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. 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%). 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.).

No epidemiological study has been conducted on HIV and vulnerability to sexually transmitted diseases (STI) among men who have sex with men (MSM) in sub-Saharan Africa A survey including questionnaire, physical examination and detection of HIV and STI was carried out among 463 MSM, aged 18–52 years, recruited through the snowball technique in five urban sites throughout Senegal. A total of 21.5% of men were found to be infected with HIV [95% confidence interval (CI), 17.8–25.6]. Active syphilis, positive serology for herpes simplex virus (HSV)-2, and polymerase chain reaction detection in urine of Chlamydia and gonorrhea infections were recorded in 4.8, 22.3, 4.1 and 5.4% of participants, respectively. Most respondents reported sex with women (94.1%). In the month preceding the interview, 24% reported at least one unprotected insertive anal intercourse with a male partner, 20% at least one unprotected receptive anal intercourse, and 18% at least one unprotected intercourse with a female partner. Genital examination showed that 5% of participants had at least one clinical sign of STI. Factors associated with HIV infection were age group, the reporting of more than nine lifetime male partners [odds ratio (OR), 3.76; 95% CI, 1.61–8.79], being a waiter or bartender (OR, 3.33; 95% CI, 1.41–7.84), and living in Dakar (OR, 3.33; 95% CI, 1.07–3.43). Men who have sex with men in Senegal are highly infected with HIV and other STI. Intervention programs targeting this population are urgently needed, given their particular vulnerability and because infections are likely to disseminate into the general population given the high proportion of bisexual activity in this community.

To identify factors that could explain differences in rate of spread of HIV between different regions in sub-Saharan Africa. Cross-sectional study. The study took place in two cities with a relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon), and two cities with a high HIV prevalence (Kisumu, Kenya and Ndola, Zambia). In each of these cities, a representative sample was taken of about 1000 men and 1000 women aged 15-49 years. Consenting men and women were interviewed about their socio-demographic background and sexual behaviour; and were tested for HIV, herpes simplex virus type 2 (HSV-2), syphilis, Chlamydia trachomatis and Neisseria gonorrhoea infection, and (women only) Trichomonas vaginalis. Analysis of risk factors for HIV infection was carried out for each city and each sex separately. Adjusted odds ratios (aOR) were obtained by multivariate logistic regression. The prevalence of HIV infection in sexually active men was 3.9% in Cotonou, 4.4% in Yaoundé, 21.1% in Kisumu, and 25.4% in Ndola. For women, the corresponding figures were 4.0, 8.4, 31.6 and 35.1%. High-risk sexual behaviour was not more common in the high HIV prevalence cities than in the low HIV prevalence cities, but HSV-2 infection and lack of circumcision were consistently more prevalent in the high HIV prevalence cities than in the low HIV prevalence cities. In multivariate analysis, the association between HIV infection and sexual behavioural factors was variable across the four cities. Syphilis was associated with HIV infection in Ndola in men [aOR = 2.7, 95% confidence interval (CI) = 1.5-4.9] and in women (aOR = 1.7, 95% CI = 1.1-2.6). HSV-2 infection was strongly associated with HIV infection in all four cities and in both sexes (aOR ranging between 4.4 and 8.0). Circumcision had a strong protective effect against the acquisition of HIV by men in Kisumu (aOR = 0.25, 95% CI = 0.12-0.52). In Ndola, no association was found between circumcision and HIV infection but sample sizes were too small to fully adjust for confounding. The strong association between HIV and HSV-2 and male circumcision, and the distribution of the risk factors, led us to conclude that differences in efficiency of HIV transmission as mediated by biological factors outweigh differences in sexual behaviour in explaining the variation in rate of spread of HIV between the four cities.

Changing the mindset of road users in Africa will be a challenge, says the author, but many lives are at stake.