Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial

Hôpital Ambroise-Paré, Assitance Publique-Hôpitaux de Paris, Boulogne, France.
PLoS Medicine (Impact Factor: 14.43). 12/2005; 2(11):e298. DOI: 10.1371/journal.pmed.0020298
Source: PubMed


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.).

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    • "7 Women's greater susceptibility is attributed to a number of biological mechanisms, including differences in genital immunology that are well described in the literature (Chersich and Rees 2008; Higgins, Hoffman, and Dworkin 2010; Yi et al. 2013). A variety of co-factors may alter susceptibility to HIV infection, including the presence of both viral and bacterial sexually transmitted infections (STI) (Cohen 2004; Glynn et al. 2001; Hertog 2008; UNAIDS/WHO 2000) 8 and male circumcision (Auvert et al. 2005; Hertog 2008). The contributions of pregnancy (Gray et al. 2005; Marston et al. 2013; Morrison et al. 2007) and hormonal contraceptives to women's disproportionally high infection rates are less certain (WHO 2012). "
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    ABSTRACT: BACKGROUND Empirical estimates of the female-to-male ratio of infections in generalized HIV epidemics in sub-Saharan Africa range from 1.31 in Zambia to 2.21 in Ivory Coast. Inequalities in the gender ratio of infections can arise because of differences in exposure (to HIV-positive partners), susceptibility (given exposure), and survival (once infected). Differences in susceptibility have to date received most attention, but neither the relatively high gender ratio of infections nor the heterogeneity in empirical estimates is fully understood. OBJECTIVE Demonstrate the relevance of partnership network attributes and sexual mixing patterns to gender differences in the exposure to HIV-positive partners and the gender ratio of infections. METHOD Agent-based simulation model built in NetLogo. RESULTS The female-to-male ratio of infections predicted by our model ranges from 1.13 to 1.75. Gender-asymmetric partnership concurrency, rapid partnership turnover, elevated partnership dissolution in female-positive serodiscordant couples, and lower partnership re-entry rates among HIV-positive women can produce (substantial) differences in the gender ratio of infections. Coital dilution and serosorting have modest moderating effects. CONCLUSION Partnership network attributes and sexual mixing patterns can have a considerable effect on the gender ratio of HIV infections. We need to look beyond individual behavior and gender differences in biological susceptibility if we are to fully understand, and remedy, gender inequalities in HIV infection in generalized epidemics.
    Demographic Research 09/2015; 33(1):425-450. DOI:10.4054/DemRes.2015.33.15 · 1.20 Impact Factor
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    • "One of the major success stories in HIV prevention was of three trials in Kenya, South Africa and Uganda that demonstrated that voluntary medical male circumcision (VMMC) reduced HIV acquisition among heterosexual men by up to 60% (Auvert et al. 2005; Bailey et al. 2007; Grey et al. 2007; Padian et al. 2011). Mathematical modelling indicated that the potential public health benefit of VMMC could significantly reduce HIV prevalence in men, which may also indirectly benefit women (Njeuhmeli et al. 2011; Williams et al. 2006). "
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    ABSTRACT: While the uptake of voluntary medical male circumcision (VMMC) is increasing, South Africa has only attained 20% of its target to circumcise 80% of adult men by 2015. Understanding the factors influencing uptake is essential to meeting these targets. This qualitative study reports on findings from focus-group discussions with men in rural KwaZulu-Natal, South Africa, about what factors influence their perceptions of VMMC. The study found that VMMC is linked to perceptions of masculinity and male gender identity including sexual health, sexual performance and pleasure, possible risk compensation and self-identity. Findings highlight the need to understand how these perceptions of sexual health and performance affect men's decisions to undergo circumcision and the implications for uptake of VMMC. The study also highlights the need for individualised and contextualised information and counselling that can identify, understand and address the perceptions men have of VMMC, and the impacts they believe it will have on them.
    Culture Health & Sexuality 01/2015; 17(7):1-12. DOI:10.1080/13691058.2014.992045 · 1.55 Impact Factor
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    • "Three randomized controlled trials conducted in Uganda, Kenya and South Africa between 2002 and 2006 demonstrated the efficacy of voluntary medical male circumcision (VMMC) to partially protect men against HIV infection acquired through vaginal sex [1]–[4]. In these trials, infection rates in medically circumcised men were 50–60% lower than those among the uncircumcised group and VMMC services are now being scaled-up in 14 sub-Saharan countries, including Kenya [5]. "
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    ABSTRACT: Background: Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya. Methods: Focus groups (n=8) and interviews were conducted with circumcised (n=8) and uncircumcised men (n=14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n=20), health providers (n=12), community leaders (n=12) and employers (n=12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process. Results: Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included: a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered. Conclusions: Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period.
    PLoS ONE 12/2014; DOI:10.1371/journal.pone.0098221 · 3.23 Impact Factor
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