The potential impact of male circumcision on HIV in Sub-Saharan Africa
Date
2006-07
Authors
Williams, Brian G.
Lloyd-Smith, James O.
Gouws, Eleanor
Hankins, Catherine
Getz, Wayne M.
Hargrove, John
De Zoysa, Isabelle
Dye, Christopher
Auvert, Bertran
Journal Title
Journal ISSN
Volume Title
Publisher
Public Library of Science -- PLoS
Abstract
Background
A randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual
transmission of HIV from women to men by 60% (32% 76%; 95% CI) offering an intervention of
proven efficacy for reducing the sexual spread of HIV. We explore the implications of this
finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan
Africa. Methods and Findings
Using dynamical simulation models we consider the impact of MC on the relative prevalence
of HIV in men and women and in circumcised and uncircumcised men. Using country level data
on HIV prevalence and MC, we estimate the impact of increasing MC coverage on HIV
incidence, HIV prevalence, and HIV-related deaths over the next ten, twenty, and thirty years in
sub-Saharan Africa. Assuming that full coverage of MC is achieved over the next ten years, we
consider three scenarios in which the reduction in transmission is given by the best estimate
and the upper and lower 95% confidence limits of the reduction in transmission observed in
the RCT.
MC could avert 2.0 (1.1 3.8) million new HIV infections and 0.3 (0.1 0.5) million deaths over
the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7
(1.9 7.5) million new HIV infections and 2.7 (1.5 5.3) million deaths, with about one quarter of
all the incident cases prevented and the deaths averted occurring in South Africa. We show that
a) MC will increase the proportion of infected people who are women from about 52% to 58%;
b) where there is homogenous mixing but not all men are circumcised, the prevalence of
infection in circumcised men is likely to be about 80% of that in uncircumcised men; c) MC is
equivalent to an intervention, such as a vaccine or increased condom use, that reduces
transmission in both directions by 37%. Conclusions
This analysis is based on the result of just one RCT, but if the results of that trial are confirmed
we suggest that MC could substantially reduce the burden of HIV in Africa, especially in
southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the
protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related
illness and death will only be apparent in ten to twenty years.
Description
The original publication is available at http://www.plosmedicine.org
Keywords
HIV infections -- Africa, Sub-Saharan -- Prevention, AIDS (Diseases) -- Africa, Sub-Saharan -- Prevention, Circumcision -- Africa, Sub-Saharan
Citation
Williams, B.G. et al. 2006. The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med, 3(7), e262, 1032-1040, doi:10.1371/journal.pmed.0030262.