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Voluntary Male Circumcision as HIV Prevention in Africa

PLOS Medicine Associate Editor Linda Nevin discusses the landmark publication, and striking impact, of the first randomized clinical trial of voluntary medical male circumcision, published in PLOS Medicine in 2005.

Image credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania.
Image credit: (left) Sgt. Adam Fischman, US Army Africa & (right) Sterling Riber, MFDI for Jhpiego/Tanzania.

Since the 1980s, observational studies have shown that HIV infection rates in African tribal or ethnic groups that practice male circumcision are lower than rates in groups that do not. HIV protection by male circumcision has biologic plausibility; the removal of the foreskin reduces the covered, moist space in which the virus can incubate after sex. However, because ecological studies can never establish causality, the potential benefits of promoting male circumcision in African communities remained unclear past the year 2000. In 2005, Bertran Auvert and colleagues at the Hôpitaux de Paris, Boulogne, France published the first randomized clinical trial (RCT) of circumcision for HIV prevention, conducted in Orange Farm, a semiurban region close to Johannesburg, South Africa. In this trial, about 3,000 young, heterosexual uncircumcised men were randomly allocated to be circumcised upon enrollment, or 21 months later. In a planned interim analysis 17 months after the study was initiated, the authors observed a striking difference in incidence of HIV infection in the uncircumcised group (49 cases of 1582 participants) compared with the newly circumcised men (20 cases of 1546). The difference represented a statistically significant protection of 60% (95% confidence interval 32%–76%). At the request of the trial’s data and safety monitoring board, the trial was immediately stopped and all interested participants were circumcised.

This was broadly considered a landmark study in the field of HIV research. Its publication initiated robust debate about trial controls, blinding, covariates analyzed, and ethics; the paper has been cited in 998 scientific publications, and collected 99,867 page-views to date. At the time of publication, two other trials– in Kenya and Uganda— were underway, and researchers in the field waited on tenterhooks to see if the Orange Farm RCT results would be corroborated. They were. However, questions remained on the pragmatic front. Would a larger roll-out of a male circumcision program be effective across the diverse communities of Eastern and Southern Africa? Would circumcised men engage in risk compensation, the increase in unsafe behavior due to perceived protection?

Based on trial findings, Auvert and colleagues began a community-wide scale-up of voluntary male circumcision in Orange Farm in 2008. Their results from the 2008-2011 study period, published in PLOS Medicine in 2013, were a second landmark achievement. They observed an increased prevalence of circumcision (from 12% to 53%), a roughly 60% reduction in risk of contracting HIV among circumcised compared to uncircumcised men (consistent with the RCT), and no detectable increase in risky sexual behaviors among circumcised men. Using these numbers, the authors estimated that the VMMC scale-up reduced the 2011 prevalence of HIV in the community from a projected ~15% to ~12%.

Voluntary medical male circumcision is not without controversy. Detractors note (correctly in each case) that risk of HIV infection through sex is actually increased during the six-week recovery period after circumcision and that self-reports of risk compensation may be unreliable. However, on balance, research findings continue to support the policy. The positive results from Orange Farm have made voluntary medical male circumcision a WHO priority, and scale-up of promotional activities in Southern and Eastern African nations has proceeded at full tilt. According to a WHO report at this year’s International AIDS Conference, 5.8 million men have become circumcised in 14 eastern and southern African countries since 2008. Progress should continue at a similar pace; Malawi aims to circumcise 1.8 million men by 2018, Tanzania, 2.8 million by 2017. Notably, a recent longitudinal study in Kenya suggests that the procedure does not lead men to adopt riskier behaviours.

A number of milestones in this highly active research field have been published in PLOS Medicine or PLOS ONE. PLOS has curated a collection of research and review pieces from the field, and PLOS contributors have blogged about the topic.

Circumcision and HIV at PLOS, 2005-2014

October 2005
Bertran Auvert and colleagues publish their RCT showing that voluntary male circumcision reduces HIV transmission by 60% in a South African community.

Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial
http://www.plosmedicine.org/article/metrics/info%3Adoi%2F10.1371%2Fjournal.pmed.0020298

July 2006

Brian Williams and colleagues publish a model of the effect of male circumcision on HIV transmission across sub-Saharan African; they predict that, with 100% coverage, circumcision could avert 2 million new HIV infections and 0.3 million deaths over the next ten years.

The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0030262#close

December 2010
Matthew Westercamp and colleagues publish survey findings indicating that male interest in circumcision is linked to personal risk and to knowledge of the preventive benefit shown in RCTs.

Male Circumcision in the General Population of Kisumu, Kenya: Beliefs about Protection, Risk Behaviors, HIV, and STIs
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0015552

September 2013

Auvert and colleagues report favorably on the scale up of voluntary male circumcision in Orange Farm.

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
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001509#close

 

This is post 7 of 8 in PLOS Medicine’s 10th Anniversary blog series on the most interesting and influential articles of the last ten years.You can find links to all the posts in the series as they are published here.

 

Discussion
  1. If these studies were so well done, why have the results never been duplicated outside of Africa?
    Why is circumcision being touted as a remedy for HIV infection, when no one suggests that circumcision alone, without additionally using a condom, is safe?
    If you have to use a condom, why sacrifice all those pleasurable nerves?

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