Circumcision For Prevention Research Articles

Changes in Male Circumcision Prevalence and Risk Compensation in the Kisumu, Kenya Population, 2008-2013.

Three randomized controlled trials showed that voluntary medical male circumcision (VMMC) reduces the risk of female-to-male HIV transmission by approximately 60%. However, data from communities where VMMC programs have been implemented are needed to assess changes in circumcision prevalence and whether men and women compensate for perceived reductions in risk by increasing their HIV risk behaviors. Scale-up of free VMMC began in Kisumu, Kenya in 2008. Between 2009 and 2013, a sequence of 3 unlinked cross-sectional surveys were conducted. All individuals 15-49 years of age residing in randomly selected households were interviewed and offered HIV testing. Male circumcision status was confirmed by examination. Design-adjusted bivariate comparisons and multivariable analyses were used for statistical inference. The prevalence of male circumcision increased from 32% (95% CI: 26% to 38%) in 2009 to 60% (95% CI: 56% to 63%) in 2013. The adjusted prevalence ratio of HIV and genital ulcer disease in circumcised compared with uncircumcised men was 0.48 (95% CI: 0.36 to 0.66) and 0.51 (95% CI: 0.37 to 0.69), respectively. There was no association between circumcision status and sexual behaviors, HIV knowledge, or indicators of risk perception. The conditions necessary for the VMMC program to have a significant public health impact are present in Kisumu, Kenya. Between 2009 and 2013, circumcision prevalence increased from 30% to 60%; HIV prevalence in circumcised men was half that of uncircumcised men, and there was no or minimal sexual risk compensation.

Identification of Key Beliefs Explaining Male Circumcision Motivation Among Adolescent Boys in Zimbabwe: Targets for Behavior Change Communication.

Male circumcision (MC) significantly reduces HIV acquisition among men, leading WHO/UNAIDS to recommend high HIV and low MC prevalence countries circumcise 80% of adolescents and men age 15-49. Despite significant investment to increase MC capacity only 27% of the goal has been achieved in Zimbabwe. To increase adoption, research to create evidence-based messages is greatly needed. The Integrated Behavioral Model (IBM) was used to investigate factors affecting MC motivation among adolescents. Based on qualitative elicitation study results a survey was designed and administered to a representative sample of 802 adolescent boys aged 13-17 in two urban and two rural areas in Zimbabwe. Multiple regression analysis found all six IBM constructs (2 attitude, 2 social influence, 2 personal agency) significantly explained MC intention (R2=0.55). Stepwise regression analysis of beliefs underlying each IBM belief-based construct found 9 behavioral, 6 injunctive norm, 2 descriptive norm, 5 efficacy, and 8 control beliefs significantly explained MC intention. A final stepwise regression of all the significant IBM construct beliefs identified 12 key beliefs best explaining intention. Similar analyses were carried out with subgroups of adolescents by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group. This study demonstrates the application of theory-driven research to identify evidence-based targets for the design of effective MC messages for interventions to increase adolescents' motivation. Incorporating these findings into communication campaigns is likely to improve demand for MC.

Beliefs and Prevalence of Female Genital Circumcision among Pregnant Women Attending Ante-natal Clinic in a Mission Hospital in Uyo, Akwa Ibom State, Nigeria

Beliefs and Prevalence of Female Genital Circumcision among Pregnant Women Attending Ante-natal Clinic in a Mission Hospital in Uyo, Akwa Ibom State, Nigeria

Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection

Aim: To critically evaluate data and arguments by Van Howe defending his stance opposing male circumcision (MC), in particular his meta-regression analyses evaluating the ability of MC to reduce HIV infection risk in heterosexual populations within and outside Africa. Methods: We performed metaregression analysis of log odds of HIV infection between uncircumcised and circumcised men using a single covariate (MC prevalence) in the meta-regression model involving the metareg package in STATA 13 for 103 populations worldwide and for populations within Africa. The meta-regression of log odds and MC prevalence was fitted to a line, as were empirical Bayes estimates resulting from post-estimation. Results: Our critical evaluation of Van Howe’s arguments attempting to undermine the scientific evidence in support of the benefits of MC in protection of men against HIV during heterosexual intercourse, as well as other infections and conditions, together with his use of statistics to support his beliefs, revealed serious flaws, obfuscation and missing data. We therefore performed our own meta-regression analysis using a trivariate model. Doing so revealed that for MC prevalences of 50%, 75% and 100% for general populations within Africa, odds ratios for HIV risk in uncircumcised vs. circumcised men were 1.35, 1.58 and 1.85, respectively. Our meta-regression analysis of data for all countries yielded similar findings. For a general population outside Africa with 100% MC prevalence, OR was 1.5. Van Howe failed to acknowledge that since MC prevalence in US whites (91%) and blacks (76%) exceeds 75% his results support MC having a protective effect in those population groups. Conclusions: The protective effect of MC against HIV infection during heterosexual intercourse applies to populations both within and outside Africa. The debate engineered by MC opponents, and led by Van Howe, now appears to have run its course. The scientific evidence has prevailed.

Geographic coverage of male circumcision in western Kenya.

Voluntary Medical Male Circumcision (VMMC) for human immunodeficiency virus (HIV) prevention has scaled up rapidly among young men in western Kenya since 2008. Whether the program has successfully reached uncircumcised men evenly across the region is largely unknown. Using data from two cluster randomized surveys from the 2008 and 2014 Kenyan Demographic Health Survey (KDHS), we mapped the continuous spatial distribution of circumcised men by age group across former Nyanza Province to identify geographic areas where local circumcision prevalence is lower than the overall, regional prevalence. The prevalence of self-reported circumcision among men 15 to 49 across six counties in former Nyanza Province increased from 45.6% (95% CI = 33.2–58.0%) in 2008 to 71.4% (95% CI = 67.4–75.0%) in 2014, with the greatest increase in men 15 to 24 years of age, from 40.4% (95% CI = 27.7–55.0%) in 2008 to 81.6% (95% CI = 77.2–85.0%) in 2014. Despite the dramatic scale-up of VMMC in western Kenya, circumcision coverage in parts of Kisumu, Siaya, and Homa Bay counties was lower than expected (P < 0.05), with up to 50% of men aged 15 to 24 still uncircumcised by 2014 in some areas. The VMMC program has proven successful in reaching a large population of uncircumcised men in western Kenya, but as of 2014, pockets of low circumcision coverage still existed. Closing regional gaps in VMMC prevalence to reach 80% coverage may require targeting specific areas where VMMC prevalence is lower than expected.

Obtaining a male circumcision prevalence rate of 80% among adults in a short time: An observational prospective intervention study in the Orange Farm township of South Africa.

World Health Organization recommends a target for the male circumcision prevalence rate of 80%. This rate will have a substantial impact on the human immunodeficiency virus-acquired immunodeficiency syndrome epidemic in Eastern and Southern Africa. The objective of the study was to assess whether an innovative intervention can lead to an increased voluntary male medical circumcision (VMMC) uptake among adults in a short time. This prospective observational study of a demand generation intervention was conducted in the township of Orange Farm (South Africa) in August to November 2015. In this community male circumcision prevalence rate among adults was stable between 2010 and 2015 at 55% and 57%, despite regular VMMC campaigns at community level and the presence of a VMMC clinic that offered free VMMC. The intervention took place in a random sample of 981 households where 522 men aged 18 to 49 years accepted to participate in the study. Among the 226 uncircumcised men, 212 accepted to be enrolled in the intervention study. A personal male circumcision adviser trained in interpersonal communication skills was assigned to each uncircumcised participant. The male circumcision advisers were trained to explain the risks and benefits of VMMC, and to discuss 24 possible reasons given by men for not being circumcised. Participants were then followed for 9 weeks. Each participant had a maximum of 3 motivational interviews at home. Participants who decided to be circumcised received financial compensation for their time equivalent to 2.5 days of work at the minimum South African salary rate. Among the 212 uncircumcised men enrolled in the intervention, 69.8% (148/212; 95% confidence interval [CI]; 63.4%–75.7%) agreed to be circumcised, which defines the uptake of the intervention. The male circumcision prevalence rate of the sample increased from 56.7% (296/522) to 81.4% (425/522; 77.9%–84.6%), P < 0.001, corresponding to a relative increase of 43.6% (95% CI: 35.4%–53.7%). The reported reasons for accepting circumcision were motivational interviews with the male circumcision adviser (83.1%), and time compensation (39.4%).Increased uptake of VMMC uptake can be obtained in a short time among adult males but requires an intense intervention centered on uncircumcised men at an individual level and time compensation.

Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Strategic Demand Creation Prioritizing Subpopulations by Age and Geography.

Over 11 million voluntary medical male circumcisions (VMMC) have been performed of the projected 20.3 million needed to reach 80% adult male circumcision prevalence in priority sub-Saharan African countries. Striking numbers of adolescent males, outside the 15-49-year-old age target, have been accessing VMMC services. What are the implications of overall progress in scale-up to date? Can mathematical modeling provide further insights on how to efficiently reach the male circumcision coverage levels needed to create and sustain further reductions in HIV incidence to make AIDS no longer a public health threat by 2030? Considering ease of implementation and cultural acceptability, decision makers may also value the estimates that mathematical models can generate of immediacy of impact, cost-effectiveness, and magnitude of impact resulting from different policy choices. This supplement presents the results of mathematical modeling using the Decision Makers’ Program Planning Tool Version 2.0 (DMPPT 2.0), the Actuarial Society of South Africa (ASSA2008) model, and the age structured mathematical (ASM) model. These models are helping countries examine the potential effects on program impact and cost-effectiveness of prioritizing specific subpopulations for VMMC services, for example, by client age, HIV-positive status, risk group, and geographical location. The modeling also examines long-term sustainability strategies, such as adolescent and/or early infant male circumcision, to preserve VMMC coverage gains achieved during rapid scale-up. The 2016–2021 UNAIDS strategy target for VMMC is an additional 27 million VMMC in high HIV-prevalence settings by 2020, as part of access to integrated sexual and reproductive health services for men. To achieve further scale-up, a combination of evidence, analysis, and impact estimates can usefully guide strategic planning and funding of VMMC services and related demand-creation strategies in priority countries. Mid-course corrections now can improve cost-effectiveness and scale to achieve the impact needed to help turn the HIV pandemic on its head within 15 years.

A cut above the rest? Private anthropometrics in marriage markets

A large body of economic research suggests that publicly observable anthropometric characteristics affect labor and marriage market outcomes. Private anthropometrics may not affect these outcomes. We examine male circumcision in marriage markets in Zambia. Our analysis reveals substantial variation across local marriage markets in circumcision prevalence relative to preference for circumcised partners, as well as excess aggregate demand for circumcised males. Regression estimates suggest a marriage market premium of approximately one-half to one year of additional schooling for matching with a partner of preferred anthropometric type in a local marriage market with excess demand for that anthropometric characteristic.

Sequential Cross-Sectional Surveys in Orange Farm, a Township of South Africa, Revealed a Constant Low Voluntary Medical Male Circumcision Uptake among Adults despite Demand Creation Campaigns and High Acceptability.

BackgroundWHO recommends a male circumcision (MC) prevalence rate higher than 80% to have a substantial impact on the HIV-AIDS epidemic in Eastern and Southern Africa. Orange Farm, a township in South Africa, has a free-for-service voluntary medical male circumcision (VMMC) clinic in operation since 2008. Following an intense campaign from 2008 to 2010, MC prevalence rate increased to 55.4% (ANRS-12126). Ongoing and past VMMC campaigns focused on youths, through school talks, and adults at a community level. The main objective of the study was to assess the change in MC prevalence rate among adults aged 18–19 and 18–49 years in the past 5 years.MethodsA cross-sectional survey (ANRS-12285) was conducted among a random sample of 522 adult men in 2015. MC status and characteristics of participants were collected through a genital examination and a face-to-face questionnaire.ResultsMC prevalence rate among young adult men aged 18–19 years increased markedly from 61.2% (95%CI: 57.4% to 65.0%) in 2010 to 87.5% (76.0% to 94.6%) in 2015 (p<0.001). In the same period, among men aged 18–49 years, MC prevalence rate varied slightly from 55.4% (53.6% to 57.1%) to 56.7% (52.4% to 60.9%). In 2015, 84.9% (79.2% to 89.5%) of uncircumcised adult men reported that they were willing to be circumcised. However, we estimated that only 4.6% (11/237; 2.5% to 7.9%) of the uncircumcised men underwent circumcision in 2015, despite 117/185 (63.2%; 95%CI: 56.1% to 69.9%) who reported that they were definitely willing to become circumcised.ConclusionsIn Orange Farm, VMMC campaigns were successful among the youth and led to a sufficiently high MC prevalence rate to have a substantial impact in the future on the HIV-AIDS epidemic. However, despite high acceptability and a free VMMC service, VMMC campaigns since 2010 have failed to increase MC prevalence rate among adults to above 80%. These campaigns should be revisited.

Determinants of Poor Uptake of Voluntary Medical Male Circumcision by Males Aged 18-49 in Rural Zimbabwe. The Case of Mashonaland West Province

Uptake of VMMC services has remained low in Mashonaland West province with a total of 10,593 males having been circumcised since 2013 (MoHCC, 2013), with a percentage uptake of 7.2%, a figure way off the 80% target of circumcising 145, 646 by 2017 in the province. This low performance was transcending down to all districts which are implementing the VMMC programme. This study sought come up with determinates of poor uptake of the VMMC programme in Mashonaland West. An analytical cross sectional study design was used, where clients were drawn into the study and their circumcision status assessed at the same with measurement of the determinants variables to VMMC uptake. The study was carried out in Mashonaland West Province. Clients were interviewed from four of the seven districts of the province. 8 Key Informant interviews were conducted and an observation checklist was administered in 3 sites. Both circumcised and uncircumcised men aged 18-49 years found in the enumeration area during the course of the research, who consented to be enrolled in the study were included in the survey. Males below the age of 18 years and those above 49 years were excluded. Men residing outside the enumerated area were excluded. The sample size achieved by this survey was 718 with a response rate of 98.1%. Multistage sampling was employed with purposive sampling being utilized in the selection of 4 districts with the lowest Male Circumcision coverage which were Hurungwe and Mhondoro/Ngezi and the highest coverage in Sanyati and Kariba and then random selection of urban and rural wards in each respective district. Each district provided 25% of the sample size (175 men per district). The researchers randomly select one ward from the urban and one from the rural within each of the respective districts making up 4 rural and 4 urban wards to be randomly selected into the study. Then from each ward selected randomly systematic selection of households was done. A register of the number of households kept by the Town Council/Village Heads was used as a sampling frame and the sampling interval was calculated based on the number of households. The prevalence of male circumcision in Mashonaland West Province was found to be 12.3% in this study. Men in rural areas were less likely to be circumcised, indeed residing in rural areas was protective as men in rural areas were 0.83 less likely to be circumcised however this was not statistically significant [POR=0.83 (0.53-1.31) P-Value=0.49]. Educational level was found to be an effect modifier with those with none/primary education 3 times more likely to be circumcised [POR=3.00 95% CI (0.65-13.89)] compared to those that had attained secondary/tertiary level were 7.5 more times more likely to be circumcised after undergoing HIV testing and counselling [POR=7.5 95% CI (3.64-15.46)]. Church’s as sources of information were 15.5 times more likely to influence men to be circumcised [AOR=15.5 95%CI(3.8-63.2) P-value=0.00]. Those that failed initially to access MC services were 3.93 more times likely to be circumcised [AOR=3.93 95% CI (1.2-12.83) P-value=0.02]. Those referred for MC by counsellors were 7.17 time more likely to be circumcised [AOR=7.17 95%CI (3.34-15.41) P-value=0.00]. Men that indicated it reduces chances of penile cancer as a benefit were 3.35 times more likely to be circumcised compare to those that did not. [AOR=3.35 95% CI (1.67-6.7) P-value=0.00]. The messaging of male circumcision should take in cognisance the less educated population. There is need to decentralise the procedure to facilities in the periphery areas for easy access, and training of more nurses to ensure the procedure is not only limited to major hospitals alone. Thus need to accelerate task shifting allowing nurses to conduct the procedure be it surgical or Prepex device. They is need to design messages that target traditional/religious circumcising communities and specific messages for non-circumcising communities. Need to strengthen integration VMMC with HIV testing and counselling referral system. Need to give more emphasis of MC benefits such as reducing penile cancer, improved hygiene and cervical cancer for the 18-49 age groups to uptake MC.

Voluntary Medical Male Circumcision for HIV Prevention in Malawi: Modeling the Impact and Cost of Focusing the Program by Client Age and Geography.

BackgroundIn 2007, the World Health Organization (WHO) recommended scaling up voluntary medical male circumcision (VMMC) in priority countries with high HIV prevalence and low male circumcision (MC) prevalence. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 5.8 million males had undergone VMMC by the end of 2013. Implementation experience has raised questions about the need to refocus VMMC programs on specific subpopulations for the greatest epidemiological impact and programmatic effectiveness. As Malawi prepared its national operational plan for VMMC, it sought to examine the impacts of focusing on specific subpopulations by age and region.MethodsWe used the Decision Makers’ Program Planning Toolkit, Version 2.0, to study the impact of scaling up VMMC to different target populations of Malawi. National MC prevalence by age group from the 2010 Demographic and Health Survey was scaled according to the MC prevalence for each district and then halved, to adjust for over-reporting of circumcision. In-country stakeholders advised a VMMC unit cost of $100, based on implementation experience. We derived a cost of $451 per patient-year for antiretroviral therapy from costs collected as part of a strategic planning exercise previously conducted in- country by UNAIDS.ResultsOver a fifteen-year period, circumcising males ages 10–29 would avert 75% of HIV infections, and circumcising males ages 10–34 would avert 88% of infections, compared to the current strategy of circumcising males ages 15–49. The Ministry of Health’s South West and South East health zones had the lowest cost per HIV infection averted. Moreover, VMMC met WHO’s definition of cost-effectiveness (that is, the cost per disability-adjusted life-year [DALY] saved was less than three times the per capita gross domestic product) in all health zones except Central East. Comparing urban versus rural areas in the country, we found that circumcising men in urban areas would be both cost-effective and cost-saving, with a VMMC cost per DALY saved of $120 USD and with 15 years of VMMC implementation resulting in lifetime HIV treatment costs savings of $331 million USD.ConclusionsBased on the age analyses and programmatic experience, Malawi’s VMMC operational plan focuses on males ages 10–34 in all districts in the South East and South West zones, as well as Lilongwe (an urban district in the Central zone). This plan covers 14 of the 28 districts in the country.

Voluntary Medical Male Circumcision for HIV Prevention in Swaziland: Modeling the Impact of Age Targeting.

BackgroundVoluntary medical male circumcision (VMMC) for HIV prevention has been a priority for Swaziland since 2009. Initially focusing on men ages 15–49, the Ministry of Health reduced the minimum age for VMMC from 15 to 10 years in 2012, given the existing demand among 10- to 15-year-olds. To understand the implications of focusing VMMC service delivery on specific age groups, the MOH undertook a modeling exercise to inform policy and implementation in 2013–2014.Methods and FindingsThe impact and cost of circumcising specific age groups were assessed using the Decision Makers’ Program Planning Tool, Version 2.0 (DMPPT 2.0), a simple compartmental model. We used age-specific HIV incidence from the Swaziland HIV Incidence Measurement Survey (SHIMS). Population, mortality, births, and HIV prevalence were imported from a national Spectrum/Goals model recently updated in consultation with country stakeholders. Baseline male circumcision prevalence was derived from the most recent Swaziland Demographic and Health Survey. The lowest numbers of VMMCs per HIV infection averted are achieved when males ages 15–19, 20–24, 25–29, and 30–34 are circumcised, although the uncertainty bounds for the estimates overlap. Circumcising males ages 25–29 and 20–24 provides the most immediate reduction in HIV incidence. Circumcising males ages 15–19, 20–24, and 25–29 provides the greatest magnitude incidence reduction within 15 years. The lowest cost per HIV infection averted is achieved by circumcising males ages 15–34: $870 U.S. dollars (USD).ConclusionsThe potential impact, cost, and cost-effectiveness of VMMC scale-up in Swaziland are not uniform. They vary by the age group of males circumcised. Based on the results of this modeling exercise, the Ministry of Health’s Swaziland Male Circumcision Strategic and Operational Plan 2014–2018 adopted an implementation strategy that calls for circumcision to be scaled up to 50% coverage for neonates, 80% among males ages 10–29, and 55% among males ages 30–34.

Modeling the Impact of Uganda's Safe Male Circumcision Program: Implications for Age and Regional Targeting.

BackgroundUganda aims to provide safe male circumcision (SMC) to 80% of men ages 15–49 by 2016. To date, only 2 million men have received SMC of the 4.2 million men required. In response to age and regional trends in SMC uptake, the country sought to re-examine its targets with respect to age and subnational region, to assess the program’s progress, and to refine the implementation approach.Methods and FindingsThe Decision Makers’ Program Planning Tool, Version 2.0 (DMPPT 2.0), was used in conjunction with incidence projections from the Spectrum/AIDS Impact Module (AIM) to conduct this analysis. Population, births, deaths, and HIV incidence and prevalence were used to populate the model. Baseline male circumcision prevalence was derived from the 2011 AIDS Indicator Survey. Uganda can achieve the most immediate impact on HIV incidence by circumcising men ages 20–34. This group will also require the fewest circumcisions for each HIV infection averted. Focusing on men ages 10–19 will offer the greatest impact over a 15-year period, while focusing on men ages 15–34 offers the most cost-effective strategy over the same period. A regional analysis showed little variation in cost-effectiveness of scaling up SMC across eight regions. Scale-up is cost-saving in all regions. There is geographic variability in program progress, highlighting two regions with low baseline rates of circumcision where additional efforts will be needed.ConclusionFocusing SMC efforts on specific age groups and regions may help to accelerate Uganda’s SMC program progress. Policy makers in Uganda have already used model outputs in planning efforts, proposing males ages 10–34 as a priority group for SMC in the 2014 application to the Global Fund’s new funding model. As scale-up continues, the country should also consider a greater effort to expand SMC in regions with low MC prevalence.

Scaling Up and Sustaining Voluntary Medical Male Circumcision: Maintaining HIV Prevention Benefits.

The changes in the AIDS financing landscape and in the architecture of health financing under the post-2015 sustainable development agenda have highlighted the need to ensure that HIV and AIDS programs continue to yield health benefits regardless of funding sources, implementation mechanisms, and governance structure. Further highlighting this need are the changes in the nature of institutions implementing HIV services and the number of people who will need HIV services to end AIDS by 2030. Thus, donors in the international development arena have increasingly mandated that the interventions of their funded programs be sustainable. Yet sustainability—sometimes called institutionalization1—can mean different things in different contexts. According to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), “a sustainable response can only be achieved when the epidemic is under control and no longer expanding and the response is constantly adapting to the evolution of the epidemic to maintain control.”2 In the context of voluntary medical male circumcision (VMMC), this article defines a sustainable VMMC program as one whose local stakeholders maintain high circumcision prevalence after the initial scale-up—generally by incorporating either early infant male circumcision (EIMC), early adolescent VMMC, or both, into routine newborn and adolescent service delivery systems.3 (EIMC is performed during the first 60 days of an infant’s life and early adolescent VMMC between the ages of 10 and 14.) In a sustainable VMMC program, local stakeholders maintain high circumcision prevalence by incorporating EIMC, early adolescent voluntary medical male circumcision, or both into newborn and adolescent service delivery.

Providing a conceptual framework for HIV prevention cascades and assessing feasibility of empirical measurement with data from east Zimbabwe: a case study

SummaryBackgroundThe HIV treatment cascade illustrates the steps required for successful treatment and is a powerful advocacy and monitoring tool. Similar cascades for people susceptible to infection could improve HIV prevention programming. We aim to show the feasibility of using cascade models to monitor prevention programmes.MethodsConceptual prevention cascades are described taking intervention-centric and client-centric perspectives to look at supply, demand, and efficacy of interventions. Data from two rounds of a population-based study in east Zimbabwe are used to derive the values of steps for cascades for voluntary medical male circumcision (VMMC) and for partner reduction or condom use driven by HIV testing and counselling (HTC).FindingsIn 2009 to 2011 the availability of circumcision services was negligible, but by 2012 to 2013 about a third of the population had access. However, where it was available only 12% of eligible men sought to be circumcised leading to an increase in circumcision prevalence from 3·1% to 6·9%. Of uninfected men, 85·3% did not perceive themselves to be at risk of acquiring HIV. The proportions of men and women tested for HIV increased from 27·5% to 56·6% and from 61·1% to 79·6%, respectively, with 30·4% of men tested self-reporting reduced sexual partner numbers and 12·8% reporting increased condom use.InterpretationPrevention cascades can be populated to inform HIV prevention programmes. In eastern Zimbabwe programmes need to provide greater access to circumcision services and the design and implementation of associated demand creation activities. Whereas, HTC services need to consider how to increase reductions in partner numbers or increased condom use or should not be considered as contributing to prevention services for the HIV-negative adults.FundingWellcome Trust and Bill & Melinda Gates Foundation.

Effectiveness of combination packages for HIV-1 prevention in sub-Saharan Africa depends on partnership network structure: a mathematical modelling study

ObjectivesCombination packages for HIV prevention can leverage the effectiveness of biomedical and behavioural elements to lower disease incidence with realistic targets for individual and population risk reduction. We investigated how...

The Global Epidemiology of Syphilis in the Past Century - A Systematic Review Based on Antenatal Syphilis Prevalence.

BackgroundHow can we explain the uneven decline of syphilis around the world following the introduction of penicillin? In this paper we use antenatal syphilis prevalence (ASP) to investigate how syphilis prevalence varied worldwide in the past century, and what risk factors correlate with this variance.Methods1) A systematic review using PubMed and Google Scholar was conducted to identify countries with published data relating to ASP estimates from before 1952 until the present. Eleven countries were identified (Canada, Denmark, Finland, India, Japan, Norway, Singapore, South Africa, United States of America (USA), United Kingdom (UK) and Zimbabwe). The ASP epidemic curve for each population was depicted graphically. In South Africa and the USA, results are reported separately for the black and white populations. 2) National antenatal syphilis prevalence estimates for 1990 to 1999 and 2008 were taken from an Institute for Health Metrics and Evaluation database on the prevalence of syphilis in low risk populations compiled for the Global Burden of Diseases study and from a recent review paper respectively. National ASPs were depicted graphically and regional median ASPs were calculated for both time periods. 3) Linear regression was used to test for an association between ASP in 1990–1999 and 2008 and four risk factors (efficacy of syphilis screening/treatment, health expenditure, GDP per capita and circumcision prevalence). WHO world regions were included as potential explanatory variables.ResultsIn most populations, ASP dropped to under 1% before 1960. In Zimbabwe and black South Africans, ASP was high in the pre-penicillin period, dropped in the post-penicillin period, but then plateaued at around 6% until the end of the 20th century when ASP dropped to just above 1%. In black Americans, ASP declined in the post penicillin period, but plateaued at 3–5% thereafter. ASP was statistically significantly higher in sub-Saharan Africa in 1990–1999 and 2008 than in the other world regions (P < 0.001). On multivariate analysis in both time periods, ASP was only associated with residence in sub-Saharan Africa.ConclusionsFurther research is necessary to elucidate the reasons for the higher prevalence of syphilis in sub-Saharan Africa.

Circumcision is a primary preventive against HIV infection: Critique of a contrary meta-regression analysis by Van Howe

ABSTRACTA meta-analysis by Van Howe of 109 populations confirms the well-known association of male circumcision (MC) with reduced HIV prevalence. He then performed meta-regression adjusting for location, risk and MC prevalence. When one or two of these adjustments in combination were applied MC appeared protective, but when all three were introduced the association remained significant in high-risk populations, but not in general populations within Africa with a hypothetical MC prevalence of <25% or elsewhere with hypothetical MC prevalence of <75%. However, many MC prevalence values given differed from those reported in references cited (including all US studies). This and other problems invalidate his adjustments for MC prevalence, undermining most of his meta-regression results. Meta-regression is a highly sophisticated statistical tool and is prone to error if not applied correctly. The study contained a high risk of bias arising from confounding. We also question his use of crude, rather than adjusted, odds ratios and his inclusion of unpublished data, so precluding replication by others. Flawed statistics, opaque presentation of results and inclusion of previously repudiated arguments downplaying a role for MC in HIV prevention programmes should lead readers to be sceptical of the findings and conclusions of Van Howe’s study.

Commentary: Are geographical "cold spots" of male circumcision driving differential HIV dynamics in Tanzania?

Availability of geographic information systems and the expansion of methodological approaches in geospatial analysis over the past decade have made studies focusing on the spatial distributions of disease increasingly more common (1). These types of investigations are valuable in identifying locations with unexpectedly high or low rates of disease. They also allow for the testing of hypotheses that look to find relationships between the prevalence of a disease and environmental factors. In practice, these studies are known as ecological studies and are often conducted using secondary data. They are efficient and cost-effective and allow for the exploration and generation of hypotheses; however, they are not able to provide a strong cause-and-effect relationship between a set of variables. It is often suggested that the findings from ecological studies require careful interpretation and consideration of their limitations such as ecological fallacy (2). Cuadros et al. recently suggested a geographic association between male circumcision (MC) and HIV in Tanzania using data from demographic and health surveys (TDHS) (3). The authors also suggest MC as being a factor associated with the distribution of HIV in Tanzania. They concluded that MC was an influential factor in HIV prevalence among men and women in Tanzania. Before accepting the authors’ comments, we would like to point out the importance of considering ecological fallacy when using health data in geospatial analysis. Ecological fallacy is a logical fallacy that occurs when a conclusion about individuals are made based on the analysis of group-level data (4). A relationship between exposure and disease frequency at the group level in an ecological study does not infer that such a relationship exists at the individual level (5). According to Willian Robinson, there is a statistical difference between the correlation of variables aggregated by group or geographic area and correlation established on individual-level variables of that same population (6). In this article, HIV testing was completed for all tested men and women; subsequently, the prevalence of HIV and the prevalence of MC were assessed at each sample location. Estimates of HIV prevalence and MC were based on aggregated data for specified geographic units. As a result, there is confusion between aggregate and individual inference. The authors used the aggregated data for prevalence of MC in a given area to detect the effect it had on male HIV risk. They concluded that there is a significant spatial association between MC and HIV. In areas with a low percentage of circumcised males, a large proportion of the HIV epidemic is concentrated. This spatial correlation between MC and HIV does not necessarily mean that there is a correlation at the individual level. This study gave up the ability to perform individual-level data analysis by performing aggregate analyses, which provide a picture of group-level outcomes (cities). There are different components of ecological fallacy that can be found in this article: Ecological correlation: correlation between variables (HIV and MC) is on group level, in contrast to a correlation between these variables that describe individuals. Ecological rates: HIV rates in men and women were estimated via geographic units, in contrast to the rates that describe total rates on individual level. Confusion between higher rates and higher likelihood; where the units of analysis are geographic units, higher MC rates versus the likelihood of being HIV positive at the group level does not imply causation. On the other hand, the authors subsequently used the same variable and applied it to females, assuming the reduced risk for infection was transferrable to the opposite sex, since they live within the same area as a given set of circumcised males. Even with the assumption of high-quality data and accurate sampling strategy, the drop in HIV prevalence for circumcised males for a given area does not necessarily equate to an increased or decreased risk of infection for females living in the same area. In conclusion, this study generates a hypothesis and suggests a possible association between MC and HIV; however, the findings of this study should be interpreted in light of its limitations as an ecological study. Further research on individual-level data with a stronger study design is a requirement to support a cause-and-effect relationship between MC and HIV. It is necessary to provide a model using individual-level data and then model how the individual and group levels are associated, and finally assess whether the group-level model will add to the understanding of this association.

Strong Country Level Correlation between Syphilis and HSV-2 Prevalence.

Background. Syphilis is curable but Herpes Simplex Virus-2 (HSV-2) is not. As a result, the prevalence of syphilis but not HSV-2 may be influenced by the efficacy of national STI screening and treatment capacity. If the prevalence of syphilis and HSV-2 is found to be correlated, then this makes it more likely that something other than differential STI treatment is responsible for variations in the prevalence of both HSV-2 and syphilis. Methods. Simple linear regression was used to evaluate the relationship between national antenatal syphilis prevalence and HSV-2 prevalence in women in two time periods: 1990–1999 and 2008. Adjustments were performed for the laboratory syphilis testing algorithm used and the prevalence of circumcision. Results. The prevalence of syphilis was positively correlated with that of HSV-2 for both time periods (adjusted correlations, 20–24-year-olds: 1990–99: R 2 = 0.54, P < 0.001; 2008: R 2 = 0.41, P < 0.001 and 40–44-year-olds: 1990–99: R 2 = 0.42, P < 0.001; 2008: R 2 = 0.49, P < 0.001). Conclusion. The prevalence of syphilis and HSV-2 is positively correlated. This could be due to a common set of risk factors underpinning both STIs.