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South African Study Confirms Adult Circumcision Reduces HIV Risk

Large-scale implementation of voluntary adult male circumcision was associated with a significant reduction in rates of HIV infection in the South African town involved in the first ground-breaking circumcision for prevention study a decade ago, researchers reported in the in the open-access online journal PLoS Medicine.

In 2005 Bertran Auvert from the University of Versailles and colleagues reported that a study in Orange Farm, a township near Johannesburg in South Africa, showed that elective adult circumcision reduced men's HIV infection rate by 61%.

A couple years later a pair of large controlled studies in Kisumu, Kenya, and Rakai, Uganda -- men who expressed interest in circumcision were randomly assigned to undergo the procedure immediately or after a waiting period -- again demonstrated that circumcision can reduce the risk of HIV infection by half or more.

The World Health Organization and UNAIDS therefore recommended in 2007 that voluntary medical male circumcision (VMMC)should be offered as part of comprehensive HIV risk reduction programs in settings with generalized HIV epidemics.

Now, Auvert and co-authors have reported "real world" findings from a study looking at the effectiveness of voluntary adult circumcision roll-out on HIV levels in Orange Farm. While the benefits for individual men have been convincingly demonstrated, less is known about the population-level effect of adult circumcision as an HIV prevention method, they noted as background.

The authors surveyed random samples of men participating in the Bophelo Pele project, a community-based HIV prevention campaign that includes free male circumcision. Participants were interviewed about their sexual behavior, blood samples were tested for presence of HIV and recent HIV infection (using the BED HIV incidence assay), and circumcision status was assessed by clinical examination.

The baseline cross-sectional survey done during 2007-2008 included 1998 men aged 15 to 49 (81% response rate). A follow-up survey conducted during 2010-2011 included 3338 men (80% response rate).

Results

• The rate of circumcision increased from 12% on the initial survey to 53% on the follow-up survey, due to the large number procedures done as part of the randomized clinical trial and the Bophelo Pele project.
• Among younger men (age 15-29), the circumcision rate rose to 58%.
• Without these circumcisions, the researchers estimated that the HIV prevalence rate during 2010-2011 would have been 15% instead of 12%, or 19% higher.
• No association between circumcision status and sexual risk behavior was detected when comparing circumcised and uncircumcised men.
• 44% of circumcised men and 45% of uncircumcised men reported consistently using condoms with non-spousal sexual partners during the past 12 months, not a significant difference.
• 50% of circumcised men and 44% of uncircumcised men reported having 2 or more non-spousal partners, again not significant.
• The estimated HIV incidence rate (based on the BED assay) ranged from 57% to 61% lower among circumcised men compared with uncircumcised men.

"Findings suggest that the roll-out of VMMC in Orange Farm is associated with a significant reduction of HIV levels in the community," the researchers concluded. "The main limitation of the study is that it was not randomized and cannot prove a causal association."

"This study has shown that the roll-out of free VMMC can lead to a substantial uptake in just a few years, especially among young men, in an African community where [male circumcision] is not a social norm," they elaborated in their discussion. "[T]he roll-out of VMMC in this community was associated with a reduction in the prevalence and incidence of HIV among circumcised men in comparison with uncircumcised men, and we estimated that without the project, HIV prevalence averaged on all adult men would have been significantly higher."

"Because adult VMMC has been shown to reduce the acquisition not only of HIV but also of herpes simplex virus 2 (HSV-2) and human papillomavirus (HPV), the next step should be to confirm that these results are reproduced in similar phase 4 studies," they continued. "It will also be important to demonstrate that women, as expected, do indirectly benefit from the roll-out of adult VMMC through the reduction of their exposure to HIV, because of the overall reduction in HIV prevalence rate among men."

Addressing a common concern, the authors wrote, "The absence of a statistical association between [male circumcision] status and sexual behavior is encouraging and suggests that the so-called 'risk compensation' or 'behavioral disinhibition' (i.e., increased risky sexual behavior following adult [circumcision]) is either too small to be detectable even in large samples, or simply does not exist."

"The roll-out of VMMC among adults in sub-Saharan Africa should be an international priority and needs to be accelerated to effectively combat the spread of HIV," they recommended.

9/11/13

Reference

B Auvert, D Taljaard, D Rech, et al. Association of the ANRS-12126 Male Circumcision Project with HIV Levels among Men in a South African Township: Evaluation of Effectiveness using Cross-sectional Surveys. PLoS Medicine 10(9):e1001509. September 2013.

Other Source

Public Library of Science. Roll-out of community voluntary male circumcision is linked to reduced HIV infection levels. Press release. September 3, 2013.