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Scaling up adult male circumcision calculated to have HIV prevention benefits additional to those seen with 90-90-90 treatment target
Michael Carter, 2017-01-05 08:10:00
voluntary medical male circumcision (VMMC) in countries with a high HIV
prevalence has the potential to reduce incidence of new infections over and
above the level associated with attainment of the 90-90-90 treatment target,
according to a modelling study published in PLOS
The model was based on rollout
of VMMC to cover 90% of males aged 15-49 years. The investigators modelled
three viral suppression scenarios, two of which involved viral suppression
rates below the 90% target. In all three scenarios, male circumcision would
reduce HIV incidence to at least levels predicted with 90% viral suppression,
even when suppression rates were as low as 75%. Although VMMC scale-up would
initially increase costs, it was projected to reduce expenditure in the longer
“Compared to the
epidemic impact of scaling up ART [antiretroviral therapy] to 90-90-90 levels, three scenarios that also
include VMMC scale-up demonstrated additional reductions in HIV incidence and
lower long-term program costs in models applied to Lesotho, Malawi, South Africa and
Uganda,” write the investigators. “In the three scenarios modeled, for all four
countries initial five-year annual program costs are higher with the combined
ART and VMMC approach versus ART only, and then after 2020 are lower with the
combined approach versus ART-only.”
90-90-90 target calls for 90% of people living with HIV being aware of their
infection status; 90% of diagnosed people on ART; and 90% of people on ART with viral suppression. This would translate to 73% of all people with
HIV having viral suppression. Achievement of these targets by 2020 would mean
substantial reductions in HIV incidence and mortality and have the potential to
end the AIDS epidemic by 2030.
Progress towards these
targets in resource-limited settings has been mixed. Currently, only 51% of
HIV-positive individuals in sub-Saharan Africa are aware of their status,
approximately 43% are in receipt of ART and only a third have viral
suppression. However, 84% of people who know their status are on ART and
three-quarters of these people are virally suppressed. The biggest gap is therefore individual knowledge of HIV status.
VMMC can reduce
the risk of infection with HIV by between 60 and 74%. As part of a wider
prevention package, UNAIDS has set the target of circumcising 80% of young
males in high prevalence settings by 2020.
team of investigators wanted to see how scale-up of VMMC in four high
prevalence countries – Lesotho, Malawi, South Africa and Uganda – could contribute to 90-90-90
targets. They therefore modelled three scenarios:
- achievement of 90-90-90
- a viral suppression rate of 75%
rather than 90%
- achievement of the 90-90-90 target in
women but lower coverage in men.
The authors also
calculated the additional costs associated with scaling up VMMC (between $90
and $150 per procedure) in both the scale-up phase (to 2020) and in the longer
term (to 2049).
Achievement of a
90% VMMC target within five years and then maintaining this coverage was
projected to achieve reductions in HIV incidence over that seen with 90-90-90
alone. By 2050, annual HIV incidence would be reduced to between 0.05 and
0.5%. In all four countries, this was modestly below the levels seen with
90-90-90 alone. This was the case regardless of baseline HIV incidence levels
(1.52% to 0.25%) or baseline coverage of adult male circumcision (39% to 14%).
Scaling up VMMC in
the context of a 75% viral suppression rate was shown to achieve reductions in
HIV incidence on a par with those associated with full achievement of the
90-90-90 target. This was also the case when the full 90-90-90 target was
achieved in women but with lower coverage in men.
increased programme costs through the rollout phase compared to 90-90-90 alone.
But by 2025, adding VMMC was associated with savings compared to 90-90-90
without expansion of male circumcision programmes.
reduced morbidity, mortality, and viral transmissibility in both men and women
and must be taken early and consistently and clinically monitored for a
lifetime to effect maximum benefit,” comment the authors. “Male circumcision
conveys almost immediate substantial risk reduction to men for life after a
They conclude, “in
the context of 90-90-90, prioritizing continued successful scale-up of VMMC
increases the possibility of future generations not only free of AIDS but also