Cutting Cervical Cancer Risk with the Help of Voluntary Medical Male Circumcision

Catherine Hankins BA MD MSc FRCPC

Deputy Director, Science Amsterdam Institute for Global Health and Development Honorary Professor London School of Hygiene and Tropical Medicine

Surviving HIV and Dying of Cervical Cancer: How a $5 or Less Test Can Make the Difference

Scientific Evidence: Male Circumcision Reduces HIV Risk

Decades of ecological and observational evidence: lack of male circumcision/higher HIV prevalence Randomised controlled trials in Kenya, Uganda, and South Africa all stopped early: compelling trial evidence that medical male circumcision confers almost 60% protection Protective effect sustained/increased: Longer-term (4-5 years) follow-up of trial participants in Kenya and Uganda Community level impact evaluation in South Africa (Orange Farm) shows reduced HIV prevalence and incidence in circumcised men

Kisumu MC Trial Clinic

Orange Farm MC Center

Rakai Research Center Courtesy of K Agot

Efficacy of male circumcision against HIV acquisition in men

Risk ratio (95% CI)
Observational studies South Africa Kenya Uganda Overall (95% CI)
0.2 0.3 0.4 0.5 1 1.5

0.42 (0.34,0.54) 0.41 (0.24,0.69) 0.41 (0.24,0.70) 0.43 (0.24,0.75)

0.42 (0.31,0.57) p<0.0001

Risk ratio

Weiss et al AIDS 2008: 22: 567-574

Effect persists up to 5 years post-trial follow-up

Results from extended Rakai study (from Kong et al, CROI, 2011, now published)

Priority Countries for VMMC Scale-up

Njeuhmeli and Hankins (Co-editors PLoS Med suppl 2011)

On the near horizon: Devices for adults

Shang Ring

Alisklamp

PrePEX

Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa

20122016

Impact of MC on other STI

Difference in prevalence of high-risk HPV types: circumcised versus uncircumcised

Titel

ODDS RATIO

Bosch, Albero, Castellsague 2009

Differences in HPV prevalence between the circumcised and the uncircumcised penis

High-risk HPV types have higher prevalence closer to the tip of the penis High-risk HPV infection is lower in both the coronal sulcus and the shaft of the circumcised penis than in the uncircumcised penis HPV prevalence on the foreskin is comparable to than on the glans/corona

Glans/corona

Shaft

Foreskin

How much could VMMC help in reducing cervical cancer?

Female partners of circumcised men have less cervical cancer because these men are less likely to be have HPV
1913 couples, 5 global locations in Europe, Asia & S America Monogamous women whose male partner had 5 or more previous sexual partners were 6-fold less likely to have cervical cancer than when their partner was not circumcised MC was protective when the man had intermediate risk sexual behaviour

Current vaccines addressing the most common types (HPV 16 and 18) will reduce cervical cancer incidence over the next 20 to 30 years but. male circumcision reduces the risk of male infection & of transmission of all HPV types .and it does so within months

With thanks to:

Helen Weiss Kiwango Agot Emmanuel Njeuhmeli Brian Morris .and other colleagues