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).
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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
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
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).
A modelling study suggests that achieving scale-up of voluntary medical male circumcision (VMMC) as well as UNAIDS’ 90-90-90 HIV testing and treatment targets would result in even greater reductions in new HIV infections, Aidsmap reports. Published in a special collection of the journal PLoS One, the study estimated the cost-effectiveness of reaching 90 percent prevalence of circumcision among 15- to 49-year-old males in four countries and its potential contribution to HIV prevention under three scenarios involving different levels of HIV testing, treatment, and viral suppression. Adding VMMC scale-up to these scenarios, the authors wrote, “demonstrated additional reductions in HIV incidence and lower long-term program costs in models applied to Lesotho, Malawi, South Africa and Uganda.” Scaling up VMMC in the context of a 75% viral suppression rate was shown to achieve reductions in new HIV infections on par with those associated with reaching all three 90 percent targets (Aidsmap, 5 January 2017).
Lower historical rates of male circumcision were associated with higher HIV-2 prevalence in West African cities from 1985, a study published in the open-access journal PLoS One has found. The cities with higher male circumcision rates in 1950 tended to have lower HIV-2 prevalence when the first serosurveys were conducted in 1985-91. Cities in Guinea-Bissau and Côte d'Ivoire, which are thought to have been the epicenters for the emergence of HIV-2, had particularly low male circumcision rates. These results suggest that lack of male circumcision may have been a driving factor in the initial emergence of HIV-2, the authors write. They conclude that these findings “reinforce the public health rationale for encouraging voluntary medical male circumcision (VMMC) by showing that HIV-1 is not the only retrovirus whose spread may be thwarted or halted by VMMC” (ScienMag, 7 December 2016).
Religious and cultural beliefs compete with messages about the purpose of voluntary medical male circumcision (VMMC), affecting men’s decisions about whether to get circumcised, a Ugandan study found. News 24 reports that only about 20 percent of Ugandan men practice traditional male circumcision. In areas where circumcision is not a tradition, such as the fishing communities around Lake Victoria where the study was conducted, introducing VMMC is challenging because the procedure is associated with certain religious and cultural identities. The study found that traditional beliefs also affect men’s behaviour after they get circumcised, sometimes leading to early resumption of sex and other unsafe sexual behavior. The researchers concluded that VMMC programmes must consider local beliefs and involve religious and community leaders, including women, in planning and implementation (News 24, 5 December 2016).
Voluntary medical male circumcision (VMMC) services help men access healthcare earlier and link them to treatment when health problems are identified, according to an article published by Bhekisisa. The article describes one man’s experience with VMMC services in South Africa, where research has shown that men rarely visit clinics for regular check-ups. Before getting circumcised, all VMMC clients are screened for various diseases and undergo a full physical examination, enabling them to be treated for health conditions that might otherwise have gone undiagnosed. VMMC clients are also encouraged to get tested for HIV. In 2015, 85 percent of men circumcised at sites supported by the US President’s Emergency Plan for AIDS Relief were tested, with 2.3 percent testing HIV positive. VMMC clients who test HIV positive are referred to specialised facilities to receive treatment and care (Bhekisisa, 30 November 2016).
In preparation for an initiation season likely to involve more than 40,000 South African boys, the Eastern Cape Province’s legislature passed a law to make traditional circumcision safer, Dispatch Live reports. Under the new Cultural Male Circumcision bill, which is expected to be signed during the season, only boys ages 18 and older may participate in the initiation rite. The provincial government sponsored a month-long awareness campaign leading up to the season, and in each district doctors, other health practitioners, police officers, nongovernmental organization personnel, and traditional leaders are joining forces to monitor initiation schools. During last year’s season, 46 initiates died. A national toll-free number, 0800-66-11, is available for reporting abuse or other problems related to initiation rites (Dispatch Live, 24 November 2016).
Register now to join a webinar on Monday, 7 November, from 8 a.m. to 9 a.m. (EST) to learn about the new VMMC In-Service Communication Best Practices Guide and how to use it to improve counselling and other communication with clients of voluntary medical male circumcision programmes. Please note that Eastern Daylight Savings Time ends on Sunday, November 6, which means that the webinar will take place at 2 p.m. West Africa Time / 3 p.m. Central Africa Time / 4 p.m. East Africa Time.
The articles in a special PLoS collection of modelling studies offer insights on how to enhance the impact and cost-effectiveness of voluntary medical male circumcision (VMMC programmes), says a senior USAID advisor in a PLoS blog. In an interview, Dr. Emmanuel Njeuhmeli notes that the modelling results have already guided strategic changes in programme planning at a time when funding for VMMC in eastern and southern Africa has plateaued. “If countries focus now on prioritising certain age groups, risk groups, and geographic areas, they will minimise new HIV infections more efficiently and save future HIV treatment dollars,” he says. Dr. Njeuhmeli, who serves as senior biomedical prevention advisor in USAID’s Office of HIV/AIDS, adds that the articles in the collection provide countries with a good understanding of which age groups they should focus on for cost-effectiveness, immediacy of impact, and magnitude of impact (PLoS Collections Blog, 26 October 2016).
By reaching more than 1 million men, Kenya’s voluntary medical male circumcision (VMMC) programme has already prevented tens of thousands of HIV infections, modeling studies suggest. Medpage Today reports that the results of three different mathematical modelling studies agree that the 1.2 million circumcisions performed under Kenya’s VMMC programme from 2008 to 2015 averted an estimated 21,000 to 33,000 new HIV infections through 2015. The benefits of these male circumcisions are expected to accrue over time: the models estimate that by 2030, the VMMC programme will have averted 60,000 to 180,000 new HIV infections. By 2026, the cost of the programme is expected to be outweighed by the savings it has achieved in HIV treatment costs (Medpage Today, 20 October 2016).
Experiences in scaling up VMMC and other HIV prevention interventions offer important lessons for efforts to introduce new prevention technologies, Aidsmap reports in an article about presentations made at the HIV Research for Prevention conference, which was held in Chicago, Illinois, from 17 to 21 October. The presentations about VMMC described efforts to improve demand creation interventions through the application of market research in Zimbabwe and the use of motivational interviewing and financial compensation in South Africa. In these cases and those of other HIV interventions presented, success in expanding coverage required concerted efforts, marketing insights, and functional health systems (Aidsmap, 24 October 2016).