PLoS Medicine author, Catherine Hankins, took part in a discussion on the BBC World Service earlier this week asking what role adult male medical circumcision can play in tackling HIV. The Health Check programme reported from Botswana, where a recently launched national media campaign is encouraging young men to get circumcised by a trained provider as part of the country’s attempt to reduce HIV transmission. The government advertising campaign shows a goalkeeper protecting a goal as an analogy to the role that the simple procedure can play in preventing HIV. But, as the health officials in the report emphasize, rather than an isolated measure adult male circumcision is part of a HIV prevention package (including, of course, the promotion of condom use). The WHO recommends that countries with high a HIV prevalence and a low prevalence of male circumcision (like Botswana) consider male circumcision as one of a number of strategies to prevent HIV. The recommendation was prompted by randomized trials (the first of which was published by Bertran Auvert and colleagues in PLoS Medicine in 2005) that show that adult male circumcision reduces the risk of heterosexually-acquired HIV infection in men.
Catherine Hankins is part of the expert group that published a Policy Forum in PLoS Medicine last week reviewing what mathematical modelling can do to aid decisions about adult male circumcision and HIV. In her discussion on Health Check with Mike Youle, the Director of HIV Clinical Trials at the Royal Free Hospital London, she emphasized some of the conclusions arrived at in the paper published in PLoS Medicine. The paper, based on a series of meetings convened by experts at UNAIDS, the WHO and the South African Centre for Epidemiological Modelling and Analysis (SACEMA), reviewed six models that simulated outcomes. According to the paper, one HIV infection can be averted for every five to 15 adult male circumcisions performed. Whilst agreeing that adult male circumcision has been shown to be an effective way of reducing HIV infection in heterosexual men (observational data on HIV risk and circumcision status among men who have sex with men do not suggest a strong protective effect), Youle asked Hankins whether adult make circumcision benefits women and what the impact of it is on sexual behaviour (especially its impact in terms of women being able to negotiate condom use with men). Hankins said that it was “early days” in terms of showing the full benefit to women, but referred to the modelling study that suggested women benefit indirectly - a reduced chance of encountering a male partner infected with HIV and possible benefits in terms of reducing other sexually transmitted diseases that assist HIV transmission. The three trial sites in Africa examining male circumcision and condom use, Catherine Hankins added, involve community-based assessments, examining behaviour and perceptions. This opens up the possibility of talking about gender relations, violence, communication and negotiation of condom-use with participants, and provides an opportunity to reinforce the message that male circumcision is only one measure to prevent HIV and that safe sex is essential.
Both contributors agreed that adult male circumcision was cost-effective (according to the modelling paper the costs to avert one HIV infection ranged from US$150 to US$900 using a 10-y time horizon). You can listen again through the Health Check website – the report from Botswana starts at 6 minutes 20 seconds with the discussion happening at 11 minutes. You can also watch the SciVee video below, prepared by Catherine Hankins and colleagues from UNAIDS, about some of the challenges faced by decision-makers in relation to HIV and male circumcision that led to the mathematical modelling approach:
The summary of the paper has been translated into Arabic, Chinese, Danish, French, Russian and Spanish, all of which you can see in the Supporting Information section of the online article.