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Current drivers and geographic patterns of HIV in Lesotho: implications for treatment and prevention in Sub-Saharan Africa.

Coburn BJ, Okano JT, Blower S - BMC Med (2013)

Bottom Line: A less substantial effect was found for men: aOR 1.4 (3 to 6 partners), aOR 1.8 (≥7 partner).Interventions aimed at reducing the number of sex partners may only have a limited effect on reducing transmission.Substantially increasing levels of medical circumcision could be very effective in reducing transmission, but will be very difficult to achieve given the current high prevalence of traditional circumcision.

View Article: PubMed Central - HTML - PubMed

Affiliation: Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, 10940 Wilshire Blvd, Suite 1450, Los Angeles, CA 90024, USA. sblower@mednet.ucla.edu.

ABSTRACT

Background: The most severe HIV epidemics worldwide occur in Lesotho, Botswana and Swaziland. Here we focus on the Lesotho epidemic, which has received little attention. We determined the within-country heterogeneity in the severity of the epidemic, and identified the risk factors for HIV infection. We also determined whether circumcised men in Lesotho have had a decreased risk of HIV infection in comparison with uncircumcised men. We discuss the implications of our results for expanding treatment (current coverage is only 60%) and reducing transmission.

Methods: We used data from the 2009 Lesotho Demographic and Health Survey, a nationally representative survey of 3,849 women and 3,075 men in 9,391 households. We performed multivariate analysis to identify factors associated with HIV infection in the sexually active population and calculated age-adjusted odds ratios (aORs). We constructed cartographic country-level prevalence maps using geo-referenced data.

Results: HIV is hyperendemic in the general population. The average prevalence is 27% in women and 18% in men, but shows substantial geographic variation. Throughout the country prevalence is higher in urban centers (31% in women; 21% in men) than in rural areas (25% in women; 17% in men), but the vast majority of HIV-infected individuals live in rural areas. Notably, prevalence is extremely high in women (18%) and men (12%) with only one lifetime sex partner. Women with more partners have a greater risk of infection: aOR 2.3 (2 to 4 partners), aOR 4.4 (≥5 partners). A less substantial effect was found for men: aOR 1.4 (3 to 6 partners), aOR 1.8 (≥7 partner). Medical circumcision protected against infection (aOR 0.5), traditional circumcision did not (aOR 0.9). Less than 5% of men in Lesotho have been medically circumcised; approximately 50% have been circumcised using traditional methods.

Conclusions: There is a substantial need for treatment throughout Lesotho, particularly in rural areas where there is the greatest burden of disease. Interventions aimed at reducing the number of sex partners may only have a limited effect on reducing transmission. Substantially increasing levels of medical circumcision could be very effective in reducing transmission, but will be very difficult to achieve given the current high prevalence of traditional circumcision.

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Age distribution for factors characterizing male circumcision in Lesotho. (A) Prevalence of medical (yellow) and traditional (gray) circumcision stratified by age. (B) Age at which medical circumcision occurred. (C) Age at which traditional circumcision occurred. (D) The number of years between the age at which traditional circumcision occurred and the age of sexual debut: circumcision before sexual debut (green), circumcision and sexual debut in the same year (red), circumcision after sexual debut (blue).
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Figure 4: Age distribution for factors characterizing male circumcision in Lesotho. (A) Prevalence of medical (yellow) and traditional (gray) circumcision stratified by age. (B) Age at which medical circumcision occurred. (C) Age at which traditional circumcision occurred. (D) The number of years between the age at which traditional circumcision occurred and the age of sexual debut: circumcision before sexual debut (green), circumcision and sexual debut in the same year (red), circumcision after sexual debut (blue).

Mentions: Table 2 shows the age-adjusted factors related to circumcision and their association with HIV infection. Notably, HIV prevalence in circumcised and uncircumcised men is approximately equal (approximately 20%). A high percentage (52%) of men reported they were circumcised, but only 9% reported the procedure had been performed by a healthcare professional (that is, medical circumcision). Prevalence of circumcision increases with age from 34% in men 15 to 19 years old to a high of 61% in men 20 to 59 years old (Figure 4A). The age at which medical circumcision occurred varies considerably (Figure 4B). However, the age of traditional circumcision, which is performed at a tribal initiation ceremony, is tightly distributed around 18 years old (IQR: 16 to 20) (Figure 4C). Almost half of the circumcised men had been circumcised before becoming sexually active; the median age of sexual debut for all men was 17 years old. The other half had been circumcised soon after their sexual debut (Figure 4D). We did not find statistical significance in the bivariate analysis on the age difference between sexual debut and circumcision (Table 2).


Current drivers and geographic patterns of HIV in Lesotho: implications for treatment and prevention in Sub-Saharan Africa.

Coburn BJ, Okano JT, Blower S - BMC Med (2013)

Age distribution for factors characterizing male circumcision in Lesotho. (A) Prevalence of medical (yellow) and traditional (gray) circumcision stratified by age. (B) Age at which medical circumcision occurred. (C) Age at which traditional circumcision occurred. (D) The number of years between the age at which traditional circumcision occurred and the age of sexual debut: circumcision before sexual debut (green), circumcision and sexual debut in the same year (red), circumcision after sexual debut (blue).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4016528&req=5

Figure 4: Age distribution for factors characterizing male circumcision in Lesotho. (A) Prevalence of medical (yellow) and traditional (gray) circumcision stratified by age. (B) Age at which medical circumcision occurred. (C) Age at which traditional circumcision occurred. (D) The number of years between the age at which traditional circumcision occurred and the age of sexual debut: circumcision before sexual debut (green), circumcision and sexual debut in the same year (red), circumcision after sexual debut (blue).
Mentions: Table 2 shows the age-adjusted factors related to circumcision and their association with HIV infection. Notably, HIV prevalence in circumcised and uncircumcised men is approximately equal (approximately 20%). A high percentage (52%) of men reported they were circumcised, but only 9% reported the procedure had been performed by a healthcare professional (that is, medical circumcision). Prevalence of circumcision increases with age from 34% in men 15 to 19 years old to a high of 61% in men 20 to 59 years old (Figure 4A). The age at which medical circumcision occurred varies considerably (Figure 4B). However, the age of traditional circumcision, which is performed at a tribal initiation ceremony, is tightly distributed around 18 years old (IQR: 16 to 20) (Figure 4C). Almost half of the circumcised men had been circumcised before becoming sexually active; the median age of sexual debut for all men was 17 years old. The other half had been circumcised soon after their sexual debut (Figure 4D). We did not find statistical significance in the bivariate analysis on the age difference between sexual debut and circumcision (Table 2).

Bottom Line: A less substantial effect was found for men: aOR 1.4 (3 to 6 partners), aOR 1.8 (≥7 partner).Interventions aimed at reducing the number of sex partners may only have a limited effect on reducing transmission.Substantially increasing levels of medical circumcision could be very effective in reducing transmission, but will be very difficult to achieve given the current high prevalence of traditional circumcision.

View Article: PubMed Central - HTML - PubMed

Affiliation: Center for Biomedical Modeling, Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, 10940 Wilshire Blvd, Suite 1450, Los Angeles, CA 90024, USA. sblower@mednet.ucla.edu.

ABSTRACT

Background: The most severe HIV epidemics worldwide occur in Lesotho, Botswana and Swaziland. Here we focus on the Lesotho epidemic, which has received little attention. We determined the within-country heterogeneity in the severity of the epidemic, and identified the risk factors for HIV infection. We also determined whether circumcised men in Lesotho have had a decreased risk of HIV infection in comparison with uncircumcised men. We discuss the implications of our results for expanding treatment (current coverage is only 60%) and reducing transmission.

Methods: We used data from the 2009 Lesotho Demographic and Health Survey, a nationally representative survey of 3,849 women and 3,075 men in 9,391 households. We performed multivariate analysis to identify factors associated with HIV infection in the sexually active population and calculated age-adjusted odds ratios (aORs). We constructed cartographic country-level prevalence maps using geo-referenced data.

Results: HIV is hyperendemic in the general population. The average prevalence is 27% in women and 18% in men, but shows substantial geographic variation. Throughout the country prevalence is higher in urban centers (31% in women; 21% in men) than in rural areas (25% in women; 17% in men), but the vast majority of HIV-infected individuals live in rural areas. Notably, prevalence is extremely high in women (18%) and men (12%) with only one lifetime sex partner. Women with more partners have a greater risk of infection: aOR 2.3 (2 to 4 partners), aOR 4.4 (≥5 partners). A less substantial effect was found for men: aOR 1.4 (3 to 6 partners), aOR 1.8 (≥7 partner). Medical circumcision protected against infection (aOR 0.5), traditional circumcision did not (aOR 0.9). Less than 5% of men in Lesotho have been medically circumcised; approximately 50% have been circumcised using traditional methods.

Conclusions: There is a substantial need for treatment throughout Lesotho, particularly in rural areas where there is the greatest burden of disease. Interventions aimed at reducing the number of sex partners may only have a limited effect on reducing transmission. Substantially increasing levels of medical circumcision could be very effective in reducing transmission, but will be very difficult to achieve given the current high prevalence of traditional circumcision.

Show MeSH
Related in: MedlinePlus