Male Circumcision - External Jhp by wulinqing

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									Male Circumcision IS as Good as an HIV
Vaccine

Kelly Curran
Director HIV-AIDS-ID,

Harshad Sanghvi
Vice President & Medical Director



2008 Global Health Mini-University
   Friday, September 12, 2008
                         QUIZ

 Hard Q: What % of sexually active high school students
  in the US used a condom in their last sex encounter

 Harder Q: What % of sexually active high school student
  in the US decide not to have sex because a condom was
  not immediately available

 Hardest Q: What % of sexually active high school
  students in the US decide not to have sex because the
  male partner was not circumcised



                                                            2
                     Session Objectives

   Show that MC is
      Effective in preventing HIV
       infection
      Safe
      Acceptable in traditionally non
       circumcising communities
   Discuss
      Challenges in implementing MC
       at scale in low resource settings
      How MC advocacy, education,
       counseling, training, and
       services can be integrated in
       ongoing HIV prevention
       programs




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           Male Circumcision Definition
 Male Circumcision (MC) is the complete surgical removal
  of the prepuce (foreskin) covering the head (glans) of the
  penis

 In many countries MC is conducted in the newborn
  period; in others it is done as a rite of passage to
  adulthood

 WHO and UNAIDS estimate that globally about 30% of
  males are circumcised. In Africa, nearly 2/3 of men are
  circumcised.



                                                               4
5
Previously Recognized Benefits of Circumcision

Human Papilloma Virus (HPV)
        63% reduction in circumcised men
Cervical cancer in female partners
        2.0 – 5.8 times more frequent in women with uncircumcised partners
Urinary tract infections in infants
        12 fold increased risk in uncircumcised boys
Syphilis
        1.5-3.0 fold increased risk in uncircumcised men
Chancroid
        2.5 fold increased risk in uncircumcised men
Invasive penile cancer in men
        22 times more frequent in uncircumcised men




                                                                              6
          Correlation of Male Circumcision and HIV
              Prevalence Sub-Saharan Africa
                                   40
HIV prevalence in adults (%), 2005




                                        Swaziland
                        30




                                        Botswana
                                                                           Lesotho
            20




                                        Zimbabwe
                                                            South Africa
                                        Zambia
                                                                                     Mozambique
                                              Malawi
  10




                                                                                                          Kenya
                                                                                            Tanzania
                                                                                                                   Cameroon
                                                   Uganda                                                         Angola
                                                                                                                       Ghana
                                                                                                  Madagascar      Benin
                  0




                                         20                  40              60              80                        100
                                                            Male circumcision prevalence (%)                             7
       MC and HIV Infection: More Evidence

   Meta-analysis by Weiss et al shows
    that MC is associated with 50% lower
    rate of HIV infection


   Quinn demonstrates in Rakai, that
    partners of HIV positive women who                                      .05         .1   .2   .3 .4 .5    1
                                                                                                  Adjusted Odds Ratio
                                                                                                                      2   3 4 5

    are uncircumcised had an HIV
    incidence of 6.7/100 py) while partners
    of circumcised men 0/50 (p = 0.004)
                                                                   30                                  27.7                 27.7
                                                                        Circumcised
    (NEJM 2000)                                                         Uncircumcised
                                                                   25


                                               Acquisition/100py
                                                                   20

   Biologists find that the prepuce                               15

    contains many Langerhans (HIV target)                          10             8.2

    cells which are easily infected with HIV                        5
                                                                                                                      0
                                                                        0                         0
    in vitro                                                        0
                                                                        <10,000              10,000-49,999           >50,000




                                                                                                                                   8
            Male Circumcision: Best Evidence

 Randomized controlled trials are the gold standard in
  health research
 10,000 uncircumcised, HIV-negative men enrolled
 Intervention group underwent MC in clinical setting
 Control group “delayed” MC for 24 months, or end of the
  trial
 All participants received extensive counseling on HIV
  prevention, risk reduction and condoms

    Auvert et al, PloS med 2005, Gray et al, Lancet 2007, Bailey et al, Lancet 2007,




                                                                                       9
               Clinical Trial Results

 All three clinical trials stopped early due to
  efficacy
    MC was so protective that it was unethical to continue
     to withhold it from the control group


 MC reduced female to male HIV transmission by
  approximately 60%

    Auvert et al, PloS med 2005, Gray et al, Lancet 2007, Bailey et al, Lancet 2007,




                                                                                       10
  Male Circumcision for HIV Prevention

 Depending on HIV prevalence in the area, we need to do
  5 to15 MCs procedures to prevent 1 new HIV infection
  (numbers needed to treat)

 MC is not only cost-effective, it is actually cost-saving
  given the high costs of ART


       Male circumcision protects men from HIV infection




                                                              11
                  Adverse Events

Hemorrhage, hematoma, infection, severe pain,
  dysuria
 Kenya trial: 21 events (1.5%)
 Uganda trial: 84 events (3.6%)

 Zambia: MC services: 3.6%

  Male circumcision provided in health settings is safe



                                                          12
    Effect of MC on Male to Female Transmission


   Discordant couple study from Rakai, Uganda: circumcised men 30%
    less likely to transmit to female partners
   Clinical trial of MC for HIV+ men found that recently circumcised HIV+
    men may be more likely to transmit to female partners
   Take home messages:
        MC should be targeted to HIV-negative men
        If HIV+ men request MC, they must be STRONGLY counseled to
         abstain from sex for at least 6 weeks / until wound is fully healed



         Benefit for women partners of HIV positive men
                  who have MC still controversial

                                                                               13
Acceptability Studies in Non-Circumcising Communities (9
                         countries)

 Male circumcision is
     Universally perceived to improve hygiene

 Widely thought to reduce risk of STI
 thought to reduces risk of HIV by some
 Biggest barriers to MC are cost, and concerns about
  safety (risk of infection or mutilation), and pain
 Most communities want safe, affordable MC services
  to be available.
                                       Westercamp and Bailey 2006




                                                                    14
       Estimated number of uncircumcised males
                (Africa, under age 49)*

South Africa                                                     12.0        Sierra Leone          0.5
Uganda                                                    10.7               Ghana                 0.5
Sudan                              5.5                                       Lesotho               0.5
Tanzania                           5.4                                       Swaziland             0.5
Malawi                            5.2                                        Côte d’Ivoire        0.3
Zimbabwe                          5.1                                        Liberia              0.3
Zambia                         4.5                                           Angola               0.3
Rwanda                        4.1                                            Guinea               0.2
Mozambique                   3.8                                             Benin                0.2
Burundi                     3.5                                              Madagascar           0.2
Nigeria                  3.1                                                 Congo, Rep           0.2
Congo, Dem Rep           3.0                                                 Cape Verde           0.2
Ethiopia                2.8                                                  Cameroon             0.2
Kenya                   2.7                    TOTAL:                        Togo                 0.1
Chad             0.9                           ~ 80 million                  Niger                0.1
Namibia          0.8                                                         Senegal              0.1
Burkina Faso     0.7                                                         Mali                 0.1
CAR              0.7                                                         Eritrea              0.1
Botswana         0.7                                                         Somalia              0.1
                    * Less than 0.1: Gambia, Guinea-Bissau, Gabon, Mauritania, Equatorial Guinea, Djibouti,
                   Mauritius, Libya, Comoros, Algeria, Egypt, Morocco, Tunisia, Sao Tome and Principe,
                   Seychelles. * Assumes uniform MC rate across age groups within each country
                   Sources: U.S. Census Bureau, DHS, Williams et al, team analysis                          15
   Percentage of uncircumcised males willing to get
                     circumcised

Uganda
(1999)                        29%
Zimbabwe
(2005)                                      45%
South Africa
(2005)
                                                    51%             Huge unmet need
Swaziland                                                         for male circumcision
(2006)                                              54%
South Africa
(2003)
                                                        59%

Botswana
(2003)                                                    61%
Kenya
(2005)                                                            70%
South Africa
(2003)                                                              73%

                                                    Avg: 55%
               Sources: Bailey et al, Halperin et al, Tsela et al, Rain-Taljaard et al, Scott et al, Lagarde et
               al, Mattson et al, Kebaabetswe et al                                                               16
    % of Participants Who Would Choose to Circumcise a Male Child, if
       Offered in a Safe Hospital Setting, Free of Charge: Botswana
        (data shown only for responses following informational session)

    100


     75


%    50


     25


      0
           All Participants     Uncircumcised Men        Circumcised Men                Women
               N=605                   N=238                    N=78                    N=289
             Definitely / Probably           Definitely Not / Probably Not               Unsure
                              Source: The Botswana-Harvard AIDS Institute Partnership             17
Jhpiego’s Work in MC
         2002: Co-sponsored international consensus meeting
          on MC for HIV Prevention with USAID and PSI
         2003-2005: Implemented pilot MC / Male RH project in
          Lusaka, Zambia
         2005/6: developed International reference manual titled
          Male Circumcision Under Local Anaesthesia with WHO
         2007: First regional MC course / pilot test of MC
          courseware
         2008: Clinical Training Skills Course for MC Experts.
          Participants from Uganda, Kenya, Swaziland, Lesotho
          and Zambia
         2008: second regional MC course. Participants from
          Ethiopia, Kenya, Rwanda, Swaziland, Uganda, USA
          and Zambia
         2008: Newborn MC consultation in Nigeria

Clear international guidance now available.
                                                                  18
  Results and Lessons Learned

 Participants with minimal
  surgical skills can be trained
  to competency in short
  courses
 Training more that one
  provider per site is critical
 Adverse events are minimal
 Standardized training
  materials work well
 Investment in developing high
  performing training sites is
  essential
 Early follow up of trainees
  reinforces training.




                                   19
  Frequently Raised Issues: Risk Compensation

Issue:
 Won’t circumcised men believe they are 100% protected
   and stop using condoms and/or increase their number of
   sex partners?

Response:
 Valid concern
 No evidence of risk compensation or disinhibition from
  the MC trials or post-trial surveillance




                                                            20
Frequently Raised Issues: Women’s Issues
Issue:
 MC does not help women and might even put them at
   risk if circumcised men refuse condoms or resume sex
   too early. We should focus on microbicide research and
   the female condom instead of wasting our energy on
   something that won’t help women.
Response:
 MC scale up will reduce HIV incidence in women as well
   as men
 MC communication should also target women so that
   they know the importance of abstinence during wound
   healing
 There is no evidence that circumcised men are
   abandoning condoms

                                                            21
Frequently Raised Issues: Surgical Capacity
Issue:
 I would love to implement MC in my country but we have
   limited surgical capacity with long waiting lists. How can I
   justify using our scarce surgical resources for non-
   emergency surgery?
Response:
 It will not be easy to reach thousands of young men
 Train clinical officers and nurses to provide MC.
 “import” volunteer surgeons from other countries.
 Train nurse-midwives to provide newborn MC. This will
   reduce the numbers of adolescents & adults who need
   MC


                                                                  22
Frequently Raised Issues: Traditional Circumcisers
Issue:
 In our country we have many traditional circumcisers.
   Why can’t we train them to do MC for the non-
   circumcising communities?

Response:
 Most men from non-circumcising communities want
  medical, not traditional circumcision
 Complication rates in traditional circumcision are very
  high (more than 30%)
 Medical circumcision is safer and less painful because
  local anesthesia is used. Healing time is faster because
  the wound is sutured


                                                             23
Frequently Raised Issues: Traditional Circumcisers
Issue:
 We want to scale up medical MC in our country but the
   traditional circumcisers are opposed to it, and they are
   very powerful in the community.
Response:
 Involve the traditional circumcisers in the program to get
   their input. Encourage traditional circumcisers to do the
   whole initiation ceremony and all of the education for the
   initiates but have the MC done by a skilled provider




                                                                24
   Frequently Raised Issues: Newborn MC

Issue:
 I heard that newborn MC is much easier to perform than
   adult MC. Can we just train nurse- midwives to do
   newborn MC and forget about the adults?
Response:
 Newborn MC is easier and cheaper than adult MC
 Newborn MC is an important investment but won’t have
   an impact on HIV incidence for about 25 years
 Ideally both adult and newborn MC should be scale up
   simultaneously


                                                           25
   Frequently Raised Issues: Newborn MC

Issue:
 During antenatal care the nurse-midwife asked me if I
   wanted to have my child circumcised (if it is a boy). I
   always thought circumcision was for adolescents. Is it
   safe to circumcise such a small baby?
Response:
 Newborn circumcision is safe for healthy babies if done
   by a trained health professional
 The wound heals much faster than in adolescents or
   adults


                                                             26
                     Conclusion

 Male circumcision is
  the most effective HIV
  prevention strategy we
  have right now that is
  not user dependant
 User dependant
  methods such as
  abstinence, being
  faithful, and condoms
  provide additional
  benefits



                                  27
ABC & MC: Combination Prevention for HIV




                                                Vaccine
                                           28

								
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