Bill and Melinda Gates praise Kenya’s voluntary medical male circumcision (VMMC) programme and recent rollout of pre-exposure prophylaxis in a new report, The Star reports. In Goalkeepers 2017, the first in a series of annual reports on progress toward the United Nations Sustainable Development Goals, they cite Kenya’s use of two of the most effective prevention methods available and say that “other countries can learn a lot from Kenya’s experience.” The country’s VMMC programme reached 71 percent of its national goal for VMMCs performed by 2013 but surpassed its VMMC target for the priority region of Nyanza, where most of the implementation took place (The Star, 14 September 2017).
News & Events
Swaziland has almost reached the 90-90-90 goals for HIV testing, treatment, and viral suppression set for 2020, Medpage Today reports. Nationally representative household surveys found that in 2016, almost 85 percent of Swazi adults had been tested for HIV, more than 87 percent of those who had tested positive were on antiretroviral therapy (ART), and nearly 92 percent of those on ART had viral loads suppressed to undetectable levels. HIV incidence was almost halved, falling from 2.48 percent in 2011 to 1.39 in 2016. These results were reported in a presentation at the 9th International AIDS Society Conference on HIV Research (IAS 2017) in Paris, France, on 24 July 2017. The Medpage Today article describes how reaching more people with HIV testing, treatment, and prevention services — including more than doubling the number of men who had received voluntary medical male circumcisions from 2011 to 2016 — helped the country achieve these milestones (Medpage Today, 27 July 2017).
Women who reported that their most recent male sex partner was circumcised were less likely to have HIV and genital herpes than women whose last partner was not circumcised in a study in South Africa, Aidsmap reports. This study, which was presented at the 9th International AIDS Society Conference on HIV Research (IAS 2107) in Paris, France, on 25 July, analysed data on 4,766 women from consecutive household surveys conducted in two subdistricts of KwaZulu Natal, comparing rates of HIV and other sexually transmitted infections among the women with circumcised partners with the rates among the women with uncircumcised partners. In a multivariate analysis that attempted to control for other differences between the two groups of women, those with circumcised partners were about 30 percent less likely to have HIV and about 20 percent less likely to have herpes simplex virus 2 (Aidsmap, 26 July 2017).
A study conducted in Uganda has revealed that a 10-fold increase in several types of bacteria living under a man’s foreskin can increase his risk of acquiring HIV infection by up to 63 percent, Medical Xpress reports. The researchers said that this study, which was published in the journal MBio on 25 July, is the first to show that having more oxygen-intolerant bacteria colonizing the foreskin can be an independent risk factor for HIV. The study suggests that some species of anaerobic bacteria trigger “biochemical alarms” that draw immune cells to the penis, where they are more easily infected by HIV, one of the investigators explained. Another is quoted as saying that “this work helps us understand how medical male circumcision reduces HIV infection in men and points towards novel interventions to decrease HIV risk in the future” (Medical Xpress, 25 July 2017).
Among South African men tested for HIV before voluntary medical male circumcision (VMMC), the proportion testing positive increases with age, reports the Cape Times News. A study presented at the Eighth Annual South Africa AIDS Conference in Durban on 13 June found that the percentage of VMMC clients services who tested positive for HIV increased at age 22 and rose sharply among men age 40 and older (Cape Times News, 14 June 2017).
Well-known local actors and musicians have joined a nationwide campaign by the Community Media Trust to promote voluntary medical male circumcision (VMMC) in South Africa, Independent Online reports. The “Man Up” campaign aims to debunk myths about the procedure and encourage men to become circumcised as an additional protective measure against HIV, other sexually transmitted infections, and penile cancer. Actor Wandile Molebatsi, one of at least 11 local stars serving as ambassadors for the campaign, is quoted as saying that “we should talk more openly about the wide-ranging benefits of circumcision” (Independent Online, 7 June 2017).
Research among men in Lesotho has found that traditionally circumcised men are more likely to be HIV-positive than men who were circumcised in a health facility, Sunday World reports. The study, which was published in the online journal PLOS One, analyzed data collected on 2,546 men in Lesotho, where traditional male circumcisions account for 91 percent of all such procedures. The researchers found no evidence that men in either group engaged in riskier sexual behavior after being circumcised, making it unlikely that a difference in post-circumcision behavior explains the higher risk of HIV among those circumcised traditionally. Studies in Lesotho and South Africa have found that traditional circumcision usually does not involve complete removal of the foreskin, which harbours cells targeted by HIV. The lack of protection afforded by traditional male circumcision may explain why previous studies have shown no association between male circumcision and reduced risk of HIV in Lesotho (Sunday World, 15 May 2017).
The US President’s Emergency Plan for AIDS Relief (PEPFAR) had supported 11.7 million VMMC procedures by the end of 2016, approaching the 2017 goal of 13 million. Appendix L of PEPFAR’s 2017 Annual Report to Congress details the progress made in reaching men and boys with VMMC for HIV prevention in 14 priority countries in sub-Saharan Africa. PEPFAR is expanding its support for VMMC in 2017, with an emphasis on reaching men ages 15 to 29 to achieve the greatest possible reductions in HIV infections
Photo credit: Skye Grove/Right to Care
New modelling studies published in a PLoS collection assess the effects of focusing VMMC programmes on narrower client age groups and specific geographic areas. The studies are assisting decision makers in making more informed decisions about which strategies and investments to prioritize to achieve their goals for reducing new HIV infections.
June’s winter initiation season will be the first test of a law designed to improve the safety of traditional male circumcision in South Africa’s Eastern Cape Province, Dispatch Live reports. These changes to the Customary Male Initiation Practice Act passed the provincial legislature unanimously and were signed into law in May. The new law requires registration of traditional circumcisers and traditional nurses and sets the minimum age for traditional circumcision at 18. The Daily Dispatch reported in January that 29 initiates died and nine traditional surgeons and nurses were arrested during the 2016 summer initiation season (Dispatch Live, 15 June 2017).
The annual rate of new HIV infections has fallen by 42 percent over the past four years ― from 1.17 percent to 0.66 percent ― in one of the most-studied groups of people in Africa, Aidsmap reports. Speaking at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) in Seattle, Washington, USA, on 14 February, presenter Mary Grabowski confirmed that this is the first population-level decrease in HIV incidence observed in cohort studies in Rakai, Uganda, dating from 1994. (The Rakai Cohort Study enrolls all adults who wish to participate and are ages 15 to 49 in a 50-village territory.) Data from 12 surveys conducted in 30 villages in Rakai from 1999 to 2016 show that HIV incidence held steady for 10 years, then began to drop in 2011. Increases in the proportion of people living with HIV who are virally suppressed, in coverage of voluntary medical male circumcision, and in the delay of sexual debut among young people all appear to be contributing to the decline in new HIV infections (Aidsmap, 14 February 2017).
Three large studies in South Africa, Zimbabwe, and Kenya have found no evidence that men who have been circumcised engage in riskier sexual behaviour compared to uncircumcised men, Aidsmap reports. The studies examined self-reported behaviours, including condom use and number of sexual partners, to assess whether men adopted riskier sexual behavior after becoming circumcised. Such “risk compensation” would mitigate or negate the protective effect of male circumcision in reducing HIV infection. In each of the studies, there were no statistically significant differences in the sexual behaviors of circumcised and uncircumcised men. The studies in South Africa and Zimbabwe were presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2017), and the Kenya study was published in the February issue of the Journal of Acquired Immune Deficiency Syndromes (Aidsmap, 22 February 2017).
Updated recommendations on tetanus vaccination, published in a position paper in the Weekly Epidemiological Record of the World Health Organization (WHO) on 10 February 2017, address a gap in immunity among boys and men identified in part through safety monitoring of voluntary medical male circumcision (VMMC) programmes. A WHO-led review reported that 15 cases of tetanus identified by August 2016, after more than 12 million VMMCs, were due primarily to an increased risk of tetanus with use of an elastic collar compression method of circumcision or application to circumcision wounds of substances that may contain C tetani spores. It also revealed that adolescent boys in African countries are less likely than girls to have received the booster doses of tetanus toxoid-containing vaccine needed for lifelong protection against tetanus.
In response, WHO issued recommendations to prevent rare but potentially fatal cases of tetanus following VMMC and worked with the Strategic Advisory Group of Experts on Immunization on recommendations for increasing tetanus booster coverage among girls and boys. This guidance (see pp. 72-73 of the position paper) includes recommendations for providing “catch-up” tetanus immunisations to adolescent and adult VMMC clients prior to or at the time of VMMC and to adolescent girls and boys during delivery of HPV vaccinations. Three routine tetanus boosters are now recommended at 12 to 23 months, 4 to 7 years, and 9 to 15 years of age, allowing for the flexibility to provide these vaccinations with other services (WHO Weekly Epidemiological Record, 10 February 2017).
Photo credit: Emmanuel Dipo Otolorin, Courtesy of Photoshare
Uganda has registered a drastic decline in the number of voluntary medical male circumcisions (VMMCs) performed, from 900,000 procedures conducted annually in the past years to 556,000 in 2015, The Monitor reports. The manager of the Ministry of Health’s (MOH’s) AIDS control programme is quoted as saying that the reduction came after the government began giving VMMC clients two tetanus toxoid (TT)-containing vaccinations four weeks apart before circumcising them. The World Health Organization (WHO) recommended integrating TT vaccination into VMMC services after rare but fatal cases of tetanus infection were reported in Uganda and several other countries. WHO’s latest guidance, based on a technical review of tetanus cases after VMMC, recommends different approaches to TT vaccination depending on whether male circumcision is performed surgically or with an elastic-collar compression device. The Monitor reports that Uganda’s MOH is reviewing its policy and will likely move to giving one dose of TT-containing vaccine before surgical male circumcision but retain the two-dose schedule for nonsurgical VMMC procedures unless clients have documented evidence of adequate protection against tetanus (The Monitor, 8 February 2017).
Educating religious leaders about how voluntary medical male circumcision (VMMC) helps prevent HIV infection increased the number of men being circumcised in Tanzania, a study published in The Lancet has found. The intervention consisted of a one-day seminar co-taught by a Tanzania pastor and a clinician who worked with the Tanzanian Ministry of Health (MOH), followed by meetings with the study team every two weeks. The church leaders who received this education developed culturally appropriate ways to promote VMMC in their villages. In the eight villages where the leaders were taught about circumcision, 52.8 percent of men became circumcised during the MOH’s VMMC campaign, compared to 29.5 percent of men in eight villages that received information from the campaign only — a 23 percent increase. The researchers estimate that if the intervention were used across Tanzania, it could lead to an additional 1.4 million male circumcisions, which could prevent 65,000 to 200,000 new HIV infections. In a commentary on the study, Nelson Sewankambo and David Mafigiri of Makerere University in Uganda call for more research on innovative religious-based interventions to promote healthy behaviour in religious communities (The Lancet, 14 July 2017).