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Peter G. Johnson, CNM, PhD, FACNM Global Learning Director

On the Cutting Edge Male Circumcision & HIV Prevention. Peter G. Johnson, CNM, PhD, FACNM Global Learning Director. Objectives. Describe evidence supporting Male Circumcision (MC) as an HIV preventative measure

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Peter G. Johnson, CNM, PhD, FACNM Global Learning Director

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  1. On the Cutting Edge Male Circumcision & HIV Prevention Peter G. Johnson, CNM, PhD, FACNM Global Learning Director

  2. Objectives • Describe evidence supporting Male Circumcision (MC) as an HIV preventative measure • Describe steps taken to develop competency based MC training materials and methods • Discuss challenges associated with further MC scale up in high HIV prevalence communities

  3. The Evidence is Compelling

  4. Male circumcision & HIV: Ecological evidence Caldwell & Caldwell, Sci Am, 1996. 274(3): p. 62-3, 66-8.

  5. Correlation of male circumcision and HIV prevalence Sub-Saharan Africa 40 Swaziland 30 Botswana Lesotho HIV prevalence in adults (%), 2005 Zimbabwe 20 South Africa Zambia Mozambique Malawi 10 Kenya Tanzania Cameroon Angola Uganda Ghana Madagscar Benin 0 20 40 60 80 100 Male circumcision prevalence (%)

  6. The impact of male circumcision on the female-to-male transmission of HIV : Results of the intervention trial : ANRS 1265Bertran Auvert, INSERM, UVSQ, AP-HP, FranceAdrian Puren, NICD, South AfricaDirk Taljaard, Progressus, South AfricaEmmanuel Lagarde, INSERM, FranceJoëlle Tambekou-Sobngwi, INSERM, FranceRémi Sitta, INSERM, France NICD (South African National Institute for Communicable Diseases)ANRS (sponsor) (French National Agency for AIDS Research)INSERM (French National Institute for medical research) UVSQ (University of Versailles – Saint-Quentin) AP-HP (Paris – Hospitals) Bertran Auvert/Dirk Taljaard –Orange Farm InterventionTrial (ANRS 1265)

  7. Objective To assess the effect of MC on HIV incidence among young males Location South Africa Orange Farm (Urban area close to Johannesburg) Local context • Heterosexual spread of HIV • High HIV prevalence (ANC data: HIV=31.6%) • MC Bertran Auvert/Dirk Taljaard –Orange Farm InterventionTrial (ANRS 1265)

  8. Results Incident cases : Incidence rates : Intervention : 0.85 (0.55 - 1.32) /100 py Control : 2.1 (1.6 - 2.8) /100 py Total : 1.5 (1.2 – 1.9) /100 py Unadjusted RR :0.40 (0.24 – 0.68) p=0.00059 Protection (1-RR):60% (32% - 76%) The intervention prevented 6 out of 10 potential HIV infections Bertran Auvert/Dirk Taljaard –Orange Farm InterventionTrial (ANRS 1265) RR: rate ratio of HIV incidence

  9. Kisuma Study • The Luo have their origins in southern Sudan and live along the lakes in East Africa. • Approximately 2,600,000 Luo live in Nyanza Province, western Kenya. • Luo do not traditionally circumcision. • 9.9% of Luo men in Kisumu District are circumcised. • Kisumu District has approximately 500,000 residents • 39,000 men aged 18-24 years.

  10. Number of HIV Seroconversionsby Month of Study Visit 22 47 Slide Courtesy of Bailey et al

  11. HIV Results Summary * Based on Kaplan-Meier method

  12. Rakai Cohort • Rural population • Rakai cohort 14,000 • Circumcised males ~16% (>90% Muslims) • Predominantly Catholic • Predominantly agriculture • Male HIV prevalence ~8% • HIV incidence in uncircumcised men 1.4/100 py

  13. Slide Courtesy of Bailey et al

  14. Cumulative HIV Incidence 0-24 months. Intent-to-treat analysis Slide Courtesy of Bailey et al

  15. A Bit of Caution • Circumcision of HIV + Men • Male to Female Transmission

  16. First Steps • JHPIEGO MC Training in Zambia • WHO convened team to develop Manual for Male Circumcision under Local Anesthesia • Male Circumcision Policy Considerations • Competency Based Training for Male Circumcision • Standards for providing safe and effective Male Circumcision

  17. Package of Services Not about getting macho men to the knife! But… A community approach Slide Courtesy of K. Dickson

  18. What is the Minimum Package? • Offer of HIV testing and counselling • Active STI exclusion and management • Condom counselling and provision of condoms • Risk reduction/safer sex counselling • Accept standards in 'surgical manual' (includes consent, pain management etc) Slide Courtesy of K. Dickson

  19. Enhanced Package Minimum Package Plus • Counselling on gender based violence, family planning, substance abuse, life skills, information about other services, vaccinations/IMCI for neonates Slide Courtesy of K. Dickson

  20. WHO/JHPIEGO sponsored pilot training • June 2007 Lusaka Zambia • Four Trainers • Two Surgical Preceptors • Nine Participants • Three WHO Observers • Six Day Training

  21. Service Delivery Goal Provide MC as a SRH Intervention Group Education Individual Counseling Preoperative Assessment Postoperative Assessment Procedure Essential Competencies

  22. Participants • Lesotho • Surgeon • Nurse-Midwife X 2 Senegal • Physician • Tanzania • Surgeon • Clinical Officer • Nurse Malawi • Clinical Officer Mozambique • ID Physician

  23. Overall Challenges • First time! • Competencies occur in separate service delivery areas • IP/Anesthesia • Multiple Cadres • Site & Preceptor Standardization • Anatomic Models • Meeting Demand

  24. The Results – Skills Exposure

  25. Challenging Issues Scale Up Training Standards Operational Research

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