{"id":1207,"date":"2016-09-14T15:13:16","date_gmt":"2016-09-14T14:13:16","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=1207"},"modified":"2016-09-14T15:13:16","modified_gmt":"2016-09-14T14:13:16","slug":"first-study-of-population-level-preventative-impact-of-medical-male-circumcision-and-art-on-hiv-incidence-in-a-country-of-sub-saharan-africa","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2016\/09\/14\/first-study-of-population-level-preventative-impact-of-medical-male-circumcision-and-art-on-hiv-incidence-in-a-country-of-sub-saharan-africa\/","title":{"rendered":"First study of population-level preventative impact of Medical Male Circumcision and ART on HIV incidence in a country of sub-Saharan Africa"},"content":{"rendered":"<p>Clinical studies\u00a0have demonstrated the potential effectiveness of ART (<a href=\"https:\/\/www.hptn.org\/sites\/default\/files\/2016-05\/HPTN%20052%20Press%20Release%20_07.15.2015_FINAL.pdf\">HPTN 052<\/a>) and Voluntary Medical Male Circumcision (VMMC) (<a href=\"http:\/\/sti.bmj.com\/content\/89\/5\/345.abstract?sid=bdecd7fa-114e-41ef-8748-0df099a43f25\">Gray &amp; Kigozi\/STIs<\/a>) as preventative measures against HIV.\u00a0 This\u00a0led\u00a0WHO\/UNAIDS\u00a0to launch\u00a0a <a href=\"http:\/\/files.unaids.org\/en\/media\/unaids\/contentassets\/documents\/unaidspublication\/2011\/JC2251_Action_Framework_circumcision_en.pdf\">Joint Strategic Action Framework<\/a> (JSAF) setting a target in <strong>14 priority sub-Saharan countries<\/strong> of 80% VMMC by 2016.<\/p>\n<p>What, then,\u00a0are the potential gains of ART and VMMC interventions in these countries?\u00a0 Comparative ecological studies have shown the population-level impact of male circumcision as a cultural practice (<a href=\"http:\/\/sti.bmj.com\/content\/91\/7\/502.abstract?sid=8c026174-1f24-4358-9acc-d1ebaaa2ea34\">MacLaren &amp; Vallely\/STIs<\/a>). Various mathematical modelling studies have sought to quantify that\u00a0potential effect of interventions\u00a0both in the realm of\u00a0VMMC (<a href=\"http:\/\/sti.bmj.com\/content\/early\/2016\/06\/09\/sextrans-2015-052476.abstract?sid=5238dfce-813d-42a6-8577-4dffc136ee62\">Jenness &amp; Cassels\/STIs<\/a>) and ART (<a href=\"http:\/\/sti.bmj.com\/content\/90\/5\/423.abstract?sid=4c481d38-1b52-4189-980e-97775739d693\">Shafer &amp; White\/STIs<\/a>)\u00a0 (though other studies have highlighted the challenges that scale-up of these interventions is likely to present (<a href=\"http:\/\/sti.bmj.com\/content\/89\/Suppl_1\/A266.1.abstract?sid=bdecd7fa-114e-41ef-8748-0df099a43f25\">Kaufman &amp; Ross\/STIs<\/a>)).<\/p>\n<p>Now,\u00a0for the first time,\u00a0a study has sought to quantify the real-life population-level impact of these interventions.\u00a0 <a href=\"http:\/\/jama.jamanetwork.com\/article.aspx?articleid=2533067\">Kong &amp; Gray<\/a> (K&amp;G)\u00a0base their study on\u00a0data from the 1999-2013 Rakai Community Cohort Study (Uganda)).\u00a0 Among the 45 Rakai communities (44,688 participants surveyed over 24.6 years), VMMC coverage had, by 2013, increased from <strong>19%<\/strong> to <strong>39%<\/strong>, and ART had risen, in males, from <strong>0%<\/strong> to <strong>21%<\/strong>, and, in females, from <strong>0% to 26%<\/strong> &#8211; and HIV incidence had fallen, concurrently, from <strong>1.25<\/strong> per 100 person-years to <strong>0.84<\/strong> per 100 person-years in males, and from <strong>1.25<\/strong> to <strong>0.99<\/strong> in females.\u00a0 As regards VMMR, each 10% increase in the rate was associated amongst males with a decline in incidence that could be quantified, on multivariate analysis, at <strong>0.87<\/strong> \u2013 though, in females, the reduction was statistically insignificant.\u00a0 As for ART, the decline attributable was not statistically significant in either case, but, when ART coverage was <strong>modelled as a categorical variable<\/strong>, and coverage of over 20% was compared with coverage of under 20%, a decline in HIV incidence was observed in the former group of the order of <strong>0.86<\/strong> among males, and <strong>0.77<\/strong> among females.<\/p>\n<p>These results are not surprising.\u00a0 VMMC is, in the first instance, protective of men \u2013 though, of course, in the longer term women too will benefit from any population-level effect.\u00a0(There is, in fact,\u00a0a worrying possibility, investigated by <a href=\"http:\/\/sti.bmj.com\/content\/89\/Suppl_1\/A306.2.abstract?sid=bdecd7fa-114e-41ef-8748-0df099a43f25\">Maughan-Brown &amp; Thornton\/STIs<\/a>, that men could incorrectly assume that their VMMC will be directly protective of their partners, and modify their behaviour accordingly.)\u00a0 As for ART, here too the (as yet) limited impact in Rakai is what we might have expected.\u00a0 <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/23430656\">Tanser &amp; Newell<\/a>, in a South Africa-based study only observed significant association when ART coverage was over 30%.\u00a0 However, population level decline in incidence \u2013 especially that associated with VMMC \u2013 is encouraging.\u00a0 The results of this study allow us to predict that increasing VMMC coverage more than 40% could reduce male incidence by approximately 39% at population level. \u00a0\u00a0A major limitation of the study, of course, is its assumption that sexual networks, and hence HIV transmissions, are internal to the community. However, a recent study by <a href=\"http:\/\/sti.bmj.com\/content\/89\/2\/138.abstract?sid=4c481d38-1b52-4189-980e-97775739d693\">Chemaitelly &amp; Abu-Raddad\/STIs<\/a> would seem to indicate that, in a context\u00a0like sub-Saharan Africa the contribution of networks going beyond the wider community is likely to be limited.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Clinical studies\u00a0have demonstrated the potential effectiveness of ART (HPTN 052) and Voluntary Medical Male Circumcision (VMMC) (Gray &amp; Kigozi\/STIs) as preventative measures against HIV.\u00a0 This\u00a0led\u00a0WHO\/UNAIDS\u00a0to launch\u00a0a Joint Strategic Action Framework (JSAF) setting a target in 14 priority sub-Saharan countries of 80% VMMC by 2016. What, then,\u00a0are the potential gains of ART and VMMC interventions in [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2016\/09\/14\/first-study-of-population-level-preventative-impact-of-medical-male-circumcision-and-art-on-hiv-incidence-in-a-country-of-sub-saharan-africa\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2611,13992,4352],"tags":[],"class_list":["post-1207","post","type-post","status-publish","format-standard","hentry","category-circumcision","category-hiv-prevention","category-preventative-effect-of-art"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>First study of population-level preventative impact of Medical Male Circumcision and ART on HIV incidence in a country of sub-Saharan Africa - Sexually Transmitted Infections<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/sti\/2016\/09\/14\/first-study-of-population-level-preventative-impact-of-medical-male-circumcision-and-art-on-hiv-incidence-in-a-country-of-sub-saharan-africa\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"First study of population-level preventative impact of Medical Male Circumcision and ART on HIV incidence in a country of sub-Saharan Africa - Sexually Transmitted Infections\" \/>\n<meta property=\"og:description\" content=\"Clinical studies\u00a0have demonstrated the potential effectiveness of ART (HPTN 052) and Voluntary Medical Male Circumcision (VMMC) (Gray &amp; Kigozi\/STIs) as preventative measures against HIV.\u00a0 This\u00a0led\u00a0WHO\/UNAIDS\u00a0to launch\u00a0a Joint Strategic Action Framework (JSAF) setting a target in 14 priority sub-Saharan countries of 80% VMMC by 2016. 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