[e-med] (19)Les Nations Unies envisagent la circoncision pourfairereculer le sida

["ReMeD" <c.bruneton@remed.org>]

[Vu l'intérêt des e-mediens pour ce débat, je vous mets en direct les 2 
articles de Plos Medicines à l'origine du débat. Ce sera eut-être abordé à la conférence internationale sur le sida à Toronto ? CB]

The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa
Brian G. Williams1*, James O. Lloyd-Smith2,3, Eleanor Gouws4, Catherine 
Hankins4, Wayne M. Getz2, John Hargrove5, Isabelle de Zoysa6, Christopher 
Dye1, Bertran Auvert7,8,9
1 World Health Organization, Stop TB Department, Geneva, Switzerland, 2 
Department of Environmental Science, Policy, and Management, University of 
California Berkeley, Berkeley, California, United States of America, 3 
Center for Infectious Disease Dynamics, Pennsylvania State University, 
University Park, Pennsylvania, United States of America, 4 Joint United 
Nations Programme on HIV/AIDS (UNAIDS), Policy, Evidence, and Partnerships 
Department, Geneva, Switzerland, 5 South African Centre for Epidemiological 
Modelling and Analysis, Stellenbosch, South Africa, 6 World Health 
Organization, Family and Community Health, Geneva, Switzerland, 7 INSERM, 
Saint Maurice, France, 8 University of Versailles-Saint Quentin, Faculté de 
Médecine Paris-Ile-de-France-Ouest, Saint Maurice, France, 9 Assistance 
Publique-Hôpitaux de Paris, Hôpital Ambroise Pare, Boulogne, France

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030262

ABSTRACT

Background
A randomized controlled trial (RCT) has shown that male circumcision (MC) 
reduces sexual transmission of HIV from women to men by 60% (32%?76%; 95% 
CI) offering an intervention of proven efficacy for reducing the sexual 
spread of HIV. We explore the implications of this finding for the promotion 
of MC as a public health intervention to control HIV in sub-Saharan Africa.

Methods and Findings
Using dynamical simulation models we consider the impact of MC on the 
relative prevalence of HIV in men and women and in circumcised and 
uncircumcised men. Using country level data on HIV prevalence and MC, we 
estimate the impact of increasing MC coverage on HIV incidence, HIV 
prevalence, and HIV-related deaths over the next ten, twenty, and thirty 
years in sub-Saharan Africa. Assuming that full coverage of MC is achieved 
over the next ten years, we consider three scenarios in which the reduction 
in transmission is given by the best estimate and the upper and lower 95% 
confidence limits of the reduction in transmission observed in the RCT.
MC could avert 2.0 (1.1?3.8) million new HIV infections and 0.3 (0.1?0.5) 
million deaths over the next ten years in sub-Saharan Africa. In the ten 
years after that, it could avert a further 3.7 (1.9?7.5) million new HIV 
infections and 2.7 (1.5?5.3) million deaths, with about one quarter of all 
the incident cases prevented and the deaths averted occurring in South 
Africa. We show that a) MC will increase the proportion of infected people 
who are women from about 52% to 58%; b) where there is homogenous mixing but 
not all men are circumcised, the prevalence of infection in circumcised men 
is likely to be about 80% of that in uncircumcised men; c) MC is equivalent 
to an intervention, such as a vaccine or increased condom use, that reduces 
transmission in both directions by 37%.

Conclusions
This analysis is based on the result of just one RCT, but if the results of 
that trial are confirmed we suggest that MC could substantially reduce the 
burden of HIV in Africa, especially in southern Africa where the prevalence 
of MC is low and the prevalence of HIV is high. While the protective benefit 
to HIV-negative men will be immediate, the full impact of MC on HIV-related 
illness and death will only be apparent in ten to twenty years.

Funding: The work of JOLS and WMG was supported by NIH-NIDA grant 
R01-DA10135 and a James S. McDonnell Foundation 21st Century Science 
Initiative grant. The funders had no role in study design, data collection 
and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests 
exist.
Academic Editor: Steven Deeks, San Francisco General Hospital, United States 
of America
Received: December 7, 2005; Accepted: March 28, 2006; Published: July 11, 
2006
DOI: 10.1371/journal.pmed.0030262
Copyright: © 2006 Williams et al. This is an open-access article distributed 
under the terms of the Creative Commons Attribution License, which permits 
unrestricted use, distribution, and reproduction in any medium, provided the 
original author and source are credited.
Abbreviations: ART, anti-retroviral therapy; MC, male circumcision; RCT, 
randomized control trial
* To whom correspondence should be addressed. E-mail: williamsbg@who.int
Citation: Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, et al. 
(2006) The Potential Impact of Male Circumcision on HIV in Sub-Saharan 
Africa. PLoS Med 3(7): e262

****************

Randomized, Controlled Intervention Trial of Male Circumcision for Reduction 
of HIV Infection Risk: The ANRS 1265 Trial
Bertran Auvert1,2,3,4*, Dirk Taljaard5, Emmanuel Lagarde2,4, Joëlle 
Sobngwi-Tambekou2, Rémi Sitta2,4, Adrian Puren6
1 Hôpital Ambroise-Paré, Assitance Publique-Hôpitaux de Paris, Boulogne, 
France, 2 INSERM U 687, Saint-Maurice, France, 3 University Versailles 
Saint-Quentin, Versailles, France, 4 IFR 69, Villejuif, France, 5 
Progressus, Johannesburg, South Africa, 6 National Institute for 
Communicable Disease, Johannesburg, South Africa
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020298

ABSTRACT
Background
Observational studies suggest that male circumcision may provide protection 
against HIV-1 infection. A randomized, controlled intervention trial was 
conducted in a general population of South Africa to test this hypothesis.

Methods and Findings
A total of 3,274 uncircumcised men, aged 18-24 y, were randomized to a 
control or an intervention group with follow-up visits at months 3, 12, and 
21. Male circumcision was offered to the intervention group immediately 
after randomization and to the control group at the end of the follow-up. 
The grouped censored data were analyzed in intention-to-treat, univariate 
and multivariate, analyses, using piecewise exponential, proportional 
hazards models. Rate ratios (RR) of HIV incidence were determined with 95% 
CI. Protection against HIV infection was calculated as 1 ? RR. The trial was 
stopped at the interim analysis, and the mean (interquartile range) 
follow-up was 18.1 mo (13.0-21.0) when the data were analyzed. There were 20 
HIV infections (incidence rate = 0.85 per 100 person-years) in the 
intervention group and 49 (2.1 per 100 person-years) in the control group, 
corresponding to an RR of 0.40 (95% CI: 0.24%-0.68%; p < 0.001). This RR 
corresponds to a protection of 60% (95% CI: 32%-76%). When controlling for 
behavioural factors, including sexual behaviour that increased slightly in 
the intervention group, condom use, and health-seeking behaviour, the 
protection was of 61% (95% CI: 34%-77%).

Conclusion
Male circumcision provides a degree of protection against acquiring HIV 
infection, equivalent to what a vaccine of high efficacy would have 
achieved. Male circumcision may provide an important way of reducing the 
spread of HIV infection in sub-Saharan Africa. (Preliminary and partial 
results were presented at the International AIDS Society 2005 Conference, on 
26 July 2005, in Rio de Janeiro, Brazil.)

Competing Interests: The authors have declared that no competing interests 
exist.
Author Contributions: BA designed the study with DT, EL, and AP. DT and AP 
were responsible for operational aspects, including laboratory and field 
work and in-country administration of the study. BA monitored the study with 
input from EL and wrote the paper with input from all authors. BA analyzed 
the data with RS, with inputs from JST. RS conducted the interim analysis.
Academic Editor: Steven Deeks, San Francisco General Hospital, San 
Francisco, California, United States of America.
Received: June 29, 2005; Accepted: September 26, 2005; Published: October 
25, 2005
DOI: 10.1371/journal.pmed.0020298
Copyright: © 2005 Auvert et al. This is an open-access article distributed 
under the terms of the Creative Commons Attribution License, which permits 
unrestricted use, distribution, and reproduction in any medium, provided the 
original author and source are credited.
Abbreviations: AE, adverse event; IQR, interquartile range; M[number], month 
[number]; MC, male circumcision; py, person-year; RR, rate ratio; STI, 
sexually transmitted infection; VCT, voluntary counselling and testing
* To whom correspondence should be addressed. E-mail: 
bertran.auvert@apr.aphp.fr
Citation: Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et 
al. (2005) Randomized, Controlled Intervention Trial of Male Circumcision 
for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med 2(11): 
e298