The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa

Abstract

BackgroundA randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmission of HIV from women to men by 60% (32%−76%; 95% CI) offering an intervention of proven efficacy for reducing the sexual spread of HIV. We explore the implications of this finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan Africa.Methods and FindingsUsing dynamical simulation models we consider the impact of MC on the relative prevalence of HIV in men and women and in circumcised and uncircumcised men. Using country level data on HIV prevalence and MC, we estimate the impact of increasing MC coverage on HIV incidence, HIV prevalence, and HIV-related deaths over the next ten, twenty, and thirty years in sub-Saharan Africa. Assuming that full coverage of MC is achieved over the next ten years, we consider three scenarios in which the reduction in transmission is given by the best estimate and the upper and lower 95% confidence limits of the reduction in transmission observed in the RCT.MC could avert 2.0 (1.1−3.8) million new HIV infections and 0.3 (0.1−0.5) million deaths over the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7 (1.9−7.5) million new HIV infections and 2.7 (1.5−5.3) million deaths, with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa. We show that a) MC will increase the proportion of infected people who are women from about 52% to 58%; b) where there is homogenous mixing but not all men are circumcised, the prevalence of infection in circumcised men is likely to be about 80% of that in uncircumcised men; c) MC is equivalent to an intervention, such as a vaccine or increased condom use, that reduces transmission in both directions by 37%.ConclusionsThis analysis is based on the result of just one RCT, but if the results of that trial are confirmed we suggest that MC could substantially reduce the burden of HIV in Africa, especially in southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years.

Male Circumcision: Implications for Women as Sexual Partners and Parents

“…Already mathematical modelling suggests that in the medium term the proportion of people living with HIV in sub-Saharan Africa who are women may rise as male circumcision programmes are scaled up in high HIV prevalence settings, due to the lag time for indirect effects for women to be felt. 45 The fact that, other than an increase in the number of sexual acts by the circumcised arm in the Orange Farm study, risk enhancement was not striking in any of the three trials is not reassuring enough. None of the trial participants were told that male circumcision provided any degree of protection against HIV -in fact they were told that the trials were being conducted to find this out.…”

Male Circumcision and HIV Prevention: Is There Really Enough of the Right Kind of Evidence?

“…The predictive modelling provided so far suggests potential effectiveness by using efficacy figures only, 29 and usually using the Orange Farm figure rather than the lower average of all three trials. This is not strong when compared with male condoms, with efficacy of 80-90%.…”

La circoncision

“…En effet, au Zimbabwe, Swaziland, Botswana, Afrique du Sud, Lesotho et Namibie, où la prévalence actuelle du VIH chez les adultes est supérieure à 20 %, le taux d'hommes circoncis est inférieur à 40 %. Au Bénin, Sénégal, Cameroun, Kenya et en République Démocratique du Congo, où la prévalence actuelle du VIH chez les adultes est inférieure à 6 %, le taux d'hommes circoncis est supérieur à 80 % [1,4]. Ces constatations coïncident avec les données d'une étude écologique, publiée en 1989 [5], qui établissait à l'échelle des populations africaines une corrélation entre le taux de circoncision et la prévalence du VIH.…”

“…La généralisation de la circoncision en Afrique subsaharienne permettrait d'éviter de 1 à 4 millions de nouvelles infections et de 200 000 à 500 000 décès dans les 10 premières années puis de 2 à 8 millions de nouvelles infections et de 2 à 5 millions de décès supplémentaires au terme des 10 années suivantes [4]. Son impact serait donc considérable.…”