Jonas Z Hines1, Karampreet Sachathep2, Sherri Pals1, Stephanie M Davis1, Carlos Toledo1, Megan Bronson1, Bharat Parekh1, Maria Carrasco3, Sinokuthemba Xaba4, John Mandisarisa5, Royd Kamobyi6, Omega Chituwo7, Wilford L Kirungi8, Stella Alamo9, Geoffrey Kabuye9, Anna Colletar Awor9, Susan Mmbando10, Daimon Simbeye11, Mekondjo A Aupokolo12, Brigitte Zemburuka13, Rose Nyirenda14, Wezi Msungama15, Tapiwa Tarumbiswa16, Robert Manda17, Harriet Nuwagaba-Biribonwoha18,19, Valerian Kiggundu3, Anne G Thomas20, Heather Watts21, Andrew C Voetsch1, Dan B Williams1. 1. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia. 2. ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York. 3. Office of HIV and AIDS, U.S. Agency for International Development, Washington, District of Columbia. 4. Ministry of Health and Child Care, Harare, Zimbabwe. 5. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe. 6. Ministry of Health, Lusaka, Zambia. 7. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia. 8. Ministry of Health, Kampala, Uganda. 9. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Kampala, Uganda. 10. National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania. 11. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania. 12. National HIV/AIDS, STI and Hepatitis Control Program, Ministry of Health and Social Services, Windhoek, Namibia. 13. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Windhoek, Namibia. 14. Ministry of Health, Lilongwe, Malawi. 15. Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi. 16. Ministry of Health, Maseru, Lesotho. 17. U.S. Agency for International Development, Maseru, Lesotho. 18. ICAP at Columbia University, Mbabane, Eswatini. 19. Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York. 20. Defense Health Agency, U.S. Department of Defense, San Diego, California; and. 21. Office of Global AIDS Coordinator, Washington, District of Columbia.
Abstract
BACKGROUND: Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS: Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS: Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. DISCUSSION: Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.
BACKGROUND: Male circumcision (MC) offers men lifelong partial protection from heterosexually acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally representative samples. Data from the population-based HIV impact assessments were used to compare HIV incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS: Data were pooled from population-based HIV impact assessments conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe from 2015 to 2017. Incidence was measured using a recent infection testing algorithm and analyzed by self-reported MC status distinguishing between medical and nonmedical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random-effects logistic regression model using pooled survey weights. Analyses were age stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS:Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men [0.04% (95% CI: 0.00% to 0.10%) versus 0.34% (95% CI: 0.10% to 0.57%), respectively; P value = 0.01]; whereas among men 35-59 years, there was no significant incidence difference [1.36% (95% CI: 0.32% to 2.39%) versus 0.55% (95% CI: 0.14% to 0.67%), respectively; P value = 0.14]. DISCUSSION: Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa.