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Scaling Up Circumcision Programs in Southern Africa: The Potential Impact of Gender Disparities and Changes in Condom Use Behaviors on Heterosexual HIV Transmission

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Abstract

Circumcision significantly reduces female-to-male transmission of HIV infection, but changes in behavior may influence the overall impact on transmission. We sought to explore these effects, particularly for societies where women have less power to negotiate safe sex. We developed a compartmental epidemic model to simulate the population-level impact of various circumcision programs on heterosexual HIV transmission in Soweto. We incorporated gender-specific negotiation of condom use in sexual partnerships and explored post-circumcision changes in condom use. A 5-year prevention program in which only an additional 10% of uncircumcised males undergo circumcision each year, for example, would prevent 13% of the expected new HIV infections over 20 years. Outcomes were sensitive to potential changes in behavior and differed by gender. For Southern Africa, even modest programs offering circumcision would result in significant benefits. Because decreases in male condom use could diminish these benefits, particularly for women, circumcision programs should emphasize risk-reduction counseling.

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Ackowledgments

The authors thank Edward Kaplan for his assistance with the model structure, and the anonymous reviewers who have provided valuable insights on the content of the paper. K. M. Andersson also thanks the Department of Epidemiology and Public Health and the MD/PhD Program at the Yale University School of Medicine for supporting the dissertation research from which portions of this article evolved.

This work was supported by the National Institute on Drug Abuse (RO1DA015612), the National Institute of General Medical Sciences Medical Scientist Training Program (GM07205), and the Agency for Health Research and Quality Training Program in Health Services Research (T32HS017589). The authors do not have any associations that may pose a potential conflict of interest.

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Authors and Affiliations

  1. Division of Health Policy & Administration, Department of Epidemiology & Public Health, Yale University School of Medicine, 60 College Street, New Haven, CT, 06510, USA

    Kyeen M. Andersson & A. David Paltiel

  2. VA Palo Alto Health Care System, Palo Alto, CA, USA

    Douglas K. Owens

  3. Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, Stanford, CA, USA

    Douglas K. Owens

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  1. Kyeen M. Andersson
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  2. Douglas K. Owens
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  3. A. David Paltiel
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Correspondence to Kyeen M. Andersson.

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Research undertaken in part during graduate studies in the MD/PhD program at Yale University and under the maiden name Kyeen Mesesan.

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Andersson, K.M., Owens, D.K. & Paltiel, A.D. Scaling Up Circumcision Programs in Southern Africa: The Potential Impact of Gender Disparities and Changes in Condom Use Behaviors on Heterosexual HIV Transmission. AIDS Behav 15, 938–948 (2011). https://doi.org/10.1007/s10461-010-9784-y

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