Issues in considering the relevance of male circumcision to prevent HIV in Barbados Caroline Allen

Male circumcision: the single most successful HIV prevention intervention (in trials!) Sum global total of 31 randomised control trials of behavioural or biological HIV prevention interventions to date Only four interventions have significantly reduced HIV incidence (4/31) Three of these successful trials were of male circumcision (MC) Shown to reduce HIV incidence by 60% Difficulty in ensuring “adherence” in other HIV prevention trials

What does reduction in incidence of 60% via MC mean? HYPOTHETICAL EXAMPLE Say, each year, there is 1 new female to male HIV infection per 100 men Circumcising all the males would reduce this to 0.4 new female to male infections per 100 men

What does reduction in incidence of 60% mean? HYPOTHETICAL COMPARISON Say condoms are 100% effective if used correctly and consistently If 100% of males used condoms correctly and consistently, there would be 0 (zero) new infections But we know that condoms are not used correctly and consistently They would have to be used correctly by males having sex with women for at least 60% of sex acts to have same impact as MC In Caribbean surveys, between 7 and 49% of people report “always” using a condom. Probably overestimates.

ADHERENCE IS THE CHALLENGE with most HIV prevention methods Following surgery, MC does not require adherence

Objective Review the relevance and implications for Barbados Consider policy options Needs for further research

How? Consider characteristics of the HIV epidemic in Barbados Review existing global research and recommendations from UNAIDS and WHO on MC as a service provision option Identify pertinent issues for Barbados

Characteristics of the HIV epidemic in Barbados Males still predominate in most age groups (except 15-19), though there is some evidence of “feminisation” of the epidemic AIDS and deaths are higher among males than females The balance between female to male and male to male transmission is largely unknown Need to consider male to male transmission as an important issue

Conclusions from UNAIDS/ WHO mathematical modelling Modelling has focused on countries where prevalence >15%, heterosexual transmission predominates, and >80% of men are not circumcised (e.g. some African countries) Here they predict that over ten years, 1 new HIV infection would be averted for 5 to 15 men newly circumcised if take-up is high Cost per infection averted US$150-900 as against $7,000 for lifetime first-line HIV treatment There are some general conclusions and issues to consider elsewhere

Findings from modelling studies 1. Subpopulations In countries with low prevalence and incidence, the number of circumcisions needed to avert one infection is higher However, even in such countries, programmes that focus on subpopulations with high HIV prevalence and incidence would have substantial impact on HIV incidence. Barbados: who are the males most-at-risk of heterosexual infection? Most obviously: men in serodiscordant couples, STI patients Need epidemiological research to identify other groups POSSIBLY uniformed services (defence, police), entertainment workers, sportsmen, migrant workers, watersports operators, hotel staff, transport workers (including taxi operators)

Findings from modelling studies 1. Subpopulations (contd.) In long-term, circumcising males who have not yet started sexual activity leads to greatest population benefit Benefits of circumcising babies (1/3 the cost) would probably take 20-25 years to become evident Circumcising adults and neonates would maximise short and long term impact Barbados: MC before sexual debut? What is the current rate of infant circumcision? Is it concentrated in certain population groups (e.g. religious)? What is the acceptability of infant circumcision among key decision-makers, especially parents and health care workers? Babies cannot give informed consent!

Findings from modelling studies 2. MSM Observational data on HIV risk and circumcision status among MSM do not suggest a strong protective effect In anal intercourse, some evidence that benefits of MC accrue to the insertive partner but not the receptive partner Many MSM do both (and some neither) Difficult to design a MC trial among MSM Barbados Research in Latin America suggests some MSM are ONLY insertive OR receptive, but evidence for English-speaking Caribbean not clear MSM may benefit indirectly from expansion in MC through reduction in chance of meeting an infected partner

Findings from modelling studies 3. Impact on women Does circumcision of HIV+ men protect female partners? A trial found no such direct effect MC reduces the probability of transmission of other STIs Women may benefit indirectly from expansion in MC through reduction in chance of meeting an infected partner Wound healing: trend towards increased risk for women if sexual activity is resumed soon after circumcision Barbados Will women be able to avoid sex with newly circumcised men while the wound heals? Women need reminders that MC reduces risk by 60%, not 100% Other HIV prevention methods must still be promoted

Findings from modelling studies 4. Circumcision of HIV+ men WHO/ UNAIDS advocate against promoting MC for HIV+ men, but state that it should not be denied unless for medical reasons HIV testing is recommended for men seeking circumcision (not mandatory) Reduces onward transmission of genital ulcer disease (HIV inconclusive) Barbados Promote universal precautions for health service staff conducting circumcision operations

Findings from modelling studies 5. Risk compensation? Decrease in perceived risk may lead to increase in sexual risk-taking behaviour Trials of MC found minimal or no risk compensation among newly circumcised men. But these trials included intensive health education At high levels of risk compensation, women who partner with circumcised men believing them to be HIV- may be at increased risk Beneficial impact of MC maybe reduced if risk behaviours increase across entire population Barbados Need for education to prevent risk compensation and combination with other prevention strategies

Discussion Issues surrounding a MC strategy for Barbados Cost per infection averted likely to be lower than cost of HIV treatment, despite lower HIV prevalence and incidence than Africa Establishing and promoting services for heterosexual men at high risk likely to bring most rapid benefits in HIV prevention Likely to be population-level benefits for partners Need combined preventive services to bring synergies and avert “risk compensation”

Discussion Issues surrounding a MC strategy for Barbados Unknown extent of MSM transmission MC may not offer substantial protective benefits for MSM Human rights issues in ensuring informed consent and circumcising babies

Personal anecdote BUT CAN HE? Responses to proposed circumcision of my infant son by doctors in UK (1), Trinidad and Tobago (2) and Barbados (1) We might provide it on religious grounds, but you are not asking for it on that basis (UK) Risk is low in UK and we don’t do MC any more (UK) They don’t do that any more in UK, where I trained (T&T) That research is all very well, but what about the risks to your child? (T&T) It is a complex operation in infants, with risk of complication, as the foreskin is still attached to the glans (Barbados and T&T) It is unnecessary as your son’s penis is healthy (Barbados, T&T and UK) What about your son’s right to choose? Human rights of infant (T&T) When he grows up he can decide for himself (T&T) BUT CAN HE?

Acknowledgement UNAIDS/ WHO/ SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention (2009) ‘Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision-Making?’ PLoS Medicine, 6(9), e1000109.