Should male circumcision be recommended for the prevention of HIV infection?

Mar 28 2007

In response to the urgent need to reduce the number of new HIV infections globally, WHO and the UNAIDS Secretariat convened an international expert consultation to determine whether male circumcision should be recommended for the prevention of HIV infection.

Based on the evidence presented, which was considered to be compelling, experts attending the consultation recommended that male circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. The international consultation, which was held 6-8 March 2007 in Montreux, Switzerland, was attended by participants representing a wide range of stakeholders, including governments, civil society, researchers, human rights and women's health advocates, young people, funding agencies and implementing partners.

"The recommendations represent a significant step forward in HIV prevention," said Dr Kevin De Cock, Director, HIV/AIDS Department in WHO. "Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men. Scaling up male circumcision in such countries will result in immediate benefit to individuals. However, it will be a number of years before we can expect to see an impact on the epidemic from such investment."

There is now strong evidence from three randomized controlled trials undertaken in Kisumu, Kenya; Rakai District, Uganda (funded by the US National Institutes of Health); and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. This evidence supports the findings of numerous observational studies that have also suggested that the geographical correlation long described between lower HIV prevalence and high rates of male circumcision in some countries in Africa, and more recently elsewhere, is, at least in part, a causal association. Currently, 665 million men, or 30 % of men worldwide, are estimated to be circumcised.

Male circumcision should be part of a comprehensive HIV prevention package

Male circumcision should always be considered as part of a comprehensive HIV prevention package, which includes

• the provision of HIV testing and counselling services;
• treatment for sexually transmitted infections;
• the promotion of safer sex practices; and
• the provision of male and female condoms and promotion of their correct and consistent use.

Counselling of men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behaviours that could undermine the partial protection provided by male circumcision. Furthermore, male circumcision service provision was seen as a major opportunity to address the frequently neglected sexual health needs of men.

"Being able to recommend an additional HIV prevention method is a significant step towards getting ahead of this epidemic," said Catherine Hankins, Associate Director, Department of Policy, Evidence and Partnerships at UNAIDS. "However, we must be clear: Male circumcision does not provide complete protection against HIV. Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners."

Need for quality and safe services

Health services in many developing countries are weak and there is a shortage of skilled health professionals. There is a need, therefore, to ensure that male circumcision services for HIV prevention do not unduly disrupt other health care programmes, including other HIV/AIDS interventions. In order to both maximize the opportunity afforded by male circumcision and ensure longer-term sustainability of services, male circumcision should, wherever possible, be integrated with other services.

The risks involved in male circumcision are generally low, but can be serious if circumcision is undertaken in unhygienic settings by poorly trained providers or with inadequate instruments. Wherever male circumcision services are offered, therefore, training and certification of providers, as well as careful monitoring and evaluation of programmes, will be necessary to ensure that these meet their objectives and that quality services are provided safely in sanitary settings, with adequate equipment and with appropriate counselling and other services.

Male circumcision has strong cultural connotations implying the need also to deliver services in a manner that is culturally sensitive and that minimizes any stigma that might be associated with circumcision status. Countries should ensure that male circumcision is undertaken with full adherence to medical ethics and human rights principles, including informed consent, confidentiality and absence of coercion.

A significant public health impact is likely to occur most rapidly if male circumcision services are first provided where the incidence of heterosexually acquired HIV infection is high. It was therefore recommended that countries with high prevalence, generalized heterosexual HIV epidemics that currently have low rates of male circumcision consider urgently scaling up access to male circumcision services. A more rapid public health benefit will be achieved if age groups at highest risk of acquiring HIV are prioritized, although providing male circumcision services to younger age groups will also have public health impact over the longer term. Modelling studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years.

Experts at the meeting agreed that the cost-effectiveness of male circumcision is acceptable for an HIV prevention measure and that, in view of the large potential public health benefit of expanding male circumcision services, countries should also consider providing the services free of charge or at the lowest possible cost to the client, as for other essential services.

In countries where the HIV epidemic is concentrated in specific population groups such as sex workers, injecting drug users or men who have sex with men, there would be limited public health impact from promoting male circumcision in the general population. However, there may be an individual benefit for men at high risk of heterosexually acquired HIV infection.

Experts at the meeting identified a number of areas where additional research is required to inform the further development of male circumcision programmes. These included

• the impact of male circumcision on sexual transmission from HIV-infected men to women;
• the impact of male circumcision on the health of women for reasons other than HIV transmission (e.g. lessened rates of cancer of the cervix);
• the risks and benefits of male circumcision for HIV-positive men;
• the protective benefit of male circumcision in the case of insertive partners engaging in homosexual or heterosexual anal intercourse; and
• research into the resources needed for, and most effective ways, to expand quality male circumcision services.

Research to determine whether there are modifications in perceptions and HIV risk behaviour over the longer term in men who are circumcised for HIV prevention, and in their communities, will also be essential.