title: Could Circumcision of HIV-Positive Males Benefit Voluntary Medical Male Circumcision Programs in Africa? Mathematical Modeling Analysis.
abstract: BACKGROUND
  The epidemiological and programmatic implications of inclusivity of HIV-positive males in voluntary medical male circumcision (VMMC) programs are uncertain. We modeled these implications using Zambia as an illustrative example.
  
  
  RESULTS
  We used the Age-Structured Mathematical (ASM) model to evaluate, over an intermediate horizon (2010-2025), the effectiveness (number of VMMCs needed to avert one HIV infection) of VMMC scale-up scenarios with varying proportions of HIV-positive males. The model was calibrated by fitting to HIV prevalence time trend data from 1990 to 2014. We assumed that inclusivity of HIV positive males may benefit VMMC programs by increasing VMMC uptake among higher risk males, or by circumcision reducing HIV male-to-female transmission risk. All analyses were generated assuming no further antiretroviral therapy (ART) scale-up. The number of VMMCs needed to avert one HIV infection was projected to increase from 12.2 VMMCs per HIV infection averted, in a program that circumcises only HIV-negative males, to 14.0, in a program that includes HIV-positive males. The proportion of HIV-positive males was based on their representation in the population (e.g. 12.6% of those circumcised in 2010 would be HIV-positive based on HIV prevalence among males of 12.6% in 2010). However, if a program that only reaches out to HIV-negative males is associated with 20% lower uptake among higher-risk males, the effectiveness would be 13.2 VMMCs per infection averted. If improved inclusivity of HIV-positive males is associated with 20% higher uptake among higher-risk males, the effectiveness would be 12.4. As the assumed VMMC efficacy against male-to-female HIV transmission was increased from 0% to 20% and 46%, the effectiveness of circumcising regardless of HIV status improved from 14.0 to 11.5 and 9.1, respectively. The reduction in the HIV incidence rate among females increased accordingly, from 24.7% to 34.8% and 50.4%, respectively.
  
  
  CONCLUSIONS
  Improving inclusivity of males in VMMC programs regardless of HIV status increases VMMC effectiveness, if there is moderate increase in VMMC uptake among higher-risk males and/or if there is moderate efficacy for VMMC against male-to-female transmission. In these circumstances, VMMC programs can reduce the HIV incidence rate in males by nearly as much as expected by some ART programs, and additionally, females can benefit from the intervention nearly as much as males.
authors.affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.
authors.forename: Susanne F
authors.initials: SF
authors.lastname: Awad
authors.affiliation: Surgo Foundation, Washington, District of Columbia, United States of America.|Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America.|Department of Global Health, University of Washington, Seattle, Washington, United States of America.
authors.forename: Sema K
authors.initials: SK
authors.lastname: Sgaier
authors.affiliation: Surgo Foundation, Washington, District of Columbia, United States of America.
authors.forename: Fiona K
authors.initials: FK
authors.lastname: Lau
authors.affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.
authors.forename: Yousra A
authors.initials: YA
authors.lastname: Mohamoud
authors.affiliation: Ministry of Community Development and Mother and Child Health, Lusaka, Zambia.
authors.forename: Bushimbwa C
authors.initials: BC
authors.lastname: Tambatamba
authors.affiliation: Health Policy Initiative, Avenir Health, Washington, District of Columbia, United States of America.
authors.forename: Katharine E
authors.initials: KE
authors.lastname: Kripke
authors.affiliation: Naval Health Research Center, U.S. Department of Defense, San Diego, California, United States of America.
authors.forename: Anne G
authors.initials: AG
authors.lastname: Thomas
authors.affiliation: Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Naomi
authors.initials: N
authors.lastname: Bock
authors.affiliation: Jhpiego, Washington, District of Columbia, United States of America.
authors.forename: Jason B
authors.initials: JB
authors.lastname: Reed
authors.affiliation: United States Agency for International Development, Washington, District of Columbia, United States of America.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
authors.affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.|Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.|College of Public Health, Hamad bin Khalifa University, Qatar Foundation, Education City, Doha, Qatar.
authors.forename: Laith J
authors.initials: LJ
authors.lastname: Abu-Raddad
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002944:Circumcision, Male / Q000523:psychology; D058872:Epidemics / Q000517:prevention & control; D005260:Female; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control* / Q000523:psychology / Q000635:transmission; D006679:HIV Seropositivity; D015528:HIV Seroprevalence / Q000639:trends; D006291:Health Policy; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D010342:Patient Acceptance of Health Care; D015397:Program Evaluation; D012725:Sexual Behavior; D035501:Uncertainty; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology