Male circumcision for the prevention of human immunodeficiency virus (<scp>HIV</scp>) acquisition: a meta‐analysis

Sharma, Sanjeev; Raison, Nicholas; Khan, Shamim; Shabbir, Majid; Ahmed, Kamran

doi:10.1111/bju.14102

Cited by 47 publications

(52 citation statements)

References 61 publications

(26 reference statements)

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“…Previous observational studies and trials have confirmed the protective effect of male circumcision, which can reduce the risk that heterosexual men will contract HIV by 60% to 70%. 6,7,[39][40][41] The last cluster included Southern and East African countries. These countries had high HIV prevalence and incidence, except for Rwanda and Burundi, and their rate of male circumcision was low.…”

Section: Discussionmentioning

confidence: 99%

Clusters of sub-Saharan African countries based on sociobehavioural characteristics and associated HIV incidence

Merzouki¹,

Estill

Orel³

et al. 2019

Preprint

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ObjectiveHIV incidence varies widely between sub-Saharan African (SSA) countries. This variation coincides with a substantial sociobehavioural heterogeneity, which complicates the design of effective interventions. In this study, we investigated how socio-behavioural heterogeneity in sub-Saharan Africa could account for the variance of HIV incidence between countries.MethodsWe used unsupervised machine learning to analyse data from the Demographic and Health Surveys of 29 SSA countries completed after 2010. We preselected 48 demographic, socio-economic, behavioural and HIV-related attributes to describe each country. We used Principle Component Analysis to visualize sociobehavioural similarity between countries, and to identify the variables that accounted for most sociobehavioural variance in SSA. We used hierarchical clustering to identify groups of countries with similar sociobehavioural profiles, and we compared the distribution of HIV incidence and sociobehavioural variables within each cluster.FindingsThe most important characteristics, which explained 69% of sociobehavioural variance across SSA among the variables we assessed were: religion; male circumcision; number of sexual partners; literacy; uptake of HIV testing; women’s empowerment; accepting attitude toward people living with HIV/AIDS; rurality; ART coverage; and, knowledge about AIDS. Our model revealed three groups of countries, each with characteristic sociobehavioural profiles. HIV incidence was mostly similar within each cluster and different between clusters (median(IQR); 0.5/1000(0.6/1000), 1.8/1000(1.3/1000) and 5.0/1000(4.2/1000)).ConclusionOur findings suggest that sociobehavioural factors play a key role in determining the course of the HIV epidemic, and that similar techniques can help to design and predict the effects of targeted country-specific interventions to impede HIV transmission.Research in contextKnowledge before this studyWe searched PubMed with the terms: “HIV”, “inequality”, “factors” and “sub-Saharan Africa” for articles published in English before February 28th, 2019. The reviewed literature was usually limited to a certain sub-population, sub-national region, or country; but some recent studies covered up to 31 sub-Saharan African countries. Based on a relatively small number of variable (5 to 13), and using descriptive statistics, regressions and concentration indices, previous works analysed the association between socio-economic inequalities, male circumcision, high-risk sexual behaviour, or HIV-related stigma, with HIV testing, uptake of treatment, ART adherence, or HIV prevalence.Contribution of this studyTo our knowledge, this is the first study where unsupervised machine learning techniques (Principle Component Analysis and hierarchical clustering) were used to analyse the sociobehavioural heterogeneity in sub-Saharan Africa (SSA) and how it associates with the variability of HIV incidence in the region. We identified three distinct sociobehavioural profiles, which were associated with different geographical regions and different levels of HIV incidence in SSA. Because the association between the variability of HIV incidence across SSA and its underlying sociobehavioural factors is still not well understood, we believe that our analysis that compares 29 SSA countries based on 48 sociobehavioural characteristics brings significant value to the field. Identifying and comparing sociobehavioural profiles of countries helps to design and predict the effect of tailored country-specific interventions to impede HIV transmission.

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Section: Discussionmentioning

confidence: 99%

Clusters of sub-Saharan African countries based on sociobehavioural characteristics and associated HIV incidence

Merzouki¹,

Estill

Orel³

et al. 2019

Preprint

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“…However, when subgroups were analyzed, the results of 7 studies of men reporting an insertive role were statistically significant for a 27% reduction in HIV acquisition in contrast to the 3 studies of men reporting a receptive role [53]. However, a more recent metaanalysis by Sharma et al that examined the impact of sexual roles among homosexual men reported that MC did not definitively have a protective effect among predominantly insertive homosexual men or receptive men but acknowledged that there were a small number of studies reporting the effect of sexual role on HIV acquisition [54].…”

Section: Homosexual Transmissionmentioning

confidence: 91%

Male Circumcision and Infection

Mielke¹

2020

Circumcision and the Community

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Worldwide, male circumcision is done for religious or cultural reasons, and to a lesser degree for medical indications. Newborn male circumcision is associated with fewer genitourinary infections in younger males. In the current decade, a substantial body of research suggests that male circumcision is effective as a prophylactic measure against HIV and other sexually transmitted infections. The compelling HIV reductions in 3 African randomized control trials in circumcised men have prompted use of male circumcision as a key part of HIV prevention in developing nations. More recently, the use of male circumcision as a public health measure in developed nations is a topic of international discussion.

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“…Recent meta‐analyses have shown HIV protective effects of MC in circumcised men of 70% (95% CI 0.24‐0.38; P < .00001) and 72% (95% CI 1.7‐7.1) …”

Section: Physical Harmmentioning

confidence: 99%

“…(95% CI 1.7-7.1). 226 Compelling biological reasons explain the vulnerability of the foreskin to HIV infection. 80,[227][228][229][230][231] Infectivity is exacerbated in inflammatory states and ulceration from sexually transmitted infections (STIs), [232][233][234][235][236] coital injuries (more common in uncircumcised men), [127][128][129] and foreskin size.…”

Section: In Heterosexual Menmentioning

confidence: 99%

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Critical evaluation of arguments opposing male circumcision: A systematic review

Morris

Moreton²,

Krieger

2019

J Evidence Based Medicine

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Objective To systematically evaluate evidence against male circumcision (MC). Methods We searched PubMed, Google Scholar, EMBASE and Cochrane databases. Results Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high‐quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high‐quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk‐benefit analyses reported that benefits exceed risks by 100‐200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low‐risk, high‐benefit interventions such as MC for better health. Expert evaluations of case‐law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost‐saving to health systems. Conclusions Arguments opposing MC are supported mostly by low‐quality evidence and opinion, and are contradicted by strong scientific evidence.

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Male circumcision for the prevention of human immunodeficiency virus (HIV) acquisition: a meta‐analysis

Cited by 47 publications

References 61 publications

Clusters of sub-Saharan African countries based on sociobehavioural characteristics and associated HIV incidence

Clusters of sub-Saharan African countries based on sociobehavioural characteristics and associated HIV incidence

Male Circumcision and Infection

Critical evaluation of arguments opposing male circumcision: A systematic review

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