Are Geographical "Cold Spots" of Male Circumcision Driving Differential HIV Dynamics in Tanzania?
BACKGROUND
Growing evidence suggests significant geographic clustering of male circumcision (MC) in Tanzania. The impact of spatial heterogeneity of MC prevalence on HIV transmission dynamics in this country is not well documented. The aim of this study was to assess the spatial association between MC and HIV infection in Tanzania.


METHODS
Data from three Demographic and Health Survey rounds conducted in Tanzania were analyzed to identify spatial associations between MC and HIV using bivariate local indicators of spatial association (LISA). Spatial clusters with low MC prevalence (MC cold spots) were identified using scan statistics. HIV incidence rates for males and females within and outside the MC cold spots were calculated.


RESULTS
Local indicators of spatial association analysis indicated a significant association between MC and HIV in the northern and southwestern regions of Tanzania. Scan statistics identified two MC cold spots in the same locations. Males located outside the MC cold spots had the lowest HIV incidence rate at 0.28 per 100 person-years at risk (pyar). HIV incidence in females located outside the MC cold spots increased from 0.40/100 pyar during 2004-2008 to 0.68/100 pyar in 2008-2012.


CONCLUSIONS
Our study provides evidence for a geographic association between MC and HIV in Tanzania. MC could be one of the key factors driving the geographical distribution of the HIV epidemic in the country. Furthermore, in areas where most males are circumcised, the HIV infection burden could be concentrating in the female population. Therefore, along with the voluntary medical MC program, efforts targeting the female population should also be considered.
Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Qatar Foundation, Cornell University , Doha , Qatar ; Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University , Ithaca, NY , USA.
Diego F
DF
Cuadros
College of Public Health and Human Sciences, Oregon State University , Corvallis, OR , USA.
Adam J
AJ
Branscum
Department of Tropical Medicine and Medical Microbiology and Pharmacology, University of Hawaii , Honolulu, HI , USA.
F DeWolfe
FD
Miller
Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Qatar Foundation, Cornell University , Doha , Qatar.
Susanne F
SF
Awad
Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Qatar Foundation, Cornell University , Doha , Qatar ; Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University , Ithaca, NY , USA ; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center , Seattle, WA , USA.
Laith J
LJ
Abu-Raddad
HIV; Tanzania; male circumcision; medical geography; spatial analysis