk of bias using the Newcastle-Ottawa scale. FINDINGS We identified 62 observational studies including 119 248 MSM. Circumcision was associated with 23% reduced odds of HIV infection among MSM overall (OR 0·77, 95% CI 0·67-0·89; number of estimates [k]=45; heterogeneity I2=77%). Circumcision was protective against HIV infection among MSM in countries of low and middle income (0·58, 0·41-0·83; k=23; I2=77%) but not among MSM in high-income countries (0·99, 0·90-1·09; k=20; I2=40%). Circumcision was associated with reduced odds of herpes simplex virus (HSV) infection among MSM overall (0·84, 0·75-0·95; k=5; I2=0%) and penile human papillomavirus (HPV) infection among HIV-infected MSM (0·71, 0·51-0·99; k=3; I2=0%). INTERPRETATION We found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income. In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs. FUNDING National Natural Science Foundation of China, National Science and Technology Major Project of China, Australian National Health and Medical Research Council Early Career Fellowship, Sanming Project of Medicine in Shenzhen, National Institutes of Health, Mega Projects of National Science Research for the 13th Five-Year Plan, Doris Duke Charitable Foundation.
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Affiliation(s)
- Tanwei Yuan
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
| | | | - Nai-Ying Ko
- Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yong Cai
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingqing Chen
- Department of Biostatistics, University of Washington, Seattle, WA, USA; Vaccine and Infectious Disease Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jin Zhao
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Linghua Li
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Junjie Xu
- Key Laboratory of AIDS Immunology of the National Health and Family Planning Commission, the First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jing Gu
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Jinghua Li
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Chun Hao
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Zhengrong Yang
- Shenzhen Center for Disease Control and Prevention, Shenzhen, China
| | - Weiping Cai
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Chien-Yu Cheng
- Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Zhenzhou Luo
- Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Kechun Zhang
- Shenzhen Longhua Center for Disease Control and Prevention, Shenzhen, China
| | - Guohui Wu
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Xiaojun Meng
- Wuxi Municipal Center for Disease Control and Prevention, Wuxi, China
| | - Andrew E Grulich
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Yuantao Hao
- School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China; Shenzhen Center for Disease Control and Prevention, Shenzhen, China; School of Public Health, and Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China; Kirby Institute, University of New South Wales, Sydney, NSW, Australia.
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Barone MA, Li PS, Lee RK, Ouma D, Oundo M, Barasa M, Oketch J, Otiende P, Nyangweso N, Maina M, Kiswi N, Chirchir B, Goldstein M, Awori QD. Simplifying the ShangRing technique for circumcision in boys and men: use of the no-flip technique with randomization to removal at 7 days versus spontaneous detachment. Asian J Androl 2020; 21:324-331. [PMID: 30520424 PMCID: PMC6628734 DOI: 10.4103/aja.aja_91_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To assess safety of the no-flip ShangRing male circumcision technique and to determine clinical course and safety of spontaneous detachment (i.e., allowing the device to fall off), we conducted a case series of no-flip ShangRing circumcision combined with a randomized controlled trial of removal 7 days postcircumcision versus spontaneous detachment at two health facilities in Kenya. The primary outcome was the safety of the no-flip technique based on moderate and severe adverse events (AEs) during the procedure and through 42-day follow-up. A main secondary outcome was clinical course and safety of spontaneous detachment. Two hundred and thirty males 10 years and older underwent no-flip circumcision; 114 randomized to 7-day removal and 116 to spontaneous detachment. All circumcisions were successfully completed. Overall 5.3% (6/114) of participants in the 7-day group and 1.7% (2/116) in the spontaneous group had an AE; with no differences when compared to the 3% AE rate in historical data from African studies using the original flip technique (P = 0.07 and P = 0.79, respectively). Overall 72.4% (84/116) of participants in the spontaneous group wore the ShangRing until it detached. Among the remaining (27.6%; 32/116), the ring was removed, primarily at the participants' request, due to pain or discomfort. There was no difference in AE rates (P = 0.169), visit day declared healed (P = 0.324), or satisfaction (P = 0.371) between randomization groups. The median time to detachment was 14.0 (IQR: 7–21, range: 5–35) days. The no-flip technique and spontaneous detachment are safe, effective, and acceptable to boys and men 10 years and older. Phimosis and penile adhesions do not limit successful ShangRing circumcision with the no-flip technique.
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Affiliation(s)
| | - Philip S Li
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | - Richard K Lee
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
| | | | | | | | - Jairus Oketch
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Patrick Otiende
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Nixon Nyangweso
- Homa Bay County Teaching and Referral Hospital, Homa Bay 40300, Kenya
| | - Mary Maina
- Vipingo Health Centre, Vipingo 80119, Kenya
| | | | | | - Marc Goldstein
- Center for Male Reproductive Medicine and Surgery, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY 10065, USA
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25
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Pintye J, Baeten JM. Benefits of male circumcision for MSM: evidence for action. LANCET GLOBAL HEALTH 2020; 7:e388-e389. [PMID: 30879496 DOI: 10.1016/s2214-109x(19)30038-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA 98104, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA 98104, USA; Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA.
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26
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Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees. AIDS Behav 2020; 24:1422-1431. [PMID: 31720907 DOI: 10.1007/s10461-019-02729-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28 years (IQR 24-32 years) with 26.3% aged < 25 years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive -among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12-1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41-1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43-8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60-9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.
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Gilbertson A, Ongili B, Odongo FS, Hallfors DD, Rennie S, Kwaro D, Luseno WK. Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets. PLoS One 2019; 14:e0224548. [PMID: 31682626 PMCID: PMC6827911 DOI: 10.1371/journal.pone.0224548] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. Methods and results The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including “mobilizers”, HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. Conclusion Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.
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Affiliation(s)
- Adam Gilbertson
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | | | | | - Denise D. Hallfors
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
| | - Stuart Rennie
- UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), Chapel Hill, North Carolina, United States of America
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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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29
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Jiang ZL, Sun CW, Sun J, Shi GF, Li H. Subcutaneous tissue-sparing dorsal slit with new marking technique: A novel circumcision method. Medicine (Baltimore) 2019; 98:e15322. [PMID: 31008987 PMCID: PMC6494260 DOI: 10.1097/md.0000000000015322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Circumcision is a very common surgical procedure that is performed for medical and traditional purposes in the world. However, many technical of circumcision is needed to improve. Thus, this study introduced a novel method of circumcision that is a refined version of the sleeve technique, termed subcutaneous tissue sparing dorsal slit with new marking, and evaluated the safety and efficacy of this novel method of circumcision.The randomized clinical trial included 93 adult patients with redundant foreskin or phimosis treated from May 2015 to March 2017. Patients were randomly divided into the novel circumcision method (n = 45) or conventional dissection (n = 48). The groups were compared regarding rates of intraoperative hemorrhage, operative time, pain, healing, satisfaction with penis appearance, and relevant adverse events.No patient suffered any obvious complication. Compared with the patients given conventional dissection, the patients who underwent the new surgical device experienced significantly less wound healing time, scar width, and recovery time (P <.05). The new method resulted in greater intraoperative bleeding volume and surgical time (P <.05). The rate of satisfaction with appearance of the penis was significantly higher in the group treated with the novel technique. In addition, the cost of surgery of these 2 methods was similar.Based on the above research, we found that subcutaneous tissue-sparing dorsal slit with new marking technique was an effective and safe procedure for circumcision, and deserved further application in clinical practice.
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Affiliation(s)
| | - Cheng-Wen Sun
- Department of Urology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Jian Sun
- Department of Urology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | | | - Hu Li
- Department of Plastic Surgery
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McGillen JB, Stover J, Klein DJ, Xaba S, Ncube G, Mhangara M, Chipendo GN, Taramusi I, Beacroft L, Hallett TB, Odawo P, Manzou R, Korenromp EL. The emerging health impact of voluntary medical male circumcision in Zimbabwe: An evaluation using three epidemiological models. PLoS One 2018; 13:e0199453. [PMID: 30020940 PMCID: PMC6051576 DOI: 10.1371/journal.pone.0199453] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 12/26/2022] Open
Abstract
Background Zimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future. Methods Three mathematical models describing Zimbabwe’s HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017. Results The VMMC program averted 2,600–12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400–69,800 infections (2.3–5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000–171,000 infections (10–13% of all new infections) by 2030, costing $2,100–3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction. Conclusions VMMC can substantially impact Zimbabwe’s HIV epidemic in the coming years; this investment will save costs in the longer term.
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Affiliation(s)
- Jessica B. McGillen
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - John Stover
- Avenir Health, Glastonbury, Connecticut, United States of America
| | - Daniel J. Klein
- Institute for Disease Modeling, Seattle, Washington, United States of America
| | | | - Getrude Ncube
- Ministry of Health and Child Welfare, Harare, Zimbabwe
| | | | | | | | - Leo Beacroft
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | | | - Rumbidzai Manzou
- Zimbabwe Country Office, Clinton Health Access Initiative, Harare, Zimbabwe
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Schenker I. Cutting-Edge Success in Preventing Heterosexual HIV Transmission in Africa: Voluntary Medical Male Circumcision Has Reached 15 Million Men. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2018; 30:232-242. [PMID: 29969309 DOI: 10.1521/aeap.2018.30.3.232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Male circumcision is a minor surgery performed for religious and medical reasons. Three randomized clinical trials demonstrated it could reduce heterosexual HIV transmission from infected females to males by over 60%, paving the way in 2006 for multinational efforts to circumcise 27 million men in sub-Saharan Africa by 2021. It is estimated that by 2030 male circumcision will avert at least 500,000 HIV infections in Africa, saving lives and budgets. Voluntary medical male circumcision (VMMC) of adults and adolescents has challenged policy makers, implementers, funders, and civil society in bringing surgery to the frontline of HIV prevention. Five key challenges are discussed: policy, clinical, demand, supply, and scaling up. A unique Israel-Senegal-South Africa collaboration, which enhanced high-volume (100 VMMCs per day) and high-quality (less than 2% minor adverse events) procedures, is described, highlighting VMMC as one of the most impressive public health collaborative interventions in HIV/AIDS prevention globally.
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