Research conducted in South Africa suggests that the roll-out of circumcision is reducing the prevalence and incidence of HIV among men. Published in PLOS Medicine, the study also showed circumcision does not lead to the adoption of riskier sexual behaviour that could potentially cancel its benefits.
The French researchers who conducted the study believe its findings support the accelerated roll-out of circumcision programmes for men living in settings with high HIV prevalence.
The results of three randomised controlled trials published between 2005 and 2007 showed that circumcision reduced men’s risk of infection with HIV by between 50 and 60%. As a result, since 2007 both UNAIDS and WHO have recommended that voluntary medical male circumcision (VMMC) programmes should be incorporated into prevention initiatives in settings with a high HIV prevalence.
However, little is known about the impact of circumcision roll-out programmes on the spread of HIV among men.
French investigators from the Bophelo Pele project designed a cross-sectional study involving men in the Orange Farm township in South Africa. The first randomised controlled trial to test the effectiveness of VMMC on HIV acquisition was conducted in the township between 2002 and 2005.
Roll-out of VMMC started in Orange Farm in 2008 and between 2007 and 2008 the French investigators recruited 1998 men between the ages of 15 and 49 years to a baseline survey. The men were tested for HIV, their circumcision status was determined and demographic data were collected. The men were also asked about their sexual risk behaviour, including condom use and number of non-spousal partners.
A follow-up survey was conducted in 2010 and 2011 and involved 3388 men.
The investigators calculated the prevalence of circumcision, compared HIV prevalence rates and sexual risk behaviour between circumcised and uncircumcised men and calculated the impact of circumcision roll-out on HIV incidence.
Circumcision prevalence increased from 17% in the baseline survey to 53% in the 2010-2011 survey.
“This study has shown that the roll-out of free VMMC can lead to a substantial uptake in just a few years,” comment the authors.
There were no significant differences in the sexual behaviour of circumcised and uncircumcised men. The proportion of circumcised and uncircumcised men reporting consistent condom use in the previous twelve months was 44 vs 45%. The proportion reporting two or more non-spousal partners was 50 vs 44%.
The HIV prevalence rate among uncircumcised men was 19% compared to 7% among circumcised men with an overall prevalence rate of 12%. The investigators calculated that it would have been 15%, almost a fifth higher, if the circumcision programme had not been rolled out.
Moreover, the authors also calculated that the roll-out of VMMC reduced the incidence of new HIV infections by between 57 and 61%.
“The 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 estimate that without this project, HIV prevalence averaged on all adult men would have been significantly higher,” write the authors.
They acknowledge that their study has limitations, chief among these its cross-sectional design. As the study was not randomised, it could not prove a causal relationship between circumcision status and the risk of HIV infection.
Nevertheless, the authors believe their research shows the value of circumcision and conclude: “the main implication of this study is that the current roll-out of adult VMMC…should be accelerated.”
Auvert B et al. Association of the ANRS-12126 male circumcision project with HIV levels among men in a South African township: evaluation of effectiveness using a cross-sectional surveys. PLOS Medicine, 10:9, e1001509, 2013.