The Year 2011 has seen a renaissance of hope in the field of HIV prevention. After several years of disappointing results of HIV prevention strategies, the positive results of recent biomedical prevention trials have engendered new hope for eventual control of the epidemic—trumpeted by a cover page of The Economist which asked: “The end of AIDS?”.1 The prevention efficacy of 40%–60% across several trials of antiretroviral pre-exposure prophylaxis as oral or vaginal gel preparations,2–4 and the highly significant 96% reduction of transmission seen in discordant couples where early antiretroviral treatment was provided for the infected partner,5 have potentially moved HIV prevention into a new era. The successful translation of this new scientific knowledge into program interventions will be extremely challenging not only because of the costs involved but also from the increased demands on the health systems of the most affected countries, which are already overburdened and underfunded.
Against this background, important lessons can be learned from medical male circumcision. The HIV prevention benefits of medical male circumcision have been demonstrated in a wide range of observational data and from 3 randomized trials, showing reductions of around 60% in HIV acquisition in circumcised men.6–8 Some studies have shown a protective effect of circumcision against herpes simplex-2 infection in men9 and additional data have shown that male circumcision reduces the prevalence and incidence of high-risk human papillomavirus infection in men and provides partial protection against human papillomavirus transmission to female partners.10 Although there have been conflicting study data on the potential of male circumcision to protect female partners, recent modelling has suggested that circumcision could confer a 46% reduction in the rate of male-to-female HIV transmission in high prevalence settings.11
The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS estimate that universal male circumcision in sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and million deaths over 20 years. More than 38 million adolescent and adult males in Africa could benefit from circumcision, which could reduce their lifetime risk of infection by 60%.12 Based on this assessment, the WHO has recommended the scale-up of voluntary medical male circumcision as an HIV prevention intervention since March 2007. Despite this guidance, scale-up of service has been slow and patchy, although 14 African countries have incorporated medical male circumcision in their national plans, with coverage targets of 80% of men for circumcision scale-up.
By mid-2011, only Kenya had achieved more than 60% coverage of circumcision, after an impressive mass medical male circumcision drive, which has circumcised close to 300,000 men since November 2008. In contrast, South Africa and Tanzania have reached 3% and Mozambique, Namibia, and Zimbabwe have each only achieved 1% coverage.13 South Africa is targeting circumcision coverage of 80% of men aged 15–49 (approximately 4.3 million men) by 2015 and had conducted around 238,000 by June 2011.14 Health service, staffing, supply chain, and financing constraints are major barriers to expansion, but lack of political or policy support is also a factor in the implementation gap in some countries.15
The WHO has promoted the use of 3 surgical techniques for adult male circumcision: the forceps guided method, the sleeve resection method, and the dorsal slit method, each of which requires trained personnel and 20–30 minutes of surgical time. To increase the competence and capacity of medical male circumcision services, WHO recommends the use of models for optimizing the volume and efficiency of male circumcision services (The MOVE model).16 There is growing experience that using this approach can deliver high volume medical males circumcision services and impact on HIV transmission. The pioneering Orange Farm, South Africa site, which has provided circumcision since 2007, has demonstrated that circumcision prevalence increased from 15.6% to 49.4% in men aged 15–49 in the area, and HIV incidence rate in this age group was 2.86/100 person-year among uncircumcised men and 0.42/100 person-year among circumcised men.17
One major limiting factor of the MOVE model is the need for doctors and other skilled personnel for these services. In contrast, the use of male circumcision devices could have the potential to expand access to the intervention in low-resource settings. The use of devices could require less highly trained health workers, provide a faster service, which could be decentralized, and may be very acceptable to men.18 Although a number of devices are widely used for circumcision in infants and boys, there is limited data on acceptability, safety, and effectiveness of the use of devices in adults. The WHO has not yet endorsed the use of any circumcision devices for adults, but has established a WHO Technical Advisory Group on Technical Innovations in Male Circumcision, which will issue such guidance, and has established the criteria that they will consider for such an approval.18
Ongoing research into new circumcision devices is providing promising results. The initial trials in Kenya of the Shang Ring device (Wuhu Snnda Medical Treatment Appliance Technology Co., Ltd., Wuhu, China), building on the first studies in China, and reported in this journal in May 2011, demonstrated excellent acceptability of the device, short procedure times, and the ability of nonphysicians to use the device.19 The Shang Ring does, however, require local anaesthesia, standard surgical cleansing, and excision of the foreskin. Large-scale studies are in progress to investigate the use of the device in other settings and its potential to expand circumcision services in countries where implementation challenges remain.
Rwanda provides a perfect example of the challenges of the implementation gap for circumcision services. The country has a national target to circumcise 2 million men within 2 years but has a health service with only 300 doctors to provide all medical care for a population of close to 10 million. The need for innovative approaches which facilitate task shifting of circumcision to other health workers in such a low-resource setting is clear. The safety and feasibility study of the PrePex device (Circ MedTech, Tel Aviv, Israel) conducted by the Rwandan government and reported in this issue of the journal provides a potentially useful solution.
This initial study describes a promising new device, which can be applied in a short procedure without anesthetic, with no cutting or bleeding at the time of application, and which is acceptable to men in the initial trials, with a low adverse event rate. The overall time to complete healing is similar to that from surgical methods. As a nonsurgical procedure, the device could enable scale-up of circumcision services without requiring doctors, other than for referral of complicated cases. Much more work is clearly needed before the device could be recommended by the WHO and used at scale—a second, larger study in Rwanda comparing the PrePex device to surgical circumcision (ClinicalTrials.gov NCT01284088) is reported to be complete, and a similar trial is planned in Zimbabwe.18
Several concerns about PrePex will need to be addressed in larger scale studies. Because the foreskin is not removed at device placement (unlike surgical procedures or other devices), the acceptability and hygiene consequences for the participant of having a necrosing foreskin in place for a week, before it is removed with the device, may be different in other settings. Larger studies will enable more reliable comparisons of clinical outcomes, staff utilization and cost-effectiveness compared with surgical methods at high and low volume circumcision sites.
New approaches which would enable medical male circumcision to be scaled-up and delivered by staff with more limited training and skills could have a major impact on HIV prevention in Africa. As with other new biomedical prevention strategies, research must now address issues of implementation, effectiveness at scale and mechanisms to combine a range of potential prevention interventions. The lessons from medical male circumcision for other prevention strategies are that issues of delivery are fundamental to introduction and that new approaches to providing interventions, new models of provider and innovative delivery mechanisms will be key to being able to move rapidly from proof of efficacy to real world use. Researcher and policymakers need to consider how best to tailor delivery of successful biomedical HIV prevention interventions to populations in need, in parallel with scientific advances in prevention.
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