Incremental role of male circumcision on a generalised HIV epidemic through its protective effect against other sexually transmitted infections: from efficacy to effectiveness to population-level impact
- 1Department of Infectious Disease Epidemiology, Imperial College, London, UK
- 2Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
- 3Department of Mathematics, University of Manitoba, Canada
- Dr M-C Boily, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College, London W2 1PG, UK;
- Accepted 24 July 2008
Background: Male circumcision (MC) can reduce HIV acquisition. However, a better understanding of the indirect protective effect of MC on sexually transmitted infections (STIs) is required.
Objective: To assess the incremental benefits conferred by MC on HIV infection at the individual level in circumcision trials (no herd immunity effect) and at the population level (with herd immunity effect) owing to its protective effect against other STIs.
Methods: A dynamic stochastic model of HIV and STI infections in a Kenyan population was used to simulate the impact of MC offered to a few trial participants or to a large proportion of men in order to study the protective role of MC on HIV infection at the individual and population levels.
Results: Fewer than 20% of the HIV infections prevented in the circumcised arm of the circumcision trials (individual level) could be attributable to the efficacy of MC against STIs rather than against HIV. At the population level, MC can significantly reduce the prevalence of HIV, especially among men and women in the longer term. However, even at the population level, the long-term incremental impact of MC on HIV due to the protection against STI is modest (even if MC efficacy against the STI and STI prevalence was high).
Conclusions: The protection of MC against STI contributes little to the overall effect of MC on HIV. Additional work is needed to determine whether, and under what conditions, the protective effect of MC efficacy against STIs can have a significant incremental benefit on the HIV epidemic.
Funding: BM: Part of this work was supported by the National Institute of Allergy Infectious Diseases of the US National Institute of Health (SU01AI068615).
Competing interests: None.
All authors contributed to the planning, interpretation of the results and the redaction of the manuscript. In addition, MCB and KD wrote the first version of the manuscript, designed the study and performed the analysis.