Awad, S.F., Sgaier, S.K., Lau, F.K., et al. PLOS ONE (January 2017), 12(1): e0170641, doi:10.1371/journal.pone.0170641.
This paper modeled the epidemiological and programmatic implications of including HIV-positive males in voluntary medical male circumcision (VMMC) programs, with Zambia as an illustrative example. Using the Age-Structured Mathematical model, the authors evaluated the effectiveness (potential number of VMMCs needed to avert one HIV infection) of including varying proportions of HIV-positive males in VMMC programs; and the potential reduction in incidence rate. They concluded that implementing VMMCs regardless of HIV status can reduce the number of VMMCs needed to avert one infection. Programs that inadvertently focus on HIV-negative males may discourage VMMC uptake in higher-risk males, the authors said. They suggested that including HIV-positive males in VMMC programs could achieve reductions in HIV incidence rates equal to those of some lifelong antiretroviral programs. This enhanced effectiveness would occur with only moderate increases (i.e., 20%) in the uptake of VMMC among higher-risk males, and/or if male circumcision has moderate efficacy against male-to-female HIV transmission. Under these conditions, VMMC's efficacy in preventing male-to-female transmission means that programs can benefit females nearly as much as males. They suggested framing VMMC recruitment messages broadly as a sexual and reproductive health service; emphasizing that HIV testing services are offered but not required; and ensuring that providers offer VMMC to clinically eligible males regardless of HIV status and willingness to test for HIV.