Circumcision Reduces HIV Incidence in Uganda, Rakai Community Study Finds

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The growing uptake of medical male circumcision by men in Uganda’s Rakai district is leading to a substantial reduction in HIV incidence among men in one of the country’s worst-hit districts, Xiangrong said Kong of the Johns Hopkins Bloomberg School of Public Health Conference on Retroviruses and Opportunistic Infections (CROI 2015) in Seattle, United States, Thursday.

Three large clinical trials in sub-Saharan Africa, including one in Rakai district, have shown that medical male circumcision reduces the risk of contracting HIV by 50 to 60%. These findings led to the scaling up of services offering medical circumcision to men, especially adolescents and young men.

However, so far, the only evidence of an impact of medical male circumcision on HIV incidence in the communities where it is offered comes from a cross-sectional study in the Orange Farm community in South Africa, where another clinical trials showing efficacy took place. This study showed that the deployment of circumcision reduced the incidence of HIV from 57% to 61%.

Glossary

circumcision

Surgical removal of the foreskin of the penis (the retractable fold of tissue that covers the head of the penis) to reduce the risk of HIV infection in men.

mathematical models

A range of complex mathematical techniques that aim to simulate a sequence of probable future events, in order to estimate the impact of a health intervention or the spread of infection.

cross-sectional study

An “instant” study in which information is collected about people at a given point in time. See also ‘longitudinal’.

opportunistic infection (OI)

An infection that occurs more frequently or is more severe in people with weakened immune systems, such as people with low CD4 counts, than in people with healthy immune systems. Common opportunistic infections in people with advanced HIV disease include Pneumocystis jiroveci pneumonia; Kaposi’s sarcoma; cryptosporidiosis; histoplasmosis; other parasitic, viral and fungal infections; and some types of cancer.

The study conducted in Rakai aimed to assess the impact of the extension of circumcision in the district of Rakai since 2007, through the analysis of annual cross-sectional surveys among adults aged 15 to 49 years conducted by the Rakai Community Cohort Study. The analysis excluded Muslim men who would have been circumcised anyway, and sought to assess the impact of circumcision as an HIV prevention intervention. The analysis also assessed and monitored the level of antiretroviral coverage over time among women, as increased antiretroviral coverage is expected to reduce HIV transmission to men, regardless of the level of circumcision.

The study found that circumcision coverage among non-Muslim men increased from 9% during the Rakai circumcision study to 26% in 2011, four years after the trial ended. Each 10% increase in circumcision coverage was associated with a 12% reduction in HIV incidence (0.88, 95% confidence interval 0.80-0.96).

However, there was no evidence of a reduction in incidence in women as a result of the reduction in HIV prevalence in men due to circumcision. Dr Xiangrong Kong said previous modeling studies suggested it could take up to a decade for medical male circumcision to impact HIV incidence in women.

Preliminary data for 2013-14 shows that the proportion of non-Muslim men who underwent medical circumcision in the Rakai community cohort increased to 49%.


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