1. Research activities in Orange Farm Bertran Auvert INSERM University of Versailles, France Country update meeting on scaling - up of male circumcision programmes in the southern and eastern Africa Region Arusha, Tanzania, 8 - 10 June 2010

2. Background Orange Farm About 200 000 people Objective of the current project (Bophelo pele) To roll out MC To study the effect at community level (sexual behavior, HIV) Schedule 2007: S1: baseline cross sectional survey (men and women) 2008  Roll out of MC 2011: S2: Second cross sectional survey 2013: S3: Third cross sectional survey 20082009201020112012 S1 (baseline) MC roll out S2 2013 S3

3. 1 Uptake of MC Objective: Proportion of uncircumcised men who will accept to become circumcised? Methods: Cross sectional survey S2 in 2011 (3 years after the beginning of the roll out) Questionnaire Genital examination Results: Before 2008: MC prevalence=15% After the roll out? In 2011. 40%? 60%? 20082009201020112012 S1 (baseline) MC roll out S2 2013 S3

4. 2 Who is coming for MC? Objective: To compare those who are coming for MC with those who did not come. Comparison on HIV and sexual behavior Methods: Sample among those who are coming for MC (2010) Sample among uncircumcised (2011 survey) Questionnaire (sexual behavior, condom use) Blood sample (HIV prevalence and incidence) Other STIs (HSV-2, HPV, NG, CT) Results: More at risk? Less at risk? Difference in HIV prevalence, incidence? 20102011 S2

5. 3 Effect of MC on sexual behavior Objective: To compare those who are coming for MC with those who were recently circumcised. Comparison on sexual behavior Methods: Sample among those who are coming for MC (2010) Sample among recently circumcised (2011 survey) Questionnaire (sexual behavior, condom use) STIs as a proxy of sexual behavior (NG, CT) Results: Risk compensation? 20102011 S2

6. 4 Effect of MC on HIV among women Objective: To compare HIV among women having had a partner circumcised during the partnership not having had a partner circumcised during the partnership Methods: Sample among women (2011 survey) Questionnaire (MC status of partner, sexual behavior, condom use) Blood sample tested for HIV Results: Can we detect any difference in HIV incidence? 20102011 S2

7. 5 Effect of the roll out on HIV Objective: To compare HIV incidence between those who came for MC who didn’t come for MC Methods: Sample among men (2011 survey) Questionnaire (sexual behavior, condom use) Clinical examination Blood sample tested for HIV Repeat the study in 2013 (S3) Effect on other STIs (HSV-2, HPV) Results: Can we detect any difference in HIV incidence? Sample size of the 2013 survey? 20102011 S2 20122013 S3

8. HIV incidence ? It is used for HIV incidence. Does it work for comparison of HIV incidence (HIV incidence ratios) ? Using the blood sample collected at the final follow up visit MC trial 2946 blood tube 194 HIV+ 121 Tested as “recently infected” (18 months)  RR of HIV infection (incidence rate ratio) 53% (30% to 70%) * Trial :60% (34% to 76%) “Recently” infected “Not recently” infected “Recently”: BED incidence assay  3 to 18 months (cut off) Careful: correction for false recently infected, those under ARVs * BMC Infect Dis. 2010 May 27;10(1):137 HIV incidence assay

9. Acknowledgement Orange Farm population (South Africa) Bophelo Project team (South Africa) ANRS (France) University of Versailles (France INSERM (France) NICD – NHLS (South Africa)