In a study appearing in the July 12 issue of JAMA, an HIV/AIDS theme issue, Xiangrong Kong, Ph.D., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues examined whether increasing community medical male circumcision and antiretroviral therapy (ART) coverage was associated with reduced community HIV incidence in Uganda.
Randomized trials have shown that medical male circumcision (MMC) reduces male HIV acquisition by 50 percent to 60 percent, and that early initiation of ART reduces HIV transmission by more than 90 percent in HIV-discordant couples. There are limited data on the population-level effect of scale-up of these interventions in sub-Saharan Africa. Such evaluation is important for planning and resource allocation.
Using data from population-based surveys conducted from 1999 through 2013 in 45 rural Rakai, Uganda communities, community-level ART and MMC coverage, sociodemographics, sexual behaviors, and HIV prevalence and incidence were estimated in 3 periods: prior to the availability of ART and MMC (1999-2004), during early availability of ART and MMC (2004-2007), and during mature program scale-up (2007-2013).
From 1999 through 2013, 44,688 persons participated in 1 or more surveys. Median community MMC coverage increased from 19 percent to 39 percent, and median community ART coverage rose from 0 percent to 21 percent in males and from 0 percent to 26 percent in females. Median community HIV incidence declined from 1.25 to 0.84 per 100 person-years in males, and from 1.25 to 0.99 per 100 person-years in females. Analysis indicated that increasing community-level coverage of MMC was associated with significant reductions in male community HIV incidence. For example, in communities with MMC more than 40 percent, male HIV incidence was 0.66 per 100 person-years lower than in communities with MMC coverage 10 percent or less.
"This difference is substantial to these communities and suggests that increasing MMC coverage more than 40 percent could reduce male incidence by approximately 39 percent at a population-level. This is comparable with the estimated reduction in individual HIV acquisition risk associated with comparable ART coverage in South Africa," the authors write.
"Because MMC provides direct protection against male HIV acquisition, this association is plausible and consistent with the estimated associations of increasing MMC coverage with male HIV prevalence from cross-sectional analyses in South Africa. Female community HIV incidence was not significantly associated with male MMC coverage during the study period, consistent with mathematical models suggesting that the HIV prevention benefits of MMC to women accrue over longer periods."
The researchers write that if similar associations are found elsewhere regarding increasing community MMC and female ART coverage, this would support further scale-up of MMC and ART for HIV prevention in sub-Saharan Africa.
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