Male Circumcision:
Translation of Evidence into Action

                      Professor Helen Rees
   Co-chair of SANAC Pr...
So how’s prevention going?
In South Africa there
                                          are three new
                                          pe...
Why did we consider male circumcision?




Source: UNAIDS 2006 Report on the Global AIDS PandemicIAS Conference Toronto 20...
Why did we consider male circumcision?




 About 30% of males globally are circumcised mainly for
          religious, cu...
We already knew about some health
                  advantages…..
• Urinary tract infections in       • Human Papilloma Vi...
There’s been a lot of research…
• 4 ecological studies: Studies that look    HIV prevalence is
  at associations in large ...
And then came the Randomised
       Controlled Trials
Randomised controlled trials of male
circumcision to reduce HIV infection
                                                ...
How were these RCTs designed?
 Men are from the               Select the population:
same community so              Young ...
Results of the three MC trials (RCTs) 2007
                     Orange      Rakai,      Kisumu,
                      Farm...
RCT Results of three MC trials (RCTs) 2007
                     Orange
                      Farm       Rakai       Kisumu...
Impact on HIV incidence:
Evidence from observational studies & RCTs
                                                      ...
Does it make sense biologically?
Does it make sense biologically?
Diagram of erect uncircumcised penis with
             foreskin retracted




Inner mucos...
Acceptability in Africa?
Acceptable in sub-Saharan Africa ?

2006: review of 13 acceptability studies
       in 9 sub-Saharan countries:

Uncircumc...
Acceptability of MC from 13 African studies
 The percentage of men and women who agreed with the following statements:



...
Some curved balls:
           Self reported MC status
• Men asked “Are you circumcised?”
• Physical examination by a male ...
HIV (%) and circumcision status

25
                             PRR=0.93
                             p=0.73
20
         ...
HIV (%) and circumcision status
25

            PRR=0.48 p=0.002
20
                                                      ...
With all the available data the
scientific world needed no more
            convincing
The Global Recommendations
  WHO/UNAIDS Technical Consultation Male
  Circumcision and HIV Prevention: Research
Implicatio...
Global Recommendations
• Countries with high prevalence (>15%), generalized
  heterosexual HIV epidemics and low rates of ...
UN Support Actions

The UN partners joint work plan on male circumcision
assists countries to make evidence-based policy a...
UN Operational Guidance for MC Scale-up
1. Leadership and             6. Quality assurance and
   partnership             ...
Two years later……
Activities for Male Circumcision for HIV Prevention,
                             2009
Tanzania, Malawi
Situation analysis...
Snapshot of countries’ progress 2009
                                Situation   Policy &   Training                 Quali...
What is South Africa doing and
          thinking?
What's been happening in South Africa?
                                          Leadership and
                          ...
What's been happening in South Africa?
                                            Leadership and
                        ...
What's been happening in South Africa?
                                            Leadership and
                        ...
South Africa Score Card
    Leadership and partnership          Quality assurance
Researchers, civil society, and now     ...
Predicting the impact…Modelling
Modeling the Impact of MC on HIV Prevalence
                & Incidence
 Williams 2006
 • 100% uptake of MC could avert 2....
Questions beyond modelling…
How do we scale up in the public sector?




                  ?
Male Circumcision Service Planning

Modelling circumcision
Services in the public
sector in Hillbrow, Inner
City Johannesb...
Alternative scenarios for Hillbrow
• Only 19% of the target population need to be interested to operate
  one theatre at f...
We asked who was interested




?                                 ?
              ?
Joburg Circumcision Model Outputs
• Survey showed 80% men interested in MC

• This would mean over 67,000 males could
  re...
Moving onto South African policy




        SOUTH AFRICA
Recommendations from SANAC
         plenary
  These recommendations were developed from
   two national consultations invo...
Importance of male sexual health package
 • MC should be introduced to adolescents and young
   men as part of a comprehen...
Communication strategy
• Community messaging outlining what MC offers,
  and discouraging unsafe MC services
• Messages mu...
MC programmes must be gender sensitive

 • Messaging must target women as partners &
   mothers of sons
 • Messaging must ...
MC rollout in health services
• More than 3 million young men are
  uncircumcised in SA
• Design programmes with reference...
Costing and Research
• Modelling and costing should be undertaken
  to assess affordability, impact and cost-
  effectiven...
Take home messages in South Africa
• Policy or guidelines?

• Address traditional male circumcision within a policy?

• Sp...
Conclusion

• We have a highly effective intervention
• We must implement this speedily with
  ongoing stakeholder consult...
Thank you
                    Acknowledgments
     All the men and women who participated in the
                      man...
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05 Prof~1

  1. 1. Male Circumcision: Translation of Evidence into Action Professor Helen Rees Co-chair of SANAC Programme Implementation Committee Executive Director, Reproductive Health and HIV Research Unit, University of Witwatersrand Honorary Professor: London School of Hygiene & Tropical Medicine
  2. 2. So how’s prevention going?
  3. 3. In South Africa there are three new people infected For every one person commencing treatment in 2009…….. We will never overcome this epidemic if we only treat patients
  4. 4. Why did we consider male circumcision? Source: UNAIDS 2006 Report on the Global AIDS PandemicIAS Conference Toronto 2006 Beyrer C.
  5. 5. Why did we consider male circumcision? About 30% of males globally are circumcised mainly for religious, cultural or social reasons
  6. 6. We already knew about some health advantages….. • Urinary tract infections in • Human Papilloma Virus (HPV) infants - 63% reduction in - 12 fold increased risk in circumcised men uncircumcised boys • Sexually transmitted • Cervical cancer (HPV) in infections female partners • Syphilis (Ulcer) - 2.0 – 5.8 times more - 1.5-3.0 fold increased risk frequent in women with in uncircumcised men uncircumcised partners • Chancroid (Ulcer) - 2.5 fold increased risk in • Penile cancer (HPV) in men uncircumcised men - 22 times more frequent in uncircumcised men
  7. 7. There’s been a lot of research… • 4 ecological studies: Studies that look HIV prevalence is at associations in large populations lower where circumcision if • 35 cross-sectional studies: Studies that higher look at associations in a population at one point in time HIV infection reduced by • 14 prospective studies: Studies that about 50% follow up a group of men for a period of time and observe what happens to HIV infection them reduced by 50% or more
  8. 8. And then came the Randomised Controlled Trials
  9. 9. 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)
  10. 10. How were these RCTs designed? Men are from the Select the population: same community so Young men at risk of HIV are likely to behave in similar ways and have the same Explain that they might be circumcised environment now or after 18 months Divide the men into two groups, half will be circumcised now and half will be circumcised later. The researchers and the participants are ‘told’ which group they go into. Counsel all the men about circumcision and about safer sexual practices Follow the group up for a year to see who gets HIV infected. Is it the circumcised men or the uncircumcised men?
  11. 11. Results of the three MC trials (RCTs) 2007 Orange Rakai, Kisumu, Farm Uganda Kenya Sample size (Number of men) 3128 4996 2784 Total sero- 69 65 69 conversions HIV+ MC arm 20 22 22 HIV+ control arm 49 43 47 % reduction in HIV 61% 48% 53% P < 0.001 P < 0.005 P < 0.005
  12. 12. RCT Results of three MC trials (RCTs) 2007 Orange Farm Rakai Kisumu Sample size (Number of men) 3128 4996 2784 Total sero- 69 65 69 conversions HIV+ MC arm 20 22 22 HIV+ control arm 49 43 47 % reduction in HIV 61% 48% 53% P < 0.001 P < 0.005 P < 0.005
  13. 13. Impact on HIV incidence: Evidence from observational studies & RCTs Effect size Study (95% CI) Overall 0.42 ( 0.34, 0.52) High-risk groups 0.29 ( 0.20, 0.42) General Population 0.56 ( 0.44, 0.71) South Africa 0.40 ( 0.24, 0.67) Kenya 0.41 ( 0.24, 0.70) Uganda 0.49 ( 0.28, 0.86) .15 .2 .3 .4 .5 1 1.5 Effect size
  14. 14. Does it make sense biologically?
  15. 15. Does it make sense biologically? Diagram of erect uncircumcised penis with foreskin retracted Inner mucosal layer of inner foreskin is exposed McCoombe & Short, AIDS 2006 20:1491-1495
  16. 16. Acceptability in Africa?
  17. 17. 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%) Westercamp et al. AIDS Behav. 2006 Oct. .
  18. 18. Acceptability of MC from 13 African studies The percentage of men and women who agreed with the following statements: Not surprising: Zulus, Twanas …
  19. 19. Some curved balls: Self reported MC status • Men asked “Are you circumcised?” • Physical examination 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 Orange Farm, Taljard et al 2008
  20. 20. HIV (%) and circumcision status 25 PRR=0.93 p=0.73 20 20.2% 18.8% 15 10 5 0 ‘’Circumcised’’ Uncircumcised with foreskin
  21. 21. 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
  22. 22. With all the available data the scientific world needed no more convincing
  23. 23. The Global Recommendations WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming, 2007
  24. 24. Global Recommendations • Countries with high prevalence (>15%), generalized heterosexual HIV epidemics and low rates of MC should consider urgently scaling up access to MC services • 13 countries identified: Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe • Consider ethics, communication, culture, health systems, funding, gender, comprehensive prevention strategies
  25. 25. UN Support Actions The UN partners joint work plan on male circumcision assists countries to make evidence-based policy and programme decisions to improve the availability, accessibility and safety of male circumcision and reproductive health services as an integral component of comprehensive HIV prevention strategies.
  26. 26. UN Operational Guidance for MC Scale-up 1. Leadership and 6. Quality assurance and partnership improvement 2. Situation analysis 7. Human resource development 3. Advocacy 8. Commodity security 4. Enabling policy and 9. Social change regulatory environment communication 5. Strategy and operational 10. Monitoring and evaluation plan
  27. 27. Two years later……
  28. 28. Activities for Male Circumcision for HIV Prevention, 2009 Tanzania, Malawi Situation analysis, pilot Kenya: national guidance & service sites strategy, situation analysis, guidelines, training, Quality Rwanda advocacy Assurance guide, expanded service campaign, situation delivery, communication & advocacy assessment under development, M&E, research underway, services in military Uganda Situation analysis, policy Lesotho: advocacy, development, Comms draft situation analysis, policy development, draft Zambia: Situation analysis, strategy & comms trainings, policy, strategy & Implementation plan, service Namibia: delivery Champions visit, advocacy, DMPPT,draft Botswana: Situation analysis, policy, strategy, training DMPPT,policy, strategy, training, and QA planned, M&E, communications and QA communications plan Swaziland South Africa Policy approved, situation analysis, Situation analysis strategy & Implementation plan, underway, draft leg/regulatory assessment, trainings, guidelines QA, M&E draft, comms draft
  29. 29. Snapshot of countries’ progress 2009 Situation Policy & Training Quality Service delivery Leadership I II Analysis Reg I Training II Assur M&E Botswana Kenya Lesotho Malawi Mozambique Namibia Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe
  30. 30. What is South Africa doing and thinking?
  31. 31. What's been happening in South Africa? Leadership and civil society concerns 2008 MC raised in RCT Studies SANAC, 2008 available, 2007 Action taken MC raised in in SANAC, SANAC, 2007 2009 Pietermaritzburg SANAC plenary Commitment to Orange Farm agreed to pilot 2007 pilot 2009 public sector scale develop public onwards onwards up in 2010? sector guidelines Lack of political support SANAC reinvigorated by SANAC political and civil society indecisiveness SANAC reinvigorated by about policy versus civil society leadership leadership guidelines
  32. 32. What's been happening in South Africa? Leadership and civil society concerns 2008 MC raised in Studies available, SANAC, 2008 2007 MC raised in Action taken SANAC, in SANAC, 2007 2009 Orange Pietermaritzburg SANAC plenary Commitment to Farm pilot pilot 2009 agreed to public sector scale develop public 2007 onwards up in 2010? onwards sector guidelines Lack of political support SANAC reinvigorated by SANAC political and civil society indecisiveness SANAC reinvigorated by about policy versus civil society leadership leadership guidelines
  33. 33. What's been happening in South Africa? Leadership and civil society concerns 2008 MC raised in Studies available, SANAC, 2008 2007 MC raised in Action taken SANAC, in SANAC, 2007 2009 Orange Pietermaritzburg 2009 SANAC Commitment to Farm pilot pilot 2009 plenary agreed public sector scale to develop public 2007 onwards up in 2010? onwards sector guidelines Lack of political support SANAC reinvigorated by SANAC SANAC reinvigorated by civil political and civil society indecisiveness society leadership leadership about policy versus guidelines
  34. 34. South Africa Score Card Leadership and partnership Quality assurance Researchers, civil society, and now and improvement politicians, traditional leader & practitioners Human resource Situation analysis development Being completed Commodity security Advocacy Social change Researchers, treatment activist communication Enabling policy and regulatory environment Monitoring and Being explored evaluation Strategy and operational plan Plan not policy being developed
  35. 35. Predicting the impact…Modelling
  36. 36. Modeling the Impact of MC on HIV Prevalence & Incidence Williams 2006 • 100% uptake of MC could avert 2.0 million new infections and 0.3 million deaths over ten years in sub-Saharan Africa • Could avert 5.7 million new infections over 20 years Nagelkerke 2007 • 50% uptake of circumcision over 10 years would reduce prevalence from 18% to 8% over 30 years in Nyanza Province, Kenya Mesesan 2006 • 50% uptake of MC could avert 32,000 – 53,000 new infections in Soweto, SA over 20 yrs. • HIV Prevalence would decline from 23% to 14%
  37. 37. Questions beyond modelling…
  38. 38. How do we scale up in the public sector? ?
  39. 39. Male Circumcision Service Planning Modelling circumcision Services in the public sector in Hillbrow, Inner City Johannesburg
  40. 40. Alternative scenarios for Hillbrow • Only 19% of the target population need to be interested to operate one theatre at full capacity for five years • With five theatres instead of one: – 54,704 surgeries could be performed in the 5 years, resulting in 81% coverage • Performing operations for 10 hours a day instead of 5 hours: – Would achieve coverage of 37% up from 19% • If Professional Nurses performed the surgery in lieu of doctors: – The procedure would be 12% less costly
  41. 41. We asked who was interested ? ? ?
  42. 42. Joburg Circumcision Model Outputs • Survey showed 80% men interested in MC • This would mean over 67,000 males could request MC services in Hillbrow over 5 yrs • If there is 19% uptake of MC of those men interested this will require one full-time MC theatre to run at full capacity for 5 years doing 2500 surgeries per year • The services will require 1.0 full time equivalent doctor, 1.77 FTE staff nurses, 1.22 FTE counsellors and 0.23 non health care workers
  43. 43. Moving onto South African policy SOUTH AFRICA
  44. 44. Recommendations from SANAC plenary These recommendations were developed from two national consultations involving all SANAC sectors and SANAC government departments and consultations by sectors: traditional leaders, NGOs, PLWHA, women, children, men……..
  45. 45. Importance of male sexual health package • MC should be introduced to adolescents and young men as part of a comprehensive sexual health package that could include: HCT, STI treatment, safer sex messaging, condoms, alcohol counselling • HIV testing should be offered prior to MC but should not be a prerequisite for MC.
  46. 46. Communication strategy • Community messaging outlining what MC offers, and discouraging unsafe MC services • Messages must be clear – Partial efficacy (only 60% effective) – Sustaining safer Sexual practices – Delay sexual debut – Alcohol abuse – Changing gender norms – ‘Male Morality’ e.g. respect of women • Appropriate media for the disabled
  47. 47. MC programmes must be gender sensitive • Messaging must target women as partners & mothers of sons • Messaging must explain advantages to women of MC • MC programmes should not pull funds away from existing programmes targeting women eg PMTCT, Female condoms • MC should not further stigmatise HIV+ve women by blaming them should a circumcised male become infected
  48. 48. MC rollout in health services • More than 3 million young men are uncircumcised in SA • Design programmes with reference to demonstration projects underway e.g. Orange Farm 8000 MCs in 18 months • Beware of creating demand for MC without services being able to respond
  49. 49. Costing and Research • Modelling and costing should be undertaken to assess affordability, impact and cost- effectiveness (WHO model available) • Sustainable funding required • Research agenda ongoing
  50. 50. Take home messages in South Africa • Policy or guidelines? • Address traditional male circumcision within a policy? • Speed in implementing medical male circumcision programme within an sexual health package as part of SRH service provision • Communication strategy informing communities of MC and HIV prevention data in sexual health context and discourage unsafe MC practices • Ongoing consultations with Houses of Traditional Leaders and traditional practitioners, private sector, other sectors
  51. 51. Conclusion • We have a highly effective intervention • We must implement this speedily with ongoing stakeholder consultations “If this was a pretty drug in nice packaging….”
  52. 52. Thank you Acknowledgments All the men and women who participated in the many studies Dirk Taljard, Orange Farm Kim Dickson, WHO, François Venter, RHRU AND SOUTH AFRICA

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