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

2. 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

3. 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

4. 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.

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

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

7. 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

8. Characteristics of the HIV epidemic in Barbados
Males still predominate in most age groups (except ), 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

9. 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$ as against $7,000 for lifetime first-line HIV treatment
There are some general conclusions and issues to consider elsewhere

10. 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)

11. 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 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!

12. 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

13. 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

14. 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

15. 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

16. 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”

17. 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

18. 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?

19. 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), e