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Voluntary Medical Male Circumcision Seen As Answer To Reduced HIV Infections Globally

More male circumcisions could be the answer to help reducing HIV infections worldwide. According to a new modeling study, by achieving 80 percent circumcision among men aged 15 to 49 years this year —and then sustaining it—we could avert 3.4 million HIV infections by 2025.

Voluntary medical male circumcision (VMMC) is a cost-effective, one-time intervention that has been shown to provide lifelong partial protection against HIV transmission for quite some time, according to UNAIDS.

There is conclusive epidemiological evidence that show that uncircumcised men are at a much greater risk of becoming infected with HIV than circumcised men. The reason is that the inner surface of the foreskin contains Langerhans' cells that have HIV receptors, which can increase the risk of infection from two to eight times more for uncircumcised men than their circumcised counterparts.

Furthermore, circumcision also protects against other sexually transmitted infections, such as syphilis and gonorrhea. People who already have a sexually transmitted infection are two to five times more likely to become infected with HIV, and circumcision may provide more protection.

Since 2007, tremendous efforts have been made to scale up voluntary medical male circumcision in 14 priority countries in eastern and southern Africa that have high levels of HIV prevalence and low levels of male circumcision. By the end of 2015, nearly 11.6 million men in these countries had been medically circumcised.

The study, published in PLOS One, suggests that increasing voluntary medical male circumcision (VMMC) in countries with a high HIV prevalence could reduce new HIV infections perhaps more than obtaining the UNAIDS 90-90-90 treatment target goals alone. The UNAIDS 90-90-90 target calls for 90 percent of people living with HIV being aware of their HIV status, 90 percent of HIV-diagnosed people on ART, and 90 percent of people on ART achieving viral suppression.

The study authors note that progress towards these UNAIDS targets in resource-limited settings has been mixed. Currently, only 51 percent of HIV-positive individuals in sub-Saharan Africa are aware of their status, approximately 43 percent able to obtain ART and only a third have viral suppression. However, 84 percent of people who know their status are on ART and three-quarters of these people are virally suppressed. Therefore, the biggest gap is individual knowledge of HIV status.

Investigators looked at various models that combined VMMC, assuming that 90 percent of males aged 15-49 years got male circumcision, with various viral suppression scenarios. Two of the viral suppression rates were below the 90 percent target. In all three scenarios, male circumcision would reduce HIV incidence to at least the same levels predicted with 90 percent viral suppression, even when suppression rates were as low as 75 percent. Although VMMC scale-up would initially increase costs, it was projected to reduce expenditure more than the 90-90-90 goals in the longer term.

“Compared to the epidemic impact of scaling up ART [antiretroviral therapy] to 90-90-90 levels, three scenarios that also include VMMC scale-up demonstrated additional reductions in HIV incidence and lower long-term program costs in models applied to Lesotho, Malawi, South Africa and Uganda,” write the investigators. “In the three scenarios modeled, for all four countries, initial five-year annual program costs are higher with the combined ART and VMMC approach versus ART only, and then after 2020 are lower with the combined approach versus ART-only.”

The authors also calculated the additional costs associated with scaling up VMMC (between $90 and $150 per procedure) in both the scale-up phase (to 2020) and in the longer term (to 2049). Their analysis showed that combining VMMC with the 90-90-90 targets would be more financially cost effective than the 90-90-90 targets alone. Previous studies in South Africa have shown that VMCC is very cost effective with the return on investment highest if males are circumcised between ages 20 and 25. However, this return on investment declines steeply with age.

The authors are not suggesting that the 90-90-90 goals are not a priority, but are emphasizing that antiretroviral therapy should be combined with VMMC in order to be much more effective.

“Treatment affords reduced morbidity, mortality, and viral transmissibility in both men and women and must be taken early and consistently and clinically monitored for a lifetime to effect maximum benefit,” comment the authors. “Male circumcision conveys almost immediate substantial risk reduction to men for life after a single treatment. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility of future generations not only free of AIDS but also HIV.”

As part of a wider prevention package, UNAIDS has now set the target of circumcising 80 percent of young males in high prevalence settings by 2020.