CROI 2015: Medical circumcision strategies and results include implications for partners, herpes findings, effect of ARVs

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Science Speaks is covering the 2015 Conference on Retroviruses and Opportunistic Infections in Seattle Washington live this week, from February 23-26, with breaking news on HIV research findings and implications.

Science Speaks is covering the 2015 Conference on Retroviruses and Opportunistic Infections in Seattle Washington live this week, from February 23-26, with breaking news on HIV research findings and implications.

SEATTLE, WA – A series of presentations on Tuesday in Seattle on circumcision highlighted the benefit of the procedure as an HIV intervention, providing more evidence for benefits and risks for men and their sexual partners. Findings also pointed to strategies with some success reaching men most at risk for HIV acquisition.

Mary Grabowski presented findings from a study of men with HIV infection and men with herpes infection from Rakai, Uganda showing that medical circumcision significantly reduces penile viral shedding. The findings indicate that circumcision may protect sexual partners of circumsised men from acquiring HIV or Herpes infection.  The findings came with Important caveats because viral shedding dramatically increases during the three weeks following circumcision and in many settings, including Uganda and Kenya, as many as 40-to-50 percent of newly circumcised men continue to have sex despite being counseled not to during the healing period.  The research also showed that in the case of HIV-infected men, being on antiretroviral therapy substantially reduced this spike in viral shedding. This led the study’s authors to suggest that placing men on antiretroviral therapy and co-locating treatment and circumcision services may be warranted to reduce the potential for HIV transmission to sexual partners during the healing period. Grabowski also suggested that more research is needed to learn how long HIV-infected men should be on HIV treatment prior to circumcision.

The U.S. President’s Emergency Program for AIDS Relief has supported 6.5 million medical circumcisions through 2014, but challenges remain in ensuring that circumcision reaches the highest risk age group of men from age 15-49, to deliver the greatest impact on the HIV epidemic. Approximately 30-to-40 percent of the circumcisions to date have been conducted on 10-14 year old boys. One strategy that seems to hold some promise for reaching older men is the use of the PrePrex device instead of a surgical procedure to remove the foreskin. This device can only be used on males 18 years old and older. Eugene Rugwizangoga reported high rates of acceptability of the device by men in Rwanda where circumcision has been integrated into primary care settings, and a greater preference for the device among older men.  Older men appreciate that the procedure is quick, and that they lose less time from  work. Since February 2014, almost 21,000 circumcisions were conducted, 63 percent of them using PrePrex. The numbers have been increasing thanks to task shifting to nurses and the use of mobile teams.

Augustino Hellar from Jhpiego highlighted models for circumcision in Tanzania, where providing circumcisions in primary care facilities, launching intense, high volume circumcision campaigns and more recently sending out mobile teams to conduct circumcisions have all been part of the scale-up plan. The mobile teams have had more success in reaching older men, including men living in more remote locations and these clients have higher followup rates than those who are circumcised in facilities or through campaigns. The mobile teams have also identified more HIV-infected men, although linkage to care is challenging in these remote settings.

 

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