Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial
ABSTRACT Observational studies suggest that male circumcision may provide protection against HIV-1 infection. A randomized, controlled intervention trial was conducted in a general population of South Africa to test this hypothesis.
A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a control or an intervention group with follow-up visits at months 3, 12, and 21. Male circumcision was offered to the intervention group immediately after randomization and to the control group at the end of the follow-up. The grouped censored data were analyzed in intention-to-treat, univariate and multivariate, analyses, using piecewise exponential, proportional hazards models. Rate ratios (RR) of HIV incidence were determined with 95% CI. Protection against HIV infection was calculated as 1 - RR. The trial was stopped at the interim analysis, and the mean (interquartile range) follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 HIV infections (incidence rate = 0.85 per 100 person-years) in the intervention group and 49 (2.1 per 100 person-years) in the control group, corresponding to an RR of 0.40 (95% CI: 0.24%-0.68%; p < 0.001). This RR corresponds to a protection of 60% (95% CI: 32%-76%). When controlling for behavioural factors, including sexual behaviour that increased slightly in the intervention group, condom use, and health-seeking behaviour, the protection was of 61% (95% CI: 34%-77%).
Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa. (Preliminary and partial results were presented at the International AIDS Society 2005 Conference, on 26 July 2005, in Rio de Janeiro, Brazil.).
Full-textDOI: · Available from: Dirk Taljaard, May 30, 2015
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ABSTRACT: Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. Kenya, for example, has embraced MC and has been dubbed a 'leader' by the global health community, while Malawi has been branded a 'laggard' in its slow adoption of a national programme, with a strong political discourse of resistance forming around MC. Regardless of any epidemiological or technical evidence, the uptake of international recommendations will be shaped by how a policy, and the specific artefacts that constitute that policy, intersect with local concerns. MC holds particular significance within many ethnic and religious groups, serving as an important rite of passage, but also designating otherness or enabling the identification of the social and political self. Understanding how the artefact of MC intersects with local social, economic, and political contexts, is therefore essential to understand the acceptance or resistance of global policy recommendations. In this paper we present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a 'narrative of defiance' around the need to resist donor manipulation, and a 'narrative of doubt' which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, we found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.Social Science [?] Medicine 04/2015; 15. DOI:10.1016/j.socscimed.2015.04.020 · 2.56 Impact Factor
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ABSTRACT: Background Zimbabwe adopted voluntary medical male circumcision (VMMC) as an additional HIV prevention strategy in 2009. A number of studies have been conducted to understand the determinants of VMMC uptake but few studies have examined the characteristics of men who are willing to get circumcised or the link between wanting circumcision and risky sexual behaviour. This study investigated the relationship between wanting male circumcision and engaging in risky sex behaviours. This was based on the assumption that those who are willing to undergo circumcision are already engaging in risky sexual behaviours. Data and methods Data from men age 15–45 years who were interviewed during the 2010–11 Zimbabwe Demographic and Health Survey of 2010–11 was used. A total of 7480 men were included in the sample for this study. Logistic regression was used to assess the association between wanting circumcision and risky sexual behaviours. Findings Men in the highest wealth tercile were significantly more likely to want circumcision compared to men in lower wealth terciles (OR = 1.36, p < 0.01). Wanting circumcision was also significantly associated with age. Men in the 25–34 age category reported wanting circumcision more (OR = 1.21, p < 0.05) while older men were significantly less likely to want circumcision (OR = 0.63, p < 0.01). Christian men and those residing in rural areas were also less likely to want circumcision (OR = 0.74, p < 0.05 and OR = 0.75, p < 0.001 respectively). The findings of this study indicate a strong association between wanting circumcision and having had risky sex (OR = 1.36, p < 0.01), having multiple partners (OR = 1.35, p < 0.01) and having paid for sex (OR = 1.42, p < 0.001) However, wanting circumcision was negatively associated with having used a condom at the last risky sex (OR = 0.76, p < 0.001). Conclusions The association between demand for VMMC and risky sexual behaviour need continuous monitoring. We emphasise that the promotion of VMMC for HIV prevention should not overshadow the promotion of existing methods of HIV prevention such as condoms and reduction of sexual partners.Reproductive Health 03/2015; 12(1). DOI:10.1186/s12978-015-0001-3 · 1.62 Impact Factor
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ABSTRACT: While the per-contact risk of sexual HIV transmission is relatively low, it is fourfold higher in sub-Saharan Africa, and this may partly explain the major global disparities that exist in HIV prevalence. Genital immune parameters are key determinants of HIV transmission risk, including epithelial integrity and the presence of highly HIV-susceptible intraepithelial or submucosal CD4+ T cell target cells. Biological parameters that may enhance mucosal HIV susceptibility in highly HIV-affected regions of sub-Saharan Africa include increased levels of mucosal inflammation, which can affect both epithelial integrity and target cell availability, as well as the increased mucosal surface area that is afforded by an intact foreskin, contraceptive choices, and intravaginal practices. There are multifactorial causes for increased mucosal inflammation, with the prevalence and nature of common co-infections being particularly relevant.Current HIV/AIDS Reports 04/2015; 12(2). DOI:10.1007/s11904-015-0269-5