The roll-out of male circumcision: reduction in HIV prevalence, condom use maintained

The ongoing roll-out of male circumcision in Orange Farm, South Africa, has succeeded in bringing the proportion of men who are circumcised from 16 to 49% in three years, delegates heard at the sixth International AIDS Society conference (IAS 2011) in Rome on Wednesday. Among men aged 15 to 49 who are circumcised, HIV prevalence is 55% lower.

At the same time, a number of studies have shown that circumcision has not led to increases in sexual risk-taking. This is particularly important now that it is known that circumcision reduces HIV risk and therefore there could be 'behavioural disinhibition'.

But countries which have implemented large programmes to make male circumcision widely available remain the exception rather than the rule. Bertran Auvert, principal investigator at Orange Farm said that his study “shows that the roll-out of safe adult male circumcision should become a top health priority in Southern and Eastern Africa, and that a strong political commitment is needed”.

Scale-up in Orange Farm, South Africa

In 2005, a randomised controlled trial in Orange Farm (a large township 45km from Johannesburg) was the first to report that male circumcision gives men partial protection against HIV infection. Beginning in 2008, a programme to make medical male circumcision widely available has been rolled out.

All males aged 15 and over are eligible for free circumcision, which is promoted through community mobilisation and outreach. Counselling, condom distribution and testing and treatment for HIV and sexually transmitted infections are offered as part of the programme. (The roll-out activities were described in a freely available journal article last year.)

To see the reach the programme has had in the township, two cross-sectional household surveys were carried out amongst random samples of men aged 15 to 49. One was done before roll-out in 2007, the second in 2010, with each recruiting just under 1200 men.

The proportion that was circumcised rose from 15.6% at baseline to 49.4% three years later. Rates were highest in the youngest men.

In the 2010 survey, participants were counselled and tested for HIV. The researchers found that 20.0% of men who remained uncircumcised had HIV, whereas in those men who were circumcised, 6.2% had HIV.

This is an observational study, in which men chose themselves to get circumcised, so there are likely to be differences in the characteristics of those who were and were not circumcised. The researchers observed that men who were circumcised tended to be younger, better educated and more likely to know their HIV status. However, they did not observe any differences in sexual behaviour between the groups (as described below).

Taking the known differences between the groups into account, the researchers calculated that circumcision reduced the prevalence of HIV by 55% (confidence interval 39 to 70%).

Jean-Francois Delfraissy, director of the ANRS (the French AIDS research agency), the trial's sponsors, commented: “This important study confirms the data of the original randomized trials, but this time on a community scale, in 'real life': male circumcision affords men partial but substantial protection against HIV infection.”

The researchers will continue to monitor the impact of circumcision in Orange Farm. A particular focus will be to see whether HIV infections go down in women too (due to fewer of their sexual partners having HIV).

No reports of behavioural disinhibition

A concern with the introduction of any new HIV prevention method – especially one that is only partially effective – is that people using it will use condoms or other prevention methods less than before, thus cancelling out any benefit. This is sometimes called ‘behavioural disinhibition’ or ‘risk compensation’.

In Orange Farm, the researchers reported that there were no differences in sexual behaviour between those who were circumcised and those who were not. For example, the adjusted odds ratio for circumcised men to report consistent condom use (with non-circumcised men as a reference group) was 0.84 (95% confidence interval 0.63 to 1.1). This appears to be a little lower, but the difference is not statistically significant.

A survey of women in Orange Farm confirmed this finding – equal numbers of women with circumcised and uncircumcised partners reported consistent condom use. Women who expressed a preference preferred circumcised partners, but generally understood that circumcision afforded complete protection from HIV neither to men nor women.

Also presented at the conference were two studies from Kisumu, Kenya, one of the other locations where one of the key randomised controlled trials into circumcision was conducted. The two studies used different methodologies.

Firstly, household surveys of men and women aged 15 to 49 were conducted in 2009 and 2011. Although four-fifths of respondents were Luo (a cultural group that traditionally has not been circumcised), by 2011 half the men had been circumcised. Moreover, the proportion of men who said they would prefer to be circumcised rose from 60 to 69%, while the number of women who preferred men to be circumcised rose from 73 to 92%.

Comparing circumcised and uncircumcised men, there were no differences in the proportion of men who self-reported having sex without a condom, having more than one sexual partner, or being willing to risk HIV infection.

The second Kisumu study was a follow-up of 1016 men who had been circumcised six months previously, compared to a group of young men in the same area who chose not to be circumcised. These are initial findings – data from follow-up after two years will be presented at a later date.

When comparing the behaviour of circumcised men before circumcision and six months later, it appeared that men have sex slightly more often, but with the same number of partners and with small increase in condom use. There were also increases in sexual behaviour in the men who had not been circumcised, leading researcher Robert Bailey to conclude that circumcision was not the cause of more sexual activity. He said that these increases could be explained by this being a young population (average age 20), who are becoming more sexually active as they enter their twenties.

The survey also found that, six months after the operation, fewer men reported pain, abrasions or bleeding during sex. Also, fewer men reported aspects of sexual dysfunction such as an inability to climax.

Slow to scale-up

However, in the majority of countries where researchers and international agencies recommend that circumcision be scaled-up, implementation is slow and coverage remains low. Kenya is a notable exception, while the conference also heard about rapid progress in Tanzania.

Catherine Hankins of UNAIDS reviewed facilitating factors in the scale-up of male circumcision. Some key factors include community buy-in and the engagement of traditional leaders (as has happened with the Luo in Kenya); political will and leadership within the country (as has more recently been seen in South Africa); and carefully designed communication programmes.

As an example of the latter, she cited the use of a football analogy to explain partial protection in materials produced in Botswana. Circumcision is described as being like a goal-keeper, able to prevent some but not all the balls from entering the goal. Other players in the team also protect the goal (condoms, partner reduction, knowledge of status, etc). The analogy is culturally appropriate, Hankins said: “Young men get it.”

Other factors in effective scale-up include sufficient resources, task-shifting, a range of models of service delivery (outreach campaigns, mobile units, in health facilities etc.) and being open to innovations.