Policy amp Programming Compelling Evidence Protection Against HIV Knowledge Check Male circumcisions ability to reduce transmission of HIV has been proven beyond reasonable doubt ID: 288146
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Slide1
Male Circumcision: Policy & Programming
Compelling
Evidence –
Protection Against HIVSlide2
Knowledge Check
Male circumcision's ability to reduce ___________ transmission of HIV has been proven beyond reasonable doubt.
Male-to-female
Female-to-maleMale-to-maleAll of the abovea and bThe protective effect of male circumcision is only partial. So, male circumcision should be part of a comprehensive HIV prevention package.TrueFalseThe foreskin contains cells that are targets for HIV infection.TrueFalse
Male circumcision lowers risk of some sexually transmitted infections, which are co-factors for HIV transmission.TrueFalseIn terms of HIV prevalence, how do West African countries – where male circumcision is common – compare with countries in eastern and southern Africa that have similar HIV risk factors?Much lower HIV prevalenceAbout the same HIV prevalenceHigher HIV prevalence
Answer the following questions to see how much you know about this topic.Slide3
Different Types of Male Circumcision
MC Is Performed:
By different providers
Under different conditionsAt different timesFor different reasonsWith differing amounts of foreskin removedThis course focuses on medical MC, performed under local anesthesia, by trained medical staff on adolescents/adults for the purpose of preventing HIV. Medical MC is delivered as part of a comprehensive package of HIV prevention services and includes HIV prevention and risk reduction counseling before and after surgery.Neonatal medical MC will be discussed in a separate course.Slide4
What Is Medical MC?
Medical
MC
is the complete surgical removal of the foreskin, performed by trained providers, using appropriate and sterile instruments, in a hygienic setting under local anesthesia. Medical MC includes follow-up care.Slide5
The Research Evidence Is Compelling.
MC's ability to reduce female-to-male transmission of HIV has been proven beyond reasonable doubt.
In three RCTs – in South Africa, Kenya, and Uganda –
medical MC reduced female-to-male HIV transmission by approximately 60%.Source: UNAIDS 2006Slide6
Epidemiological Evidence
In addition to extremely strong trial evidence, there is an abundance of epidemiological and ecological evidence of reduced risk of HIV infection among circumcised men.
For example, a
systematic review and meta-analysis of 27 observational studies (Weiss, Quigley, and Hayes 2000) showed a significantly reduced risk of HIV infection among circumcised men in sub-Saharan Africa, particularly those at high risk of HIV.Did You Know?Epidemiology is the study of factors that affect health and illness in populations.By identifying risk factors for disease and determining optimal treatment approaches, epidemiological evidence provides a foundation for public health interventions.Slide7
Ecological Evidence: Developing Countries
Findings
MC was strongly associated with lower HIV prevalence:
In sub-Saharan Africa, independent of religionAmong countries with primarily heterosexual HIV transmissionThese findings suggest that MC is a true protective factor that reduces the sexual transmission of HIV, independent of Muslim and Christian religions.Source: Drain et al. 2006Slide8
HIV and MC Prevalence in Eastern and Southern Africa
In places where MC prevalence is lowest, we find the highest HIV prevalence
.
This map shows adult HIV prevalence in 14 countries in eastern and southern Africa, based on current DHS data.This map (also based on current DHS data) shows adult MC prevalence in these same 14 countries. Source: The PEPFAR Male Circumcision Technical Working GroupSlide9
Supporting Evidence from West Africa and Asia
Despite other HIV risk factors, countries in West Africa where MC is common have HIV prevalence levels well below those of countries in eastern and southern Africa.
In those countries in south and southeast Asia where nearly all men are circumcised (Bangladesh, Indonesia, Pakistan, and Philippines), HIV prevalence remains extremely low.Slide10
Biological Plausibility:
The Foreskin Is Physically Vulnerable.
Many HIV target cells are present in the human foreskin.
Source: Adapted from McCoombe and Short 2006Slide11
How Does Foreskin Removal Reduce HIV Acquisition in Men?
MC removes HIV target cells and reduces vulnerability to inflammation.
MC removes vulnerable tissue and eliminates an environment that is favorable for
anaerobic bacteria.MC lowers the risk of some STIs, which are co-factors for HIV transmission.In summary, the foreskin is vulnerable to infection, which causes inflammation, which increases the density of CD4 and CD8 cells, which increases the risk of HIV acquisition. So, removing the foreskin decreases vulnerability to HIV infection.In all probability, MC works by some combination of the following biological mechanisms:Slide12
How Does MC Affect Male-to-Female HIV Transmission?
MC has NOT been proven to reduce the risk of male-to-female HIV transmission.
The long-term effect of MC on male-to-female HIV transmission is not entirely clear. This is an area that needs more research.Slide13
What about MC's Potential to Reduce HIV Transmission in MSM?
Circumcised MSM who predominantly take the insertive role may be at a lower risk of HIV infection.
Effective HIV prevention for MSM is urgently needed because in most countries MSM have HIV prevalence rates many times higher than the general adult population
.Currently, there is little compelling evidence to support recommending MC as an HIV risk reduction measure for men who have sex with men (MSM).However, the implications of MC for MSM need to be studied further because:Slide14
What about MC for Men Who Have Sex with Men AND with Women?
The association between MC status and HIV infection may differ between men who exclusively have sex with men and MSM who also have sex with women (MSM/W)
Highlights:
"Given the potential for circumcision [MC] to decrease HIV transmission at the population level, and that many MSM who are insertive partners with men also have sex with women, this association should continue to be explored."Source: Lane et al. 2009Slide15
Remember: MC Does Not Provide Complete Protection Against HIV.
Recommendations
MC should never replace other known methods of HIV prevention.
MC should always be considered as part of a comprehensive HIV prevention package, which includes:Source: Adapted from WHO and UNAIDS 2007bReduction in the number of sexual partnersCorrect and consistent use of male or female condomsDelay in the onset of sexual relationsAbstinence from penetrative sex
HIV testing and counseling servicesTreatment of STIsSlide16
Knowledge Recap
Answer the following questions to see how much you know about this session.
Male circumcision's ability to reduce ___________ transmission of HIV has been proven beyond reasonable doubt.
Male-to-femaleFemale-to-maleMale-to-maleAll of the abovea and bThe protective effect of male circumcision is only partial. So, male circumcision should be part of a comprehensive HIV prevention package.TrueFalseThe foreskin contains cells that are targets for HIV infection.
TrueFalseMale circumcision lowers risk of some sexually transmitted infections, which are co-factors for HIV transmission.TrueFalseIn terms of HIV prevalence, how do West African countries – where male circumcision is common – compare with countries in eastern and southern Africa that have similar HIV risk factors?Much lower HIV prevalence
About the same HIV prevalence
Higher HIV prevalence
A comparison of Demographic and Health Survey (DHS) data in 14 countries in eastern and southern Africa shows that in places where male circumcision prevalence is lowest, we find:
The highest HIV prevalence
The lowest HIV prevalenceSlide17
Compelling Evidence – Protection Against HIV
Knowledge Recap Answer Key
Please note that the questions and answers match those in the
Knowledge Recap. The number and order of questions in the Knowledge Check may differ.Male circumcision's ability to reduce ___________ transmission of HIV has been proven beyond reasonable doubt.b. Female-to-maleThe protective effect of male circumcision is only partial. So, male circumcision should be part of a comprehensive HIV prevention package.TrueThe foreskin contains cells that are targets for HIV infection.True
Male circumcision lowers risk of some sexually transmitted infections, which are co-factors for HIV transmission.TrueIn terms of HIV prevalence, how do West African countries – where male circumcision is common – compare with countries in eastern and southern Africa that have similar HIV risk factors?Much lower HIV prevalenceA comparison of Demographic and Health Survey (DHS) data in 14 countries in eastern and southern Africa shows that in places where male circumcision prevalence is lowest, we find:The highest HIV prevalence