Estimates of the prevalence of male circumcision in sub-Saharan Africa from 2010–2023—A systematic review and meta-analysis

Basant Elsayed; Mohamed Elmarasi; Ruvarashe J. Madzime; Lovemore Mapahla; Menatalla M. S. ElBadway; Tawanda Chivese

doi:10.1371/journal.pone.0298387

Peer Review History

Original SubmissionNovember 27, 2023
21 Dec 2023 Decision Letter - Taurayi A Tafuma, Editor PONE-D-23-37643 Estimates of the prevalence of male circumcision in Sub-Saharan Africa from 2010 – 2023 – a systematic review and meta-analysis PLOS ONE Dear Dr. Chivese, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Feb 04 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The title is well structured and aligned to the objectives, findings and conclusions In most cases, the use of Sub-Saharan Africa in between a sentence need to be observed as it should be sub-Saharan Africa On introduction, authors should give also HIV prevalence change in countries as they give the background of VMMC prevalence so that readers are directed on VMMC contribution to HIV prevalence. On this part on prevalence for 2021 was given yet the study is for 2010 to 3023. On study design, first statement, write in past tense as it is in present tense On page 6 and afterwards, seems font type and size changed, so check on this. On analysis page 13, state the assumptions of Cochran's Q test so that its linked to the study an the test is usually used to test consistent of outcomes within different groups On sample size, 53 records were finally used out of the initial 285 meaning about 3-4 records per country, are these suffice to represent the country and make conclusions about VMMC for a country. In discussion, relate VMMC prevalence to HIV prevalence among men so that this will strengthen recommendations on scaling up VMMC which is below 50% in some countries. In conclusion, relate recommendations to specific age groups as outlined in the results so that it will be more targeted on the age groups trailing behind. Reviewer #2: The manuscript is technically sound, is presented in a clear and intelligible manner, and the data generally support the conclusions. However, I have queries about the following points/issues: 1. There is no clear rationale or justification provided for the time period selected (2010 to 2023) for inclusion of studies for review. How was the time period for studies to include determined? Was it an arbitrary decision that had no obvious justification or reasoning behind it? How does the time period selected for inclusion of studies assist or contribute towards achieving the objectives of this work? Could the rationale or justification for the time period selected (2010 to 2023) for inclusion of studies please be clearly stated in the manuscript/paper? 2. Search results initially yielded 395 records or studies, and then after assessment, some studies were excluded and a total of 53 data sources were finally included. Although there is a section of the paper titled "Characteristics of included studies"; this section only describes some features of studies that were included, it does not expressly and explicitly state why they were included; ie. inclusion criteria for inclusion of studies is not clearly stated. There is no section of the document that describes or categorically states the exclusion criteria that were used to make decisions to exclude those studies that were excluded; i.e. exclusion criteria for exclusion of studies is also not clearly stated. Would it not be better if there could be a section of the document that clearly and explicitly states and provides the inclusion and exclusion criteria for selecting studies/data sources for this work? My recommendation is that the paper would be acceptable for publication after minor revisions to address and attend to the queries that I have raised above. ****** 6. 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Revision 1
7 Jan 2024 Author Response Journal requirements: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. Response: Thank you. The manuscript has been edited to meet the journal’s style requirements. 2. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. Response: Thank you. The ethics statement only appears in the Methods section under “Ethics” and has been deleted from elsewhere. 3. We note that Figure 5 in your submission contain [map/satellite] images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. We require you to either (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission: a. You may seek permission from the original copyright holder of Figure 5 to publish the content specifically under the CC BY 4.0 license. We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text: “I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.” Please upload the completed Content Permission Form or other proof of granted permissions as an ""Other"" file with your submission. In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].” b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only. The following resources for replacing copyrighted map figures may be helpful: USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/ The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/ Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/ Landsat: http://landsat.visibleearth.nasa.gov/ USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/# Natural Earth (public domain): http://www.naturalearthdata.com/ Response: Thank you – please note that this figure is not a copyrighted map but a map that we generated from the data synthesized in this meta-analysis. We have added the following statement in the methods, last paragraph on page 7 Maps of the prevalence of male circumcision in each country before and after the year 2015 were generated using TableauTM software (https://www.tableau.com/en-gb/academic/students). 4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information Response: Thank you. Captions for the supporting information are added at the end of the manuscript. 5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Response: Thank you. No retracted references are present in our reference list. 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The title is well structured and aligned to the objectives, findings and conclusions In most cases, the use of Sub-Saharan Africa in between a sentence need to be observed as it should be sub-Saharan Africa Response: Thank you for your comment. We have corrected this. On introduction, authors should give also HIV prevalence change in countries as they give the background of VMMC prevalence so that readers are directed on VMMC contribution to HIV prevalence Response: Thank you for your comment. We have added a sentence on the gradual decrease of HIV prevalence which is in parallel with a gradual increase in the coverage of VMMC in SSA, although it should be noted that the gradual decrease in HIV prevalence cannot be attributed to VMMC alone but to its combination with several multifactorial interventions. “In sub-Saharan Africa, this has resulted in a gradual increase in the prevalence of VMMC, paralleled with a gradual decrease is HIV prevalence due to multifactorial interventions [8].” On study design, first statement, write in past tense as it is in present tense Response: Thank you for your comment. The sentence has been changed to the following: This study design was a systematic review and meta-analysis design that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [16]. On page 6 and afterwards, seems font type and size changed, so check on this. Response: Thank you for your comment. Consistent font type and size have now been used across the manuscript. On analysis page 13, state the assumptions of Cochran's Q test so that its linked to the study an the test is usually used to test consistent of outcomes within different groups Response: Thank you for your comment. The following has been added to the statistical analysis paragraph: “Cochran’s Q test a generates a probability that indicates the consistent variation across studies rather than within subjects within a study with the null hypothesis assuming that male circumcision is the same across studies and variations are simply caused by chance.” On sample size, 53 records were finally used out of the initial 285 meaning about 3-4 records per country, are these suffice to represent the country and make conclusions about VMMC for a country. Response: Thank you for your comment. Some of these studies are nationally representative studies with rigorous design, and may suffice, with some limitations, in describing the prevalence of male circumcision in each country. We do agree that more studies would have provided better estimates and have also discussed this in the limitations. The local and regional studies would also not have been very useful in providing estimates. This is why we prioritized the nationally representative studies in the analyses. We have edited the discussion as follows: Limitations of the current study include the lack of enough studies per country, the lack of data from South Sudan and the lack of recent data in most countries. In discussion, relate VMMC prevalence to HIV prevalence among men so that this will strengthen recommendations on scaling up VMMC which is below 50% in some countries. Response: Thank you for your comment. We have added the following: “The benefits of this intervention cannot be understated, modelling data suggested that a quarter of a million new infections were prevented through VMMC in sub-Saharan Africa during the decade 2008-2018 [74]. Notably, male circumcision offers lifelong protection, and therefore has larger future benefits [74]. For example, if other behavioral and structural interventions remain constant, the mathematical models forecast that the impact of the VMMC up to 2018 alone would result in the prevention of 1.5million cases of HIV by 2030 and that this number could triple to 4.5million averted HIV cases by 2050 [74].” In conclusion, relate recommendations to specific age groups as outlined in the results so that it will be more targeted on the age groups trailing behind. Response: Thank you for your comment. We have added the following: “Further, countries should consider prioritizing scaling up of male circumcision in older males (>50 years) as the prevalence of male circumcision in this demographic lags behind that in other age groups.” Reviewer #2: The manuscript is technically sound, is presented in a clear and intelligible manner, and the data generally support the conclusions. However, I have queries about the following points/issues: 1. There is no clear rationale or justification provided for the time period selected (2010 to 2023) for inclusion of studies for review. How was the time period for studies to include determined? Was it an arbitrary decision that had no obvious justification or reasoning behind it? How does the time period selected for inclusion of studies assist or contribute towards achieving the objectives of this work? Could the rationale or justification for the time period selected (2010 to 2023) for inclusion of studies please be clearly stated in the manuscript/paper? Response: Thank you for your comment. Most VMMC programs started around the year 2010 after the WHO recommendation. We have added the following sentence: “This period 2010-2023 was selected as most VMMC programs started either just before or during the year 2010 (in the case of South Africa) after the WHO recommendation in 2007 [14].” 2. Search results initially yielded 395 records or studies, and then after assessment, some studies were excluded and a total of 53 data sources were finally included. Although there is a section of the paper titled "Characteristics of included studies"; this section only describes some features of studies that were included, it does not expressly and explicitly state why they were included; ie. inclusion criteria for inclusion of studies is not clearly stated. There is no section of the document that describes or categorically states the exclusion criteria that were used to make decisions to exclude those studies that were excluded; i.e. exclusion criteria for exclusion of studies is also not clearly stated. Would it not be better if there could be a section of the document that clearly and explicitly states and provides the inclusion and exclusion criteria for selecting studies/data sources for this work? Response: Thank you for your comment. A clear and explicit description of the inclusion and exclusion criteria has been added in the “Method” section under “Eligibility” as follow: Eligibility Inclusion criteria All cross-sectional, population-based and cohort studies that investigated the prevalence of male circumcision in sub-Saharan Africa were eligible for inclusion in this review. The eligible studies should have been published during the period 1 January 2010 and 7 April 2023. This period 2010-2023 was selected as most VMMC programs started either just before or during the year 2010 (in the case of South Africa) after the WHO recommendation in 2007 [14]. No language restriction was applied, and we did not attempt to distinguish between VMMC and traditional and cultural male circumcision as many data sources did not do separate analyses by type of male circumcision and others did not specify the type of circumcision. Exclusion criteria Duplicate data sources, studies that did not report male circumcision prevalence by country in the analysis, studies that were published before or after the period of interest and studies that included data for countries outside the 15 priority countries were excluded. Attachments Attachment Submitted filename: MC Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0298387.r002
24 Jan 2024 Decision Letter - Taurayi A Tafuma, Editor Estimates of the prevalence of male circumcision in Sub-Saharan Africa from 2010 – 2023 – a systematic review and meta-analysis PONE-D-23-37643R1 Dear Tawanda Chivese, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Taurayi A Tafuma, MPH, MBChB Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0298387.r003
Formally Accepted
4 Mar 2024 Acceptance Letter - Taurayi A Tafuma, Editor PONE-D-23-37643R1 PLOS ONE Dear Dr. Chivese, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Taurayi A Tafuma Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0298387.r004

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