This update is the second in a series of three summaries of some of the key highlights related to biomedical HIV prevention research released at the International AIDS Conference, which took place July 18-23 in Vienna, Austria. This update focuses on medical male circumcision for HIV prevention. An update released last week centered on antiretroviral (ARV)-based prevention findings; the final update, coming shortly, will focus on AIDS vaccine research and work towards a cure.
While AVAC's post-Vienna update series focuses on biomedical prevention research, the conference was marked by its emphasis on human rights as the foundation for an effective AIDS response. No biomedical strategy, however effective, will have a lasting impact without concurrent action on stigma, criminalization, legal rights and evidence-based, human-rights focused approaches.
It's now been more than three years since the World Health Organization (WHO) issued its recommendation that medical male circumcision be considered as an HIV prevention strategy in countries with high HIV prevalence and low rates of male circumcision. Since then, there's been a proliferation of projects aimed at implementing this strategy as part of HIV prevention programs. This was reflected in the conference program, which featured a total of 43 poster presentations, six oral poster discussions and six oral presentations about male circumcision for HIV prevention, as well as a late-breaker on July 23 reporting data from Kenya on the impact of male circumcision on HIV and STI acquisition after 54 months of follow-up.
The Clearinghouse on Male Circumcision for HIV Prevention, a collaborative project of the WHO, UNAIDS, FHI, AVAC and other partners, has compiled a listing of all of the presentations and sessions on male circumcision for HIV prevention at the Vienna conference. The Clearinghouse offers a comprehensive array of resources for all stakeholders following this topic, including a searchable database of publications and abstracts.
For this update, we've focused mainly on three complementary updates on male circumcision introduction in Kenya, along with reports from community-level monitoring of the implications that this new strategy has for women. Many more resources can be found at the Clearinghouse site and at the AIDS 2010 conference website.
Long-term Follow-up from Kenyan Trial Cohort
For every new proven HIV prevention strategy, there are questions about how durable its effect will be, and how its introduction might change rates of HIV risk behaviors over time. As male circumcision has rolled out, the trial team involved in the Kenyan randomized controlled trial that first released results in 2006 has continued to follow participants in a long-term follow-up study. (Read the fact sheet on male circumcision and visit the Clearinghouse' research page for more in-depth overview of the research.)
In a late-breaker presented on the final day of the conference, Robert Bailey, from the University of Illinois at Chicago, reported on male circumcision rates of HIV and risk behaviors among 1,469 Kenyan men, all participants in the original trial who consented to participate in the follow-up study. Of these men, 767 were in the group randomized to be offered immediate circumcision; 785 were in the control group of participants that was asked to delay circumcision, and then offered it when the trial halted randomization because of significantly lower rates of HIV infection in circumcised versus uncircumcised trial participants in late 2006. Of the control group men, nearly half have since been circumcised. Bailey reported that after 4.5 years of follow-up, the cumulative incidence among circumcised men was 4 percent, compared to 10.6 percent in uncircumcised men. This confirms the original finding that male circumcision reduced men's risk of acquiring HIV during vaginal sex by roughly 50 percent--and over time the protective benefit climbed closer to 60 percent.
Bailey also reported on rates of sexual behaviors including condom use at last sex act, paying for sex in the last six months, number of sexual partners over the last six months and whether last sex was with a regular partner. There were no differences in reported rates of these behaviors between circumcised and uncircumcised men, indicating that at least in this community, male circumcision is not associated with increased rates of risk behavior, or risk compensation (some also refer to this as behavioral disinhibition). The slide set and audio of Bailey's presentation "The protective effect of adult male circumcision against HIV acquisition is sustained for at least 54 months: results from the Kisumu, Kenya trial" can be downloaded at http://pag.aids2010.org/session.aspx?s=643#1.
Life Outside the Clinical Trial Cohort: Another look at medical male circumcision in Kenya
While Bailey focused on data from the original trial participants, his colleague Matthew Westercamp, also from University of Illinois, reviewed findings from a cross-sectional study of Kenyan men living in Kisumu (a town in the Nyanza Province) who were not enrolled in the trial. The Circumcision Impact Study, or CIRCIS, was designed to find out how male circumcision for HIV prevention was perceived and adopted by men outside of the clinical trial context.
Roughly 1,700 individuals participated in the study, which randomly selected households in Kisumu, a town located within Nyanza Province where the national medical male circumcision program was first rolled out. Men and women were interviewed for the study, and in many of the analyses, men were broken down into categories of circumcised or uncircumcised and uncircumcised with a preference for being circumcised or uncircumcised with no preference for being circumcised. A concern regarding circumcision promotion is the degree to which men (and women) will understand that the intervention only provides partial protection and that there is continued need for safe sex practices including condom use. Some interesting data on this issue came from questions posed to uncircumcised men, some of whom said that they would prefer to be circumcised and some of whom said they preferred to remain uncircumcised. There were significant differences between these two groups of uncircumcised men. For example, those who preferred circumcision were more likely than uncircumcised men who were not interested in the surgery to report that they were less worried about HIV infection now that male circumcision for HIV prevention was available. One quarter of those uncircumcised favoring circumcision interviewed agreed that condom use during sex was less necessary--this compared to just seven percent of men preferring to remain uncircumcised. Westercamp noted that this finding highlights the importance of proper counseling and appropriate community education in scale up of medical male circumcision. The study also looked at differences between men who were already circumcised versus uncircumcised men. There were fewer differences between these two groups: similar percentages (approximately 18 percent) agreed to the idea that condom use is less necessary with circumcision available. Download the slides or slides and audio from this presentation.
Moving from Research to Rollout: Kenya's national male circumcision program
Medical male circumcision reduces individual men's risk of HIV during vaginal sex. However, the population-level impact of medical male circumcision--in terms of reduction in HIV prevalence and incidence in communities or countries--will only be realized if significant numbers of previously uncircumcised men undergo the surgery. Achieving this level of coverage requires programs that focus on circumcising as many men as possible in relatively brief periods of time.
Elijah Odoyo June from the Nyanza Reproductive Health Society delivered an update on one such project, the Rapid Results Initiative in Kenya. It was launched with the goal of circumcising 30,000 Kenyan men in 30 working days as part of the country's goal of circumcising 860,000 men over four years. The project exceeded its target, showing that rapid scale-up is possible and can be done relatively safely, as evidenced by the low rates of serious adverse events and complications reported by Odoyo June. Interestingly, 45 percent of males circumcised in the initiative were 15 years of age or younger. In many instances, parents brought their sons to be circumcised; the project also had to develop procedures for ensuring consent in young males who came without parents.
Issues around uptake of HIV testing as part of male circumcision for HIV prevention are of concern to many advocates, including women (see next item). Medical male circumcision reduces HIV-negative men's risk of acquiring HIV. It has not been shown to reduce HIV-positive men's risk of transmitting HIV to their female partners, and there is some evidence that HIV-positive men who resume sex before six weeks post-procedure (necessary to allow complete healing of the surgical wound) are more likely to transmit HIV than their uncircumcised counterparts. In the Kenyan context, roughly 55 percent of the 36,077 men circumcised during the Rapid Results Initiative underwent HIV counseling and testing; of these, 38 percent were tested at the site where male circumcision was being offered; 17 percent were tested off site; and an additional 45 percent did not undergo testing that was offered as part of the procedure. Download the slides or slides and audio from this presentation.
Women's HIV Prevention Tracking Project
The Women's HIV Prevention Tracking Project, or WHiPT, a collaborative initiative of AVAC and the ATHENA Network, presented summary results from five country teams (Kenya, Namibia, South Africa, Swaziland and Uganda) at an oral poster presentation. It highlighted the need to provide counseling to counter risk compensation among men undergoing male circumcision--a concern validated by the Kenyan CIRCIS findings. Other items documented in this community-based survey included confusion between medical male circumcision and female genital cutting in some areas; lack of clear understanding of medical male circumcision; and the urgent need for female-controlled prevention methods. Download the WHiPT summary findings, Making Medical Male Circumcision Work for Women.
This brief overview of male circumcision for HIV prevention in Vienna omits many important presentations from other countries and other contexts. We'll continue to provide updates through our Advocates' Network "round-ups" on different topics and through updated content on the Advocacy home page of the Circumcision Clearinghouse. As always, if you have questions or comments on this or any other topic, we'd love to hear them!