Abstract
BackgroundRecent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-to-male transmission risk by 60% or more. However, the public health impact of large-scale male circumcision programs for HIV prevention is unclear.MethodsTwo mathematical models were examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya.ResultsIn both models, male circumcision programs resulted in large and sustained declines in HIV prevalence over time among both men and women. Men benefited somewhat more than women, but prevalence among women was also reduced substantially. With 80% male circumcision uptake, the reductions in prevalence ranged from 45% to 67% in the two "countries", and with 50% uptake, from 25% to 41%. It would take over a decade for the intervention to reach its full effect.ConclusionLarge-scale uptake of male circumcision services in African countries with high HIV prevalence, and where male circumcision is not now routinely practised, could lead to substantial reductions in HIV transmission and prevalence over time among both men and women.
Highlights
Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-tomale transmission risk by 60% or more
First a value Λf is assumed and the equation for Im(x) is solved and Λm calculated. This value is used to solve the equation for Im(x), and this process is continued until convergence is Compartmental model As some of the assumptions of the above model are questionable, we explored the effects of male circumcision using a compartmental model [33], originally developed to explore the effects of an HIV vaccine and other interventions on the HIV epidemic[22,34,35,36]
It was assumed that per-partnership male-tofemale transmission was 2.5 times more efficient than female-to-(uncircumcised) male transmission, and that male circumcision (MC) has a 60% protective effect
Summary
Recent clinical trials in Africa, in combination with several observational epidemiological studies, have provided evidence that male circumcision can reduce HIV female-tomale transmission risk by 60% or more. The protective effects of circumcision were slightly less than those found in the Orange Farm trial, the results of these more recent trials are clearly consistent with the South African trial, making the case for a protective effect of MC very strong Together they appear to constitute overwhelming evidence that male circumcision can reduce female-to-male HIV transmission by 45–65% in sub-Saharan Africa. Another Rakai trial will analyze the impact of male circumcision on male-to-female HIV transmission. Some evidence that MC reduces male-to-female transmission, especially when the male has low viral load, was provided by a study in Rakai on discordant couples[18,19]
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