About MMC

  • 1. What is Medical Male Circumcision?

    Medical male circumcision (MMC) is the surgical removal of the foreskin of the penis, by a trained health care professional or Doctor.

    Reference:

    • Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world’s oldest and most controversial operation. Obstet Gynecol Surv. 2004 May;59(5):379-95.

  • 2. What are the benefits of MMC?

    Health benefits to men

    • MMC reduces the risk of an HIV negative male contracting HIV through heterosexual sex by 60%
    • MMC reduces the risk of sexually-transmitted infections (herpes simplex)
    • MMC makes the penis easier to clean
    • MMC is linked to a reduction in prostate cancer and genital cancer

    Health benefits to women

    • MMC reduces the risk of developing cervical cancer, contracting genital ulcer disease and vaginal infections (bacterial vaginosis and trichomonas infection) for female partners of medically circumcised men;
    • At a population-level, widespread medical male circumcision will benefit women by reducing their risk of exposure to HIV;
    • Modelling of a MMC scale up at 80% suggests almost half of all HIV infections averted by 2025 are those that would have occurred among women;
    • Further indirect benefits include a reduction in rates of mother-to-child transmission of HIV.

    References:

    • Hirbod T, Bailey RC, Agot K, et al. Abundant expression of HIV target cells and C-type lectin receptors in the foreskin tissue of young Kenyan men. Am J Pathol. 2010;[publication ahead of print].
    • Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol. 2002 Sep;161(3):867-73.
    • Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 10.
    • Kamali A, Nunn AJ, Mulder DW, et al. Seroprevalence and incidence of genital ulcer infections in a rural Ugandan population. Sex Transm Infect. 1999;75:98-102.
    • Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75:3-17.
    • Corey L, Wald A, Celum CL, et al. The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics. J Acquir Immune Defic Syndr. 2004;35:435-45.
    • Bailey RC, Mehta SD. Circumcision’s place in the vicious cycle involving herpes simplex virus type 2 and HIV. J Infect Dis 2009;199:923-5.
    • Telzak EE, Chiasson MA, Bevier PJ, et al. HIV-1 seroconversion in patients with and without genital ulcer disease. A prospective study. Ann Intern Med. 1993;119:1181-6.
    • Parkin D. The global health burden of infection-associated cancers in the year 2002. Int J Cancer. 2006;118:3030-44.

    Economic, health and humanitarian benefits

    The long-term population-level benefits of implementing and scaling-up MMC services is expected to be considerable in terms of HIV infections averted, as well as net-savings associated with the reduced need for treatment, care, and support of infected individuals. In addition, the protections afforded by MMC can be expected to avert incalculable human suffering and loss.

    Savings associated with MMC:
    In some high prevalence settings, if scale-up is rapid, every US dollar spent on MMC has the potential to save US$14 in care and treatment costs.

    Results from MMC modelling suggest that scaling up adult MMC to reach 80% in 13 countries in sub-Saharan Africa with generalised HIV epidemics and low male circumcision prevalence by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in potentially averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net-savings (due to averted treatment and care costs) amounting to US$16.51 billion.

    Modelling studies also have found that expansion of MMC services produces net-savings when compared to lifetime HIV treatment costs. Scaling up MMC for HIV prevention is cost saving and creates fiscal space in the future that otherwise would have been encumbered by antiretroviral treatment costs.

    Infections averted:
    Previous model-based studies estimated that MMC scale-up in countries with generalised HIV epidemics could result in substantial reductions in HIV transmission and prevalence over time among both men and women.

    A recent review of these studies concluded that one HIV infection could be averted for every five to 15 MMCs performed.

    References:

    • Njeuhmeli E et al. 2011. Voluntary medical male circumcision: Modelling the impact and cost of expanding male circumcision for HIV prevention in Eastern and Southern Africa. PLoS Medicine 8(11): e1001132.
    • Hankins CA, Njeuhmeli E and Forsythe S. 2011. Cost, impact, and challenges of scaling up voluntary medical male circumcision. PLoS Med 8(11): e1001127.
    • (50) Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision Making? UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention mail. Published: September 08, 2009. DOI: 10.1371/journal.pmed.1000109

  • 3. Why is MMC effective for HIV prevention?

    Compared with the relatively dry and tough external surface of the exposed head of the penis, the inner surface of the foreskin is moist, soft and has a high concentration of target cells for HIV infection. Laboratory studies have shown the foreskin is more susceptible and has an affinity conducive to viral attachment to target cells compared to other tissue.

    The foreskin may have a greater susceptibility to tears and abrasions during sex, creating tiny microscopic holes for the entry of infections, including HIV. In addition, the moist micro-environment adjacent to the foreskin may be conducive to viral survival. The correlation of STIs and HIV transmission is well documented. The presence of other sexually transmitted infections (STIs), which independently may be more common in uncircumcised men, may increase the risk of HIV acquisition.

    Source: www.cdc.gov/hiv/prevention/research/malecircumcision/

    References:

    • Hirbod T, Bailey RC, Agot K, et al. Abundant expression of HIV target cells and C-type lectin receptors in the foreskin tissue of young Kenyan men. Am J Pathol. 2010;[publication ahead of print].
    • Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol. 2002 Sep;161(3):867-73.
    • Ding M, al. e. HIV-1 interactions and infection in adult male foreskin explant cultures. 16th Conference on Retroviruses and Opportunistic Infections. Montreal, Canada; 2009.
    • Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ. 2000 Jun 10;320(7249):1592-4.
    • Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 10.
    • Kamali A, Nunn AJ, Mulder DW, et al. Seroprevalence and incidence of genital ulcer infections in a rural Ugandan population. Sex Transm Infect. 1999;75:98-102.
    • Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75:3-17.
    • Corey L, Wald A, Celum CL, et al. The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics. J Acquir Immune Defic Syndr. 2004;35:435-45.
    • Bailey RC, Mehta SD. Circumcision’s place in the vicious cycle involving herpes simplex virus type 2 and HIV. J Infect Dis 2009;199:923-5.
    • Telzak EE, Chiasson MA, Bevier PJ, et al. HIV-1 seroconversion in patients with and without genital ulcer disease. A prospective study. Ann Intern Med. 1993;119:1181-6.

  • 4. What other health benefits does MMC deliver?

    Male circumcision reduces human papillomavirus (HPV) acquisition by men, thus also reducing their female partners’ exposure to HPV. HPV is the main cause of cervical cancer among women. This means that male circumcision is also indirectly beneficial to women in reducing their exposure to sexually transmitted diseases other than HIV.

    The presence of the human papillomavirus (HPV) is linked to 100% of cervical cancers, 90% of anal cancers, and 40% of cancers of the penis, vulva, and vagina. In a review, circumcision was associated with significantly less HPV infection in men.

    References:

    • Parkin D. The global health burden of infection-associated cancers in the year 2002. Int J Cancer. 2006;118:3030-44.
    • Tobian AA, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009;360:1298-309.
    • Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis. 2009;199:14-9.
    • Castellsague X, Bosch FX, Munoz N, Meijer CJ, Shah KV, de Sanjose S, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med. 2002 Apr 11;346(15):1105-12.

    The lifetime risk for a South African male of ever being diagnosed with penile cancer is 1 in 1 301. The risk of penile cancer is about 3 times higher for men who are uncircumcised, or are circumcised later in life.

    Source: www.cansa.org.za/files/2013/11/Fact-Sheet-Penile-Cancer-Nov-2013.pdf

    Studies have consistently concluded that male circumcision is associated with a significantly reduced risk of urinary tract infection (UTI).

    References:

    • Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008 Apr;27(4):302-8.
    • Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child. 2005 Aug;90(8):853-8.
    • To T, Agha M, Dick PT, Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet. 1998 Dec 5;352(9143):1813-6.
    • Wiswell TE and Hachey WE. 1993. Urinary tract infections and the uncircumcised state. Clin Pediatr 32: 130–134

    Data from clinical trials also provides evidence that circumcision is significantly associated with decreased incidence of other STIs like herpes simplex virus type 2 (HSV-2), genital ulcer disease and syphilis.

    References:

    • Tobian AA, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med. 2009;360:1298-309.
    • Sobngwi-Tambekou J, Taljaard D, Lissouba P, Zarca K, Puren A, Lagarde E, et al. Effect of HSV-2 serostatus on acquisition of HIV by young men: results of a longitudinal study in Orange Farm, South Africa. J Infect Dis. 2009 Apr 1;199(7):958-64.
    • Sobngwi-Tambekou J, Taljaard D, Nieuwoudt M, et al. Male circumcision and Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis: observations after a randomised controlled trial for HIV prevention. Sex Transm Infect. 2009;85:116-20.
    • Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-666.
    • Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female partners’ genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol. 2009;200:42 e1-7.
    • Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 10.

    Adult circumcision could potentially halve the risk of prostate cancer. When performed on men over the age of 35, circumcision could reduce the risk of developing prostate cancer by nearly half, according to a Canadian study published in the British Journal of Urology International.

    Source: www.timeslive.co.za/lifestyle/article11466712.ece

  • 5. How is MMC performed?

    Surgery

    There are three recommended methods for surgery, each with advantages and disadvantages, some better suited to specific anatomical cases (such as developing anatomy, phimosis etc.) All have excellent safety records when performed by a trained professional and all require local anaesthesia, and are conducted on an out-patient basis with full recovery in as little as six weeks.

    Medical male circumcision is one of the most common procedures performed worldwide and complications are very rare (between 1% and 2%) and usually easily resolved.

    Source: www.tac.org.za/sites/default/files/publications/2012-05-24/TACCircENGMarch2011.pdf

    Devices

    Devices may offer a potential solution toward a faster, easier method of MMC scale-up in areas of South Africa with a high prevalence of HIV infection where the surgical provision of MMC may not be ideal, such as in deep rural areas. Circumcision by device may appeal to some in the target audience, who may cite convenience, ease of application, and lack of blood loss and suturing as advantages over surgical MMC. Therefore the WHO has requested that new, cost-effective techniques be developed to facilitate scale-up and provide MMC candidates with new options.

    Several innovative circumcision devices are at different stages of investigation through closely monitored clinical trials and initial roll-outs. These trials have generally shown their benefits and adverse effects to be comparable with surgical MMC.

    There are two categories of circumcision devices in clinical trials, classified by their mechanism of action:

    (a) Elastic collar compression devices

    The mechanism of action is a slow compression of the foreskin between an elastic band and an underlying rigid ring. The band restricts the blood supply until the foreskin becomes necrotic (dead tissue), dries and can be cut off (after approximately five days). This type of device can be applied without injected local anaesthetic and does not require a sterile field for placement.

    Example: Prepex. This device consists of an elastic band that compresses the foreskin. The procedure does not involve stitches or an injectable anaesthetic but the patient does have to return to the clinic for device removal seven days after placement. For more information and illustrations, refer to www.prepex.com

    Note: This device has been ‘prequalified’ by the WHO in May 2013, and is expected to be introduced in South Africa by mid-2015. Pre-qualification means that the WHO has, following a detailed review process, determined that a device (or medicine) has met the standards for international use.

    (b) Clamp devices

    The mechanism of action is a rapid, tight compression of the foreskin between hard surfaces to achieve haemostasis (stopping of blood flow). Compression is sufficient to prevent slippage of tissue so that the foreskin can be removed at the time of, or soon after, placement of the device. Part of, or, the entire device is left in place for more than 24 hours to prevent bleeding.

    Because the device crushes the foreskin upon placement, and live tissue is excised immediately after device placement, injection of local anaesthesia is required for pain control. This category includes two subcategories: collar clamp devices and vice clamp devices. Both require a sterile field for implementation.

    Reference:

    • WHO technical advisory group on innovations in male circumcision: evaluation of two adult devices. Meeting report – Geneva, Switzerland. January 2013

    Example 1: Shang Ring. The Shang Ring is a nonsurgical device for male circumcision. It consists of two concentric plastic rings that compress the foreskin, allowing it to be cut away without suturing and with minimal bleeding. Performed in a clinic under local anaesthesia, the procedure takes about five minutes. The patient returns in one week for device removal. For more information and illustrations, refer to www.shangring.cn

    Note: This device is currently being evaluated by the WHO for pre-qualification.

    Reference:

    • Mark Barone. A field study of male circumcision using the Shang Ring, a minimally-invasive disposable device, in routine clinical settings in Kenya and Zambia. Abstract (2013).
      pag.ias2013.org/Abstracts.aspx?SID=73&AID=3078
    • Barone MA, Ndede F, Li PS, et al. The Shang Ring device for adult male circumcision: a proof of concept study in Kenya. J Acquir Immune Defic Syndr 2011;57:e7-12.

    Example 2: UniCirc. The Unicirc device clamps the foreskin, removing it and sealing the wound with tissue adhesive (which is an established wound-closure technique), avoiding the use of sutures. In limited cases where the adhesive fails, sutures are applied. The use of cyanoacrylate tissue adhesive in circumcision has been shown to be safe and effective in both boys and men.

    It is also reportedly quick, simple to learn, nearly bloodless and heals rapidly. For more information and illustrations, refer to www.circlist.com/instrstechs/unicirc.html

    Note: this device is still undergoing clinical trials and has not been prequalified for use by the WHO.

    Reference:

    • Millard PS, Wilson HR, Goldstuck N, Anaso C. Rapid, minimally invasive adult voluntary male circumcision: A randomised trial of Unicirc, a novel disposable device. S Afr Med J 2013;104(1):52-57. [http://dx.doi.org/10.7196/SAMJ.7357]

  • 6. Are there any risks associated with MMC?

    MMC is a low risk procedure. However, there are some risks associated with MMC both during and following the procedure. These are termed adverse events (AE). Most of the reported adverse events (99%) are not severe and are easily treated. The overall AE rate is typically 1%- 2% in South Africa. Adverse events are mostly caused by early resumption of sex/masturbation (abstinence period of six weeks is recommended) or poor wound care (failure to keep penis upright; not washing regularly with salt water and insufficient changing of dressings).

    Mild adverse events include:

    • Infection and delayed wound healing
    • Wound disruption or continuous bleeding
    • Swelling due to tight bandages or inappropriate application of wound-dressings

    The risk of adverse events are minimised by:

    • Counselling and education at time of procedure about wound care and the importance of sexual abstinence during the wound healing period
    • Provision of clear wound care instructions
    • Routine post-operative check-up (48 hours, 7 days and 21 days post procedure)

    Minimising pain is an important consideration for male circumcision. Appropriate use of mild analgesia is considered standard care for the procedure at all ages and is generally effective for controlling pain.

    References:

    • Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.
    • Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24;369(9562):643-56.
    • Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-666.
    • Kigozi G, Watya S, Polis CB, et al. The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU Int. 2008 Jan;101(1):65-70.
    • Kigozi G, Gray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med. 2008;5:e116.

    Clinicians are able to conduct a safe and effective circumcision on males of any age. The National Department of Health and Partners use the following guidelines on age eligibility:

    • The target age range for the National Programme is 15 – 49 years
    • Males younger than 10 are not eligible
    • Males between the ages of 10 – 17 are eligible with informed consent documentation
    • Each province follows their own mandate with regard to minimum age (10, 12 or 15)
    • Service delivery is always at the discretion of the resident health practitioner taking consideration of the best interests of the patient in respect of health and safety
    • Men over the age of 49 can access the programme but they are not a key target audience
  • 7. MMC and Minors

    Clinicians are able to conduct a safe and effective circumcision on males of any age. The National Department of Health and Partners use the following guidelines on age eligibility:

    • The target age range for the National Programme is 15 – 49 years
    • Males younger than 10 are not eligible
    • Males between the ages of 10 – 17 are eligible with informed consent documentation
    • Each province follows their own mandate with regard to minimum age (10, 12 or 15)
    • Service delivery is always at the discretion of the resident health practitioner taking consideration of the best interests of the patient in respect of health and safety
    • Men over the age of 49 can access the programme but they are not a key target audience
  • 8. Why do circumcised men still need to use condoms?

    Male circumcision provides partial protection. Education to counter the perception that circumcision is a “natural condom” or that it provides full protection is critical. In the healing period, sexually active men are likely to be at a higher risk of HIV infection due to an exposed wound. This risk should not be underestimated. Male circumcision provides partial protection.

    Risk compensation describes circumcised men who decrease condom use or engage in risky behaviour because they perceive circumcision to offer full protection. Significant risk compensation could reduce the protective effect of circumcision and reduce the impact of the programme on HIV transmission reduction. However, the available data suggest that men do not significantly change their behaviour after circumcision. Risk-taking levels remain relatively fixed over time among circumcised and uncircumcised men, even among recently circumcised men.

    Reference:

    • Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 10.

    All circumcision programmes must emphasise that circumcision provides only partial protection, and that there is a critical need to practice safe sex after circumcision (e.g. partner limitation and consistent condom use).

  • 9. MMC and HIV Positive men

    There is no evidence that circumcising men living with HIV will reduce the risk of HIV being transmitted to their sexual partners.

    • MMC is available to HIV Positive males but, as per any surgical procedure, they will be clinically assessed prior to undergoing the procedure to ensure the safety of the client.
    • There is no difference in surgically related complications for people living with HIV or HIV negative males.

    Reference:

    • Kigozi G, Gray RH, Wawer MJ, et al. The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda. PLoS Med. 2008;5:e116

    • Randomised controlled trial of male circumcision in HIV Positive men in Uganda suggest that the immediate post-operative period may be a time of high risk for HIV transmission from infected men to their uninfected partners.
    • There may also be a period of high vulnerability to HIV acquisition in the immediate post-operative period due to the presence of a healing wound in newly circumcised uninfected men.
  • 10. MMC and MSM (Men who have Sex with Men)

    Currently there is no evidence that MMC offers any benefit to MSM. The main route of HIV infection in MSM is receptive anal sex, where circumcision status is unlikely to play a protective role.

    References:

    • Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. Jama. 2008; 300(14):1674–1684. doi: 10.1001/jama.300.14.1674.
    • Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al. Lower risk of HIV infection among circumcised MSM: Results from the Soweto Men’s Study. In: 5th International Aids Society Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town; 2009.
    • Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA 2008; 301(11):1126-1129.
    • Templeton DJ, Millett GA, Grulich AE. Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men. Curr Opin Infect Dis 2010; 23(1):45-52.

    However, there is robust evidence that approximately half of South African MSM also have sex with women. Men with high levels of bisexual concurrency may derive risk-reduction benefits during sexual encounters with women.

    Reference:

    • Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al. Lower risk of HIV infection among circumcised MSM: Results from the Soweto Men’s Study. In: 5th International Aids Society Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town; 2009.

    MMC should therefore be offered to all men, irrespective of sexual orientation, but education and information needs to be nuanced correctly so that men understand the benefits and deficiencies of MMC.

    In addition to the above, MMC offers no benefit to:

    • Intravenous drug users: male circumcision is unable to prevent HIV infection in intravenous drug users who use contaminated equipment

    Further research is needed to establish:

    • MMC and a direct HIV protective effect for women exposed through vaginal sex, or either men or women engaging in anal sex
    • The risks and benefits of male circumcision with regard to HIV transmission from HIV Positive men to women
    • Men who have Sex with Men (insertive)
  • 11. What is Combination Prevention?

    Scientists have been working on a “silver bullet approach” to reduce HIV incidence for many years. Until a vaccine or cure for HIV is developed, we need to consider alternatives. The most effective tool we have in preventing new infections and working towards an AIDS-free generation is Combination Prevention – essentially, a public health approach that includes a number of effective interventions, which, when used together, can reduce the spread of HIV.

    In 2010, The Joint United Nations Programme on HIV/AIDS (UNAIDS) provided this definition of combination HIV prevention:

    “The strategic, simultaneous use of different classes of prevention activities (biomedical, behavioural, social/structural) that operate on multiple levels (individual, relationship, community, societal), to respond to the specific needs of particular audiences and modes of HIV transmission, and to make efficient use of resources through prioritising, partnership, and engagement of affected communities.”

    UNAIDS and the US Presidents Emergency Plan for AIDS Relief (PEPFAR) recommend a combination approach to prevention that includes three types of mutually reinforcing interventions:

    • Biomedical interventions are those that directly influence the biological systems through which the virus infects a new host, such as physically blocking infection (e.g. male and female condoms), decreasing infectiousness (e.g. antiretroviral therapy (ART) as prevention), or reducing acquisition/infection risk (e.g. medical male circumcision).
    • Behavioural interventions include a range of sexual behaviour change communication programmes that use various communication channels (e.g. mass media, community-level, and interpersonal) to disseminate behavioural messages designed to encourage people to reduce behaviours that increase risk of HIV and increase protective behaviours (e.g. risks of having multiple partners and benefits of using a condom correctly and consistently). Behaviour interventions are also used to increase the acceptability and demand for biomedical interventions.
    • Structural interventions address the critical social, legal, political and environmental enablers that contribute to the spread of HIV. PEPFAR uses five categories to describe structural interventions: legal and policy reform, reducing stigma and discrimination against people living with HIV and marginalised groups; ending gender inequality and gender-based violence; economic empowerment and other multi-sectoral approaches; and education.

    There may be no “silver bullet” for HIV prevention but we can bring HIV down from pandemic to low-level endemic proportions through a coordinated, sustained commitment to combination prevention.

    Reference:

  • 12. How does Combination Prevention work?

    HIV prevention and treatment have arrived at a pivotal moment when combination efforts could substantially reduce new HIV infections. Combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying vulnerabilities to HIV infection. Because these are context-specific, no standard package will apply universally.

    For combination prevention programmes to work, they must be tailored to local epidemics and be fully implemented in a coordinated manner.

    “Combination implementation for HIV prevention is the pragmatic, localised application of evidence-based strategies to enable high sustained uptake and quality of interventions for prevention of HIV.”

    Reference:

    • Larry W Chang, David Serwadda, Thomas C Quinn, Maria J Wawer, Ronald H Gray, Steven J Reynolds. Combination implementation for HIV prevention: moving from clinical trial evidence to population-level effects. Lancet Infect Dis 2013; 13: 65–76

    These strategies include HIV testing and counselling models, task shifting, linkage to and retention in care, antiretroviral therapy support, behaviour change, demand creation, and structural interventions, which are used to complement HIV prevention efforts such as medical male circumcision and treatment as prevention.

    References:

    • Catherine A. Hankinsa and Barbara O. de Zalduondob. Combination prevention: a deeper understanding of effective HIV prevention. AIDS 2010, 24 (suppl 4):S70–S80
    • Ann E. Kurth & Connie Celum & Jared M. Baeten & Sten H. Vermund & Judith N. Wasserheit. Combination HIV Prevention: Significance, Challenges, and Opportunities. Published online: 13 October 2010 # Springer Science+Business Media, LLC 2010. Curr HIV/AIDS Rep (2011) 8:62–72
    • Nancy S. Padian, MS, MPH, PhD, Michael T. Isbell, JD, Elizabeth S. Russell, PhD, and M. Essex, DVM, PhD. The Future of HIV Prevention. J Acquir Immune Defic Syndr 2012; 60:S22–S26

  • 13. How does Medical Male Circumcision Complement Combination Prevention?

    Male circumcision is the most common surgical procedure in the world. With 30% of men globally and 67% of men in sub-Saharan Africa circumcised, social and cultural factors are the main determinants of acceptability.

    The first paper suggesting a protective effect of male circumcision against HIV infection was published in 1986. Since then, many observational studies have been published, some of which have observed that most men living in East and Southern Africa, the regions with the highest prevalence of HIV, are not circumcised. Observers found that in sub-Saharan Africa male circumcision seemed to be associated with a significantly reduced risk of HIV infection among men. In the absence of robust experimental data a link between male circumcision and protection against HIV infection could not be determined. Direct experimental evidence was needed.

    Three recent randomised controlled trials, each conducted over a period of two years, demonstrated a reduced HIV acquisition risk of about 60% among circumcised men. Randomised controlled trials are considered the gold standard for judging the benefits of an intervention, since the observed effect can be attributed more readily to the actual intervention than in observational studies. (7) (8) (9). All three trials were stopped prematurely when, at interim analyses, circumcision was found to be highly efficacious in reducing HIV incidence, indicating that it would be unethical to continue withholding circumcision from the control group.

    References:

    • Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298.
    • Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007, 369:657-666.
    • Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 643-656.

    In 2007, the World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS) recognised and recommended MMC as an additional and important strategy for the prevention of heterosexually acquired HIV infection in men in countries with a high prevalence of heterosexually transmitted HIV infection (generalised epidemic) and low levels of male circumcision.

    References:

    • WHO-UNAIDS. New data on male circumcision and HIV prevention: Policy and programme implications. WHO/UNAIDS Technical Consultation on Male Circumcision and HIV Prevention: Research Implications for Policy and Programming. Montreux, Switzerland 2007.
    • Bongaarts J, Reining P, Way P, Conant F. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3: 373-377.

    Since 2007 there have been many hundreds of further observational studies and systematic reviews. The link between MMC and HIV is now well established. Male circumcision is associated with significantly lower levels of HIV infection among men in sub-Saharan Africa, particularly among those at high risk of HIV.

    Reference:

    • Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000; 14: 2361-2370