Circumcision reduces incidence in men by = 60% (32% to 76%) Reduces overall incidence (both ways) by * = = 37% (18% to 51%) Equivalent to a one-shot vaccine with life- long protection and an efficacy of 37% Auvert, B. et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk PLOS Medicine, 2005, 2; Bailey, A. et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. The Lancet, 2007. 369: 643-656; Gray, R. et al., Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. The Lancet, 2007. 369: 657-666.
Change in incidence if all men were circumcised
Greatest benefits to be had where prevalence is high and circumcision rates are low.
51.2 25.6 12.8 6.4 3.2 1.6 0.8 0.4 0.2 0.1 Circumcisions to avert one HIV infection 0 20 40 60 80 100 Prevalence of HIV (%) 51.2 25.6 12.8 6.4 3.2 1.6 0.8 0.4 0.2 0.1 Prevalence of male circumcision (%)
Life-time infections averted per circumcision done approximately equal to the prevalence
Impact of male circumcision on HIV in South Africa. Reduction in transmission = 37%. Full coverage by 2015. Mortality/yr Prevalence Incidence/yr Over 20 years this could: Avert 1.4M incident cases Reduce prevalence by 1.6M Save 0.8M lives (or people on ART).
The personal benefit is immediate; the full public health benefit will only be seen over ten years or more.
Incidence/year Prevalence Age (years) Williams, B.G. et al. Patterns of infection: using age prevalence data to understand the epidemic of HIV in South Africa. South African Journal of Science, 2000. 96: 305-312. Williams, B.G. et al. Estimating HIV incidence rates from age prevalence data in epidemic situations. Statistics in Medicine, 2001. 20: 2003-2016. Prevalence and incidence (per susceptible person) of HIV among men in Khutsong, South Africa ANC HIV prevalence
Life time risk of infection if susceptible Life time risk of infection (total) Discounted male infections averted per circumcision Risk of infection/Infections averted Age at circumcision (years)
Mean time to infection Discounted male infections averted per circumcision Infections averted Age at circumcision (years) Years
We need to think about the age at circumcision and the time over which the impact will be seen
Heterogeneity in sexual activity? Two kinds of networks Erdos-Renyi or Poisson networks: All partners are equal (but some are more equal than others). Scale free or power-law networks: To him that hath shall be given (and to him that hath not shall be taken away even that which he hath).
1 2 4 10 20 No. sexual partners in the last year (Sweden) month (Carletonville) Gilgen, D., et al., The natural history of HIV/AIDS in a major gold-mining centre in South Africa: results of a biomedical and social survey. South African Journal of Science, 2001. 97: 387-392. Liljeros, F. et al., The web of human sexual contacts. Nature, 2001. 411(6840): 907-8. Power k = 2.3 1 0.1 0.01 0.001 Relative frequency
Change in prevalence by partners and time (years given inset). Power law network cut-off at 30 partners Age at circumcision (years) Prevalence of HIV Number of partners 5 40 20 10
Transmission parameter Steady state prevalence Circumcise all men Circumcise 5% with 5+ partners Prevalence versus transmission for a power law network. Power = 2.3. Cut-off at 30 red; 5 green; circumcise if more than 5 blue. Remove 5% of men with 5+ partners
Mean no. of sexual partners in last month Age at circumcision (years) Mean number of partners Age (years) Men Women Gilgen, D., et al., The natural history of HIV/AIDS in a major gold-mining centre in South Africa: results of a biomedical and social survey. South African Journal of Science, 2001. 97: 387-392.
Summary MC reduces overall transmission by ~40%. Greatest benefit where prevalence is high, circumcision is low and populations are large. Infections averted per circumcision approximately equal to the prevalence. Personal benefit is immediate; the public health benefit takes much longer. Circumcise young men, then middle aged men then children. Find ways to target high risk men.