Protective Effect Of Male Circumcision Research Articles

Association of medical male circumcision and sexually transmitted infections in a population-based study using targeted maximum likelihood estimation

BackgroundEpidemiological theory and many empirical studies support the hypothesis that there is a protective effect of male circumcision against some sexually transmitted infections (STIs). However, there is a paucity of randomized control trials (RCTs) to test this hypothesis in the South African population. Due to the infeasibility of conducting RCTs, estimating marginal or average treatment effects with observational data increases interest. Using targeted maximum likelihood estimation (TMLE), a doubly robust estimation technique, we aim to provide evidence of an association between medical male circumcision (MMC) and two STI outcomes.MethodsHIV and HSV-2 status were the two primary outcomes for this study. We investigated the associations between MMC and these STI outcomes, using cross-sectional data from the HIV Incidence Provincial Surveillance System (HIPSS) study in KwaZulu-Natal, South Africa. HIV antibodies were tested from the blood samples collected in the study. For HSV-2, serum samples were tested for HSV-2 antibodies via an ELISA-based anti-HSV-2 IgG. We estimated marginal prevalence ratios (PR) using TMLE and compared estimates with those from propensity score full matching (PSFM) and inverse probability of treatment weighting (IPTW).ResultsFrom a total 2850 male participants included in the analytic sample, the overall weighted prevalence of HIV was 32.4% (n = 941) and HSV-2 was 53.2% (n = 1529). TMLE estimates suggest that MMC was associated with 31% lower HIV prevalence (PR: 0.690; 95% CI: 0.614, 0.777) and 21.1% lower HSV-2 prevalence (PR: 0.789; 95% CI: 0.734, 0.848). The propensity score analyses also provided evidence of association of MMC with lower prevalence of HIV and HSV-2. For PSFM: HIV (PR: 0.689; 95% CI: 0.537, 0.885), and HSV-2 (PR: 0.832; 95% CI: 0.709, 0.975). For IPTW: HIV (PR: 0.708; 95% CI: 0.572, 0.875), and HSV-2 (PR: 0.837; 95% CI: 0.738, 0.949).ConclusionUsing a TMLE approach, we present further evidence of a protective association of MMC against HIV and HSV-2 in this hyper-endemic South African setting. TMLE has the potential to enhance the evidence base for recommendations that embrace the effect of public health interventions on health or disease outcomes.

Traditional Male Circumcision is Associated with Sexual Risk Behaviors in Sub-Saharan Countries Prioritized for Male Circumcision.

To understand the sexual risk behavior of men with traditional male circumcision and medical male circumcision in the context of the World Health Organization's (WHO) campaign for voluntary medical male circumcision (VMMC) scale-up, we investigated ten countries prioritized for the scale-up from the Demographic and Health Surveys. Male respondents aged 15-49 were selected. Ordinal regression was used to analyze the relationship between three sexual risk behaviors-condom use with non-cohabiting partners, number of non-cohabiting partners, and partner type-and circumcision status (traditionally circumcised before and after the VMMC scale-up, medically circumcised before and after the scale-up, and not circumcised), while controlling for social demographic covariates. We found evidence that some sexual risky behavior, specifically lower condom use and higher number of sexual partners, was associated with traditional circumcision. This finding suggests that messages about the protective effect of male circumcision may not have reached men with traditional circumcision. We suggest that WHO's VMMC campaign should include communities where traditional male circumcision is popular. We looked for, but did not find, evidence of differences between groups circumcised at different times, which could have indicated sexual risk compensation.

Male Circumcision and Risk of HIV Transmission from Male to Women

Male circumcision has proved to be protective for male to male HIV transmission. The effect of male circumcision on female partner's HIV status is still uncertain from previous studies. This systematic review aimed to assess whether circumcision status of an HIV-infected male changes the risk of HIV transmission to his female sexual partner. We analyzed findings from one randomized controlled trial and 4 cross sectional study and found no significant evidence in support of our hypothesis that male circumcision prevents HIV transmission in female. Due to high methodological and clinical heterogeneity, meta-analysis was not done. Qualitative synthesis revealed lack of existing good quality study to address this question. Four of five studies reported no association between male circumcision and HIV transmission. One cohort study reported protective effect of male circumcision on their female partner's HIV. Only one subpopulation of RCT (resume to sexual activity before wound healing) reported increased HIV transmission in female whose male partner is circumcised. Effect of male circumcision on HIV transmission is still blurred. Large scale randomized trial is needed to answer this question. Until then, the prevention programs should also emphasize other measures of HIV transmission.Medicine Today 2016 Vol.28(1): 22-26

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.

Factors associated with married women's support of male circumcision for HIV prevention in Uganda: a population based cross-sectional study.

BackgroundDespite the protective effect of male circumcision (MC) against HIV in men, the acceptance of voluntary MC in priority countries for MC scale–up such as Uganda remains limited. This study examined the role of women’s sociodemographic characteristics, knowledge of HIV and sexual bargaining power as determinants of women’s support of male circumcision (MC).MethodsData from the Uganda AIDS Indicator Survey, 2011 were analyzed (n = 4,874). Bivariate and multivariate logistic regression analyses with random intercept were conducted to identify factors that influence women’s support of MC.ResultsOverall, 67.0 % (n = 3,276) of the women in our sample were in support of MC but only 28.0 % had circumcised partners. Women who had the knowledge that circumcision reduces HIV risk were about 6 times as likely to support MC than women who lacked that knowledge [AOR (adjusted odds ratio) = 5.85, 95 % CI (confidence interval) = 4.83–7.10]. The two indicators of women’s sexual bargaining power (i.e., ability to negotiate condom use and ability to refuse sex) were also positively associated with support of MC. Several sociodemographic factors particularly wealth index were also positively associated with women’s support of MC.ConclusionsThe findings in this study will potentially inform intervention strategies to enhance uptake of male circumcision as a strategy to reduce HIV transmission in Uganda.

PL04.1 Male circumcision for sti prevention: how well does it work and how is it done?

Interest in the possible association between male circumcision (MC) and sexually transmitted infections (STIs), including HIV, began in earnest in 1980s with studies exploring the tripartite relationship of circumcision, genital ulcer disease and HIV. The interest gathered momentum in the 1990s with more studies exploring these associations beyond within and Africa. In 2002, the first randomised controlled trial (RCT) was initiated in Kisumu, Kenya, with two others following shortly after in Orange Farm, South Africa and Rakai, Uganda. Although the RCTs focused primarily on MC and HIV, they also explored associations of MC and different STIs. This presentation focuses on the association between MC and human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), syphilis, Neisseria gonorrhoeae , Chlamydia trachomatis and Trichomonas vaginalis reported by the three RCTs as well as in systematic reviews, meta-analyses and other studies that followed. The protective effect of MC against HPV was consistent across the three trials; in addition, the Uganda trial found that female partners of circumcised men had lower rates of HPV infection. While results from the RCTs were somewhat inconsistent on the association between MC and gonorrhoeae, HSV-2, syphilis, chlamydia and trichomoniasis, several meta-analyses and post-RCT studies have reported that MC protects against most of these conditions. As a result of these benefits, several MC devices have been developed to fast-track the provision of MC services, notably PrePex and ShangRing that have been pre-approved by the World Health Organization.

Swazi men’s perception of the protective effect of male circumcision and its implications for HIV prevention strategy

Background: For years, male circumcision (MC) has been known to reduce the risk of sexually transmitted infections (STIs). Of late, MC has been recognised and recommended as a complementary HIV preventive measure in high prevalent areas. The objective of this study was to to assess the perceptions of Swazi men about the protective effect of circumcision against STIs including HIV, and its implication to the mass MC strategy for HIV prevention. Methods: An explorative qualitative study was conducted targeting men aged ≥18 years seeking services at Family Life Association of Swaziland clinic in Mbabane, Swaziland. Unstructured individual face-to-face interviews were conducted for 17 men. Results: Results showed that Swazi men perceived the protective effect of MC differently, ranging from perceptions of ineffectiveness and unworthy, especially against HIV, to perceptions of total protection and a solution to all STIs. Perceptions were influenced by the ongoing circumcision campaigns, individual knowledge of biological sciences, misconceptions as well as life experiences. Promiscuous men were more likely to have a positive perception and acceptance of the procedure than their non-promiscuous counterparts. Conclusion: Swazi men hold mixed perceptions about MC, accounting for its relatively low uptake. The relatively low uptake of circumcision does not necessarily imply failure of the strategy but rather a natural selection of the most relevant and at-risk portion of the population. It is recommended that more effort be put towards correcting misconceptions and convincing those who still hold a negative perception about the procedure.

Prevalence and acceptability of male circumcision in South Africa.

The objectives of the current national study were to determine the rates of self-reported circumcision among South African men and, more importantly, evaluate the acceptability of male circumcision in South Africa by uncircumcised adult men and all adult women. The study based on a population-based survey included a nationally representative subgroup of 6654 men aged 15 years and older who where included in the analysis on male circumcision prevalence, and a subgroup of 6796 women aged 15 to 49 years who were included in the analysis on male circumcision acceptance. An overall prevalence of self-reported male circumcision of 42.8% was found. Among the Black African population group the prevalence of male circumcision was 48.2%, 32.1% were traditionally and 13.4% were medically circumcised. Among males not circumcised 45.7% of 15-24 years olds indicated that they would consider being circumcised compared to 28.3% among 25-49 years olds. In multivariate analysis among non-circumcised men Black African and Coloured population groups and having heard of the HIV protective effect of male circumcision were significant predictors for male circumcision acceptability, and among women with a non-circumcised sexual partner, Black African and Coloured population groups and higher education were predictors for male circumcision acceptability. The study found high rates and high acceptability of male circumcision. Findings associated with the acceptability of male circumcision can be used to increase awareness of the benefits of male circumcision for HIV prevention.

Prevalence and Acceptability of Male Circumcision among Young Men in South Africa

KEYWORDS Traditional Male Circumcision. Medical Male Circumcision. HIV Protection Knowledge. Attitudes. Cross- sectional Survey ABSTRACT The objectives of this study were to determine the prevalence and acceptability of male circumcision among young men in four of nine provinces in South Africa. As part of a cross-sectional population-based household survey, 1619 men aged 18-24 completed confidential interviews. The results indicate an overall prevalence of self-reported male circumcision of 39.1% (15.3% traditional and 23.8% medical male circumcision). In the multivariate analysis, being HIV negative and having extensive social network resources were associated with male circumcision status, and knowledge of the protective effect of male circumcision against HIV, partner risk-reduction self-efficacy, extensive social network resources and having had an early sexual debut were associated with the acceptability of male circumcision. Male circumcision is common, and the acceptability is high. Factors associated with the acceptability of male circumcision can be used to scale-up the demand for medical male circumcision services.

Prevalence and Acceptability of Male Circumcision among Young Men in South Africa

The objectives of this study were to determine the prevalence and acceptability of male circumcision among young men in four of nine provinces in South Africa. As part of a cross-sectional population-based household survey, 1619 men aged 18-24 completed confidential interviews. The results indicate an overall prevalence of self-reported male circumcision of 39.1% (15.3% traditional and 23.8% medical male circumcision). In the multivariate analysis, being HIV negative and having extensive social network resources were associated with male circumcision status, and knowledge of the protective effect of male circumcision against HIV, partner risk-reduction self-efficacy, extensive social network resources and having had an early sexual debut were associated with the acceptability of male circumcision. Male circumcision is common, and the acceptability is high. Factors associated with the acceptability of male circumcision can be used to scale-up the demand for medical male circumcision services.

Male circumcision and HIV prevention

It is reported that there is grade I evidence that male circumcision reduces the risk of men acquiring human immunodeficiency virus (HIV) infection. This is based on three large randomised controlled trials (RCTs) on male circumcision that were undertaken in Africa, at Orange Farm, South Africa; Rakai, Uganda; and Kisumu, Kenya. The findings were published in The Lancet and The Journal of Infectious Diseases between 2007 and 2009. Over 10 000 men were circumcised at the three sites. The reported protective effect of male circumcision against HIV were Orange Farm (60%), Rakai (48%), and Kisumu (53%). 1

Epidemiological research in the HIV field

In 1988, AIDS published the first issue of ‘a year in review’. Nearly 25 years later, the epidemiology section makes very interesting ‘re-reading’ [1]. By the end of the 1980s, we had a fairly good understanding of the mechanisms underlying the spread of HIV. As Michael Adler and Peter Piot pointed out, progress in epidemiological research was slowing down and we entered a period of ‘fine tuning of our knowledge’. They identified a number of gaps in our understanding. These included mechanisms of transmission, the natural history of HIV infection in adults and in children, the discrepancy of the HIV epidemics in the heterosexual populations in Europe and North America and Africa, the efficiency and risk factors of mother-to-child transmission of HIV, and the ‘incapacity and/or unwillingness’ of societies to deal rationally with drug use in the face of fulminant HIV epidemics among injecting drug users. Although this latter challenge still is topical in 2012, it is now difficult to imagine that there was a time when it was thought that ‘control of perinatal transmission will only be achieved through effective programs aimed at decreasing the spread of infection to women’. Yet, there was some hope already for a treatment that would prevent progression to AIDS, although it was going to be expensive and pose major challenges for health services. We undoubtedly have made a lot of progress since 1988. We have come to realize that ‘high-risk sexual behavior’ is much more complex than just ‘high numbers of lifetime sex partners’. Much more attention is now being paid to contextual factors that shape sexual behavior. We have a better understanding of factors that influence the efficiency of transmission of HIV. Numerous randomized trials have been conducted to test the effectiveness of interventions that have been developed based on findings from observational epidemiological and behavioral research. The most spectacular trials in terms of results were the ones testing the protective effect of male circumcision and the trials of the use of antiretroviral compounds in preventing mother-to-child transmission and sexual transmission. Trials of behavioral interventions have, by and large, given disappointing results. This has led to discussions about the suitability of community randomized controlled trials for evaluating the effectiveness of nonbiomedical prevention interventions [2]. The good news, however, is that in many parts of sub-Saharan Africa, HIV prevalence has been decreasing, apparently due to changes in behavior. The challenge is to try and understand what exactly happened in these populations and whether these favorable trends can be replicated elsewhere. Classical epidemiological methods will not allow us to come to grips with the complexities of epidemic trends and mathematical modeling has become an indispensable tool to try and understand the many factors that shape HIV epidemics. What are the major challenges for epidemiological research in 2012? We urgently need a reliable, easy-to-use tool to measure incidence at a population level. We still do not fully understand why the spread of HIV has been (and still is) so different in sub-Saharan Africa compared with heterosexual populations in other parts of the world and why the incidence of HIV infection in young women in southern Africa is so high. We need to revise what we know about the efficiency of HIV transmission in populations in different parts of the world. We also do not fully understand why in some gay communities HIV incidence has declined, whereas in other communities there is no decreasing trend despite high coverage with testing and antiretroviral treatment. And last but not least, how can we evaluate complex behavioral interventions in a reliable way? There is a consensus that there is no magic bullet (yet) to control HIV epidemics, and that we have to rely on combination prevention, including interventions at the structural and the individual level. Evaluating the effectiveness of combination prevention will have to rely on combination evaluation approaches using different data sources and mixed methods to build a plausible case. This will require interdisciplinary collaborations involving epidemiologists, mathematical modelers, and social scientists, and close collaboration between researchers and program implementers. Acknowledgements Conflicts of interest There are no conflicts of interest.

‘It brought joy in my home as in the area of my wife.’ How recently circumcised adult men ascribe value to and make sense of male circumcision

The present study used a phenomenological approach to explore the everyday-life experiences of male circumcision (MC) and to learn how recently circumcised men ascribe value to and make sense of MC. Thirteen recently circumcised Zambian men were identified through the snowball technique and interviewed using a semi-structured interviewer's guide. Findings indicate that the post-operational experience of adult MC smoothly fits into the everyday-life experience of the men interviewed and is perceived and experienced as a broader social health issue, which largely transcends both the personal HIV risk of the individual male and the private sphere. The study provides three important lessons for MC programmes: (1) the broad social aspects of MC put forward by the interviewees suggest the potential for a popular intervention and, consequently, a large uptake of MC; (2) findings suggest that in addition to emphasising the HIV protective effect of MC, MC promotion should also highlight the social, sexual and romantic values perceived and experienced by the interviewees of this study; (3) the analysis reveals potentially harmful misconceptions about the health benefits of MC, demonstrating the importance of proper pre- and post-circumcision counselling as well as public health messages related to MC.

Acceptability of Newborn Circumcision to Prevent HIV Infection in the United States

To understand whether information from the African clinical trials about the partially protective effect of male circumcision against human immunodeficiency virus (HIV) infection could influence adults to circumcise a newborn son. Using the 2008 ConsumerStyles panel survey data, multiple regression analysis was performed to identify correlates of (1) inclination toward circumcising a newborn son and (2) being influenced to have a newborn son circumcised if it would reduce the chance of becoming HIV infected later in life. Response rate was 50.6% (10,108/19,996). Approximately 12% reported not being inclined to circumcise a newborn son. Higher odds of not being inclined to circumcise a newborn son were associated with Hispanic and "other" race/ethnicity, being an uncircumcised man and a man not reporting circumcision status, postgraduate education, region, and negative health-related attitudes. Lower odds were associated with black race and less number of household members. Fifty-three percent of respondents reported that information about the protective effect of circumcision would make them more likely to have a newborn son circumcised. Higher odds of being influenced to have a newborn son circumcised were associated with being ≥45 years of age, black race, living in a household with fewer than 5 members, having high school or some college education, region, and positive health-related attitudes; lower odds were associated with being an uncircumcised man and lower income. Our findings suggest that providing educational information about the HIV prevention and benefit of circumcision may increase the inclination to circumcise a newborn son for some people.

Assessment of the protective effect of male circumcision from HIV infection and sexually transmitted diseases: Evidence from 18 demographic and health surveys in Sub-Saharan Africa

A cross-sectional comparative study based on secondary data of 18 Demographic Health Surveys (DHS) carried out in Sub-Saharan Africa starting from 2003 was conducted to assess the protective effect of male circumcision from HIV infection and STDs. From all surveys, information on 70,554 males aged 15-59 years was extracted. The association between male circumcision and HIV infection and STD symptoms (Genital discharge or genital ulcer/sore) was assessed using binary logistic regression. Adjustment was made for sexual history and basic sociodemographic variables. The weighted prevalence of HIV among men 15-59 years was 3.1%. In the bivairate analysis being uncircumcised was significantly associated with risk of HIV with Odds Ratio (OR) of 4.12 aged (95% CI: 3.85-4.42). The association was even more significant, 4.95 (95% CI: 4.57-5.36), after adjustment for number of lifetime sexual partners and socio-demographic variables. The risk associated with uncircumcision is significantly lower among younger men aged 15-29 years than those in 30-59 years age category. About 5.5% of the study subjects reported either genital discharge or genital sore/ulcer in the preceding 12 months of the surveys. Circumcision was not significantly associated with either of the symptoms of STD with adjusted OR of 1.07 (95% CI: 0.99-1.15). The study concludes that male circumcision provides a strong protection against acquisition of HIV infection. Hence, it can be considered as a possible way of reducing the spread of HIV infection in areas where the practice is rare. A comprehensive study to assess the association between circumcision and different types STDs is recommended.

Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa.

Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.

Abundant Expression of HIV Target Cells and C-Type Lectin Receptors in the Foreskin Tissue of Young Kenyan Men

A biological explanation for the reduction in HIV-1 (HIV) acquisition after male circumcision may be that removal of the foreskin reduces the number of target cells for HIV. The expression of potential HIV target cells and C-type lectin receptors in foreskin tissue of men at risk of HIV infection were thus analyzed. Thirty-three foreskin tissue samples, stratified by Herpes simplex virus type 2 status, were obtained from a randomized, controlled trial conducted in Kenya. The samples were analyzed by confocal in situ imaging microscopy and mRNA quantification by quantitative RT-qPCR. The presence and location of T cells (CD3(+)CD4(+)), Langerhans cells (CD1a(+)Langerin/CD207(+)), macrophages (CD68(+) or CD14(+)), and submucosal dendritic cells (CD123(+)BDCA-2(+) or CD11c(+)DC-SIGN(+)) were defined. C-type lectin receptor expressing cells were detected in both the epithelium and submucosa, and distinct lymphoid aggregates densely populated with CD3(+)CD4(+) T cells were identified in the submucosa. Although the presence of lymphoid aggregates and mRNA expression of selected markers varied between study subjects, Herpes simplex virus type 2 serostatus was not the major determinant for the detected differences. The detection of abundant and superficially present potential HIV target cells and submucosal lymphoid aggregates in foreskin mucosa from a highly relevant HIV risk group demonstrate a possible anatomical explanation that may contribute to the protective effect of male circumcision on HIV transmission.

Male circumcision for HIV prevention - a cross-sectional study on awareness among young people and adults in rural Uganda

BackgroundMedical male circumcision is now part of a comprehensive approach to HIV prevention. It has been shown that awareness of the protective effect of male circumcision leads to high acceptability towards the introduction of medical male circumcision services within countries. The objective of this survey was to identify factors determining awareness of male circumcision for HIV prevention.MethodsWe interviewed 452 participants (267 adults >24 years of age; 185 youths 14-24 years) living in three rural Ugandan districts in 2008. Using a standardized questionnaire, we assessed socio-demographic parameters, awareness of MC for HIV prevention, general beliefs/attitudes regarding MC and MC status. Determinants for awareness of MC for HIV prevention were examined with multiple logistic regression models.ResultsOut of all adults, 52.1% were male (mean ± SD age 39.8 ± 11 years), of whom 39.1% reported to be circumcised. Out of all youths, 58.4% were male (18.4 ± 2.5), 35.0% circumcised.Adults were more aware of MC for HIV prevention than youths (87.1% vs. 76.5%; p = 0.004). In adults, awareness was increased with higher educational level compared to no school: primary school (adjusted OR 9.32; 95%CI 1.80-48.11), secondary (5.04; 1.01-25.25), tertiary (9.91; 0.76-129.18), university education (8.03; 0.59-109.95). Younger age and male sex were further significant determinants of increased awareness, but not marital status, religion, district, ethnicity, employment status, and circumcision status. In youths, we found a borderline statistically significant decrease of awareness of MC for HIV prevention with higher educational level, but not with any other socio-demographic factors.ConclusionsParticularly Ugandans with low education, youths, and women, playing an important role in decision-making of MC for their partners and sons, should be increasingly targeted by information campaigns about positive health effects of MC.

Knowledge and Attitudes About Male Circumcision for HIV-1 Prevention among Heterosexual HIV-1 Serodiscordant Partnerships in Kampala, Uganda

Male circumcision for HIV-1 prevention will require high uptake among at-risk populations. 318 HIV-1 serodiscordant couples in Kampala, Uganda [155 (48.7%) with HIV-1 uninfected male partners] were interviewed about male circumcision for HIV-1 prevention. 77.1% of men and 89.6% of women were aware that circumcision reduces men's risk for HIV-1 acquisition. Almost all understood the partial protective efficacy of circumcision for HIV-1 acquisition and lack of reduced HIV-1 transmission from circumcising HIV-1 infected men. Among couples with uncircumcised HIV-1 negative men (n=92), 53.3% of men and 88.1% of female partners expressed interest in male circumcision. Previous discussion within the couple about circumcision for HIV-1 prevention was significantly associated with interest in the procedure. HIV-1 serodiscordant couples in Uganda demonstrated a high level of understanding of the partial protective effect of male circumcision for HIV-1 prevention, but only half of HIV-1 uninfected uncircumcised men expressed interest in the procedure.

Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study

There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%. A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a "catch-up" campaign that would be needed at the start of the program but would eventually become superfluous. Please see later in the article for the Editors' Summary.