Circumcision, ART reduce new HIV infections in rural Ugandan men
Increasing medical male circumcision and female ART coverage appeared to limit the number of new HIV infections in males living in rural sub-Saharan Africa, according to new data published in JAMA.
“Before our study, there was no empirical data to show the effects of scaling up these two interventions in real-world settings,” Xiangrong Kong, PhD, associate scientist in the epidemiology and biostatistics departments at the Johns Hopkins Bloomberg School of Health, said in a press release. “It’s important to know whether prevention is working, and this is evidence that strongly suggests that African nations should redouble their efforts to scale up these programs.”
To investigate the impact of these two strategies, Kong and colleagues conducted a community-based study using population survey data collected between 1999 and 2013 in Rakai, Uganda. The researchers reviewed responses from these surveys — which were bundled with HIV testing and included information on sociodemographics, sexual behaviors, circumcision status and use of long-term medications such as ART — and stratified the data into three time periods: no availability of medical male circumcision and ART (1999-2004), early availability medical male circumcision and ART (2004-2007) and expanded availability these interventions (2007-2013). The researchers’ primary outcome was adjusted incidence rate ratios (IRR) for sex-specific HIV incidence, which they analyzed in relation to community medical male circumcision coverage and ART use among members of the opposite sex with HIV.
During the study period, 44,688 Ugandans completed at least one survey (mean participation rate, 92.6%). Of these, 56.5% were female, and the mean age upon first surveying was 24.6 years.
Median community medical male circumcision rose from 18.8% to 38.5% from the first to the third study period, while ART coverage increased in males (0% to 20.7%) and in females (0% to 26.3%). During the same time period, median community HIV incidence fell from 1.25 per 100 person-years (PY) to 0.84 per 100 PY in males, and from 1.25 per 100 PY to 0.99 per 100 PY in females.
Further analysis revealed that each 10% increase in a community’s medical male circumcision coverage was associated with an adjusted IRR for HIV incidence of 0.87 (95% CI, 0.82-0.93) among men, and that communities with medical male circumcision coverage exceeding 40% had lower HIV incidence than those with less than 10% coverage (adjusted IRR = 0.61; 95% CI, 0.43-0.88). Similar incremental increases in ART coverage among women did not demonstrate reduced male HIV incidence, although comparison between communities with female ART coverage exceeding 20% and those with lesser coverage showed a decrease in new cases (adjusted IRR = 0.77; 95% CI, 0.61-0.98). The researchers observed no changes in female incidence rates related to medical male circumcision or male ART coverage.
These observed declines in male HIV incidence reaffirm the efficacy of medical male circumcision and ART, the researchers wrote, and make a case for expanding these interventions throughout sub-Saharan Africa.
“The biology of these two prevention strategies has been proven, but the big question was whether these strategies could have an impact on the number of new HIV infections in communities still struggling to control the spread of the disease,” Kong said. “People need to adopt these strategies, and we need to have sustainable funding to support these efforts.” – by Dave Muoio
Disclosure: The researchers report no relevant financial disclosures.