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Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
Male Circumcision V2 Sanac
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Male Circumcision V2 Sanac

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  1. Bophelo Pele Male Circumcision Project: Orange Farm Dr. Dirk Taljaard, Project manager Prof. Bertran Auvert, Principal investigator Dr. Dino Rech, Clinical manager
  2. Randomised controlled trials of male circumcision to reduce HIV infection Rakai, Uganda Gray et. al. (2007) Lancet; 369: 657 – 66 Kisumu, Kenya Bailey et. al. (2007) Lancet; 369: 643 – 56 Orange Farm, South Africa Auvert et. al. (2005) Source: 2006 Report on the global AIDS epidemic PLoS Med; 2 (11): e298 (UNAIDS, May 2006)
  3. Observational Studies of male circumcision and HIV in Africa C o r r e la t io n o f m a le c ir c u m c is io n a n d H IV p r e v a le n c e S u b - S a h a r a n A f r ic a 40 HIV prevalence (%) HIV prevalence in adults (%), 2005 S w a z ila n d 30 B o ts w a n a L e s o th o Z im b a b w e 20 S o u t h A f r ic a Z a m b ia M o z a m b iq u e M a la w i 10 K en ya T a n z a n ia C a m e ro o n U ganda A n g o la G hana M adagscar B e n in 0 20 40 60 80 100 M a le c ir c u m c is io n p r e v a l e n c e ( % ) Male Circumcision (%) Source: Helen Weiss, LSHTM
  4. Where in sub-Saharan Africa? 42 countries in Africa Adult population = 331 million Uncircumcised adult men= 54 million (33% of adult men) To prioritize and calculate the economic and human resources required for this roll-out : Countries with “high” HIV prevalence (CEA criterion): > 5% And Countries with “low” MC prevalence < 80% 100 MC prevalence 80 60 40 20 0 45 HIV prevalence (adults) 40 35 30 25 20 15 10 5 0
  5. Where in sub-Saharan Africa? Countries: 42 countries 14 countries (33%) Uncircumcised men: 54 million 25 million (46%) 14 countries HIV positive: 24 million 14 million (58%) HIV MC Uncirc % total (%) (%) (million) uncirc South Africa 25 35 8.0 32% Zimbabwe 25 10 2.8 11% Tanzania 9 70 2.7 11% Malawi 14 17 2.3 9% Zambia 17 12 2.2 9% Mozambique 12 56 2.0 8% Rwanda 5 10 1.8 7% Burundi 6 2 1.7 7% Lesotho 29 0 0.4 2% Namibia 21 15 0.4 2% Botswana 37 25 0.3 1% CAR* 14 67 0.3 1% Uganda Liberia 6 70 0.2 1% Kenya (Nyanza province) Swaziland 39 50 0.1 1% Total 25.2 100% * Central African Republic
  6. Programmes established • Swaziland: • Family Life Association of Swaziland (FLAS) • PSI Swaziland • Botswana • Public Health Facilities offer MC • PSI providing counselling services • Zimbabwe • PSI Providing MC services • Zambia • PSI Providing services • Kenya • Robert Bailey’s trial group providing services • 20,000 MC done between January and June ‘09 • Uganda • Ron Gray’s trial group providing services • Rwanda • Scale up have started in the Military • Other countries have committed to scale up but have not implemented yet
  7. Potential Impact of MC on HIV in sub-Saharan Africa Modeling study: Over the next ten years in sub-Saharan Africa, MC could avert : 2.0 (1.1−3.8) million new HIV infections (men and women) 0.3 (0.2−0.5) million deaths (men and women) In the ten years after, a further : 3.7 (1.9−7.5) million new HIV infections (men and women) 2.7 (1.5−5.3) million deaths (men and women) Williams et al. PLoS Med 2006 3(7): e262.
  8. Programming benefits of MC • Entry point to reach men, including adolescents • Opportunity to offer VCT • Opportunity for behavioral change counseling: partner reduction and condom use • Roll out must include community mobilisation and involve women in decision making • Opportunity for STI treatment and advice …
  9. Evidence for other benefits of male circumcision Urinary tract infections in infants o 12X risk in uncircumcised boys than circumcised Syphilis o 1.5-3.0 fold higher risk in uncircumcised men Chancroid o 2.5 fold higher risk in uncircumcised men Human Papilloma Virus (HPV) o 63% reduction in circumcised men Invasive penile cancer in men o 22 times more frequent in uncircumcised men Cervical cancer in female partners o 2.0 – 5.8 times more frequent in women with uncircumcised partners (link with HPV)
  10. Net cost After adjustment for averted HIV medical costs >0 expenses <0 saving Private Public Cumulative net cost* at 10 years + 538 (296 – 846) - 111 (-282 – 90) Cumulative net cost* at 20 years - 3 494 (-4 698 – -2 180) - 4 358 (-5 665 – -3 246) * in million US$ saving!
  11. Number of circumcisions to avoid one HIV infection Number of MAMC to avert 1 HIV infection 7.2 (6.5 - 7.9) (in 10 years) Number of MAMC to avert 1 HIV infection 2.3 (2.0 - 2.5) (in 20 years) 2 – 7 circumcisions to avoid 1 HIV infection in the first 10-20 years
  12. Risk factors for MC roll out Unsafe surgery leading to complications/ adverse events Acceptability Cost Feasibility Possible unintended promotion of female genital mutilation or cutting FGM/C Behavioural risk compensation - MESSAGING
  13. Acceptable in sub-Saharan Africa ? 2006: review of 13 acceptability studies in 9 sub-Saharan countries: Uncircumcised men for themselves: 65% (29-87%) Women (for their partners): 69% (47-79%) Men for their son: 71% (50-90%) Women for their son: 81% (70-90%) Not surprising: Zulus, Twanas … Westercamp et al. AIDS Behav. 2006 Oct 20.
  14. In South Africa? Policy and National Guidelines are in process – SANAC Technical Task Team, Mr. Dayanund Loykissoonlal, Acting Director, Prevention Strategies, NDOH
  15. Objectives: To fulfil an ethical obligation from the 1265 Male Circumcision Trial – by offering free and safe MC to the community (Orange Farm, South Africa) where the trial was done To establish a MC program in a community To evaluate the impact of such program on: Knowledge, attitudes and practices towards MC Existing prevention strategies like sexual behaviour change, condom use, STI treatment seeking behaviour and VCT attendance The spread of HIV and HSV-2
  16. General information to the community Community advisory board CAB: Local NGO’s, Political structures, local leaders, scientists, interested parties Community meetings
  17. Recruitment Outreach activities • Schools, churches, community leaders • Local radio station: Thetha FM • Community outreach activities: all households “What women should know about MC” Local radio “What men should know about MC” • Community stakeholder workshops i.e. loveLife • Local GPs • In the clinics (STI patients) Door-to-door outreach
  18. Outreach activities In partnership with Society for Family Health Door-to-door outreach Local radio station: Thetha FM • Schools, churches, Shopping malls • Community stakeholder workshops i.e. loveLife • Train Station • Taxi ranks
  19. Outreach activities In partnership with SFH Pamphlets are distributed A Mobile speaker system is used • We working together with local GPs • We have started communication in the clinics, especially among STI patients
  20. Inclusion activities at Outreach centres • Information session, anyone can attend, parents, spouses, partners Safe sex messaging Section on MC Partial protection for men only 6-week period of abstinence Individual counselling • VCT is recommended and offered • CD4 count test (on site) ARVs • Paper work (minimum) for Inclusion, including Informed consent Wait 3 days before surgery! (7 days for smokers!)
  21. Surgery WITS Urology Department Study Site • Started with 2 surgery rooms • Need for High Volume high quality models • Dr. Dino Rech and Dr. Sean Doyle developed • 7 beds, in one room divided by curtains • 1 doctor, 4 aux nurses, 1 suture nurse = 10 MC per hour • Maximum capacity with 3 doctors = 150+ per day
  22. Surgery WITS Urology Department Study Site • HIV+ participants are also Circumcised • Cost: ZAR 300 approximately • Surgical kits developed and used • Monopolar electrocautery used • Assisted in the development of MC MOVE • There is a follow-up visit 2-3 days after surgery • Emergency response for participant after surgery • The rate of AE is 2.0% (187/9290). Ten participants (0.1%) were hospitalized.
  23. Recommendations 2007 2009 Scientific evidence 1986-2007 Where are Implementation (regional, we? national, local level) What can the research community do at this time? Basic research (biological receptors etc) Phase-4 studies Operational research Meetings, country consultations, toolkits… With the aim To improve our knowledge in MC, MC-HIV, MC-STIs To contribute to guide implementation
  24. Some research findings
  25. What are the characteristics of the men being circumcised within the project? 60% 50% Age distribution 40% Population 30% Intervention 20% 10% 0% 15-19 20-24 25-29 30-34 35-39 40-44 Age group OF Male pop MC cards 15-19 35.7 % 50.1 % Age (y) MC Pop 20-24 30.2 % 27.9 % 25-29 14.4 % 9.7 % Mean 21.8 24.5 30-34 8.0 % 6.4 % 35-39 5.2 % 3.3 % 40-44 3.3 % 1.7 % Median 20 22
  26. Self reported MC status In a survey men were asked “Are you circumcised?” After the interview a physical examination was done to which they consented at the beginning of the interview Physical examination was done by a male nurse 45% of men who said they were circumcised had intact foreskin Possible reasons: Confusion between MC and Initiation Confusion with words used, vernacular Lack of knowledge on what MC is How does HIV compare in these groups?
  27. HIV (%) and circumcision status 25 PRR=0.93 p=0.73 20 20.2% 18.8% 15 10 5 0 ‘’Circumcised’’ Uncircumcised with foreskin
  28. HIV (%) and circumcision status 25 PRR=0.48 p=0.002 20 20.2% 18.8% 15 10 9.5% 5 0 ‘’Circumcised’’ ‘’Circumcised’’ Uncircumcised without foreskin with foreskin Thus, self reported MC status is a VERY unreliable indicator
  29. Findings Preferred circumcision status of partners, for sexually active women Not surprising: Zulus, Twanas …
  30. Findings 89% of women who were included were sexually active. 35% of the 15 year olds were sexually active and of 17 year olds almost 70% were already sexually active. The mean age for sexual debut was 15.7 year of age. The percentage of men and women who agreed with the following statements: Not surprising: Zulus, Twanas …
  31. Acknowledgements David Lewis Adrian Puren Kim Dickson UNIADS Scott Billy Brian Pazvakavambwa WHO Cynthia Nhlapo George Schmidt, WHO Goliath Gumede Richard Hayes, LSHTM Veerle Dermaux-Msimang Venessa Maseko Cate Hankins, UNAIDS Frans Radebe Daniel Halperin, Harvard Bongiwe Klaas David Wilson, WB Tsietsi Mbuso Helen Weiss, LSHTM Gaph Phatedi Helen Jackson, UNFPA CST, Harare Bongani Mazibuku Agenda Gumbu Dr. Shilaluke Dr. Zulu Dr. Gwala Daniel Shabangu Audrey Makwanasi Male Chakela Pamela Maseko
  32. Thank you!

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