Following a meeting of experts and other representatives in Switzerland earlier this month the World Health Organization (WHO) and the joint United Nations Programme on HIV/AIDS (UNAIDS) have announced that male circumcision should be part of the strategy to prevent heterosexually acquired HIV infection in men.
The meeting was held in Montreux between 6th and 8th of March and was attended by HIV/AIDS experts and representatives from a wide range of stakeholders including governments, human rights, scientists, women’s health, civil society, young people, sponsoring and fundholders, and programme implementers.
HIV/AIDS experts said the evidence supporting male circumcision was compelling and strongly recommended that it form a major part of the strategy to prevent HIV from spreading by heterosexual means in men.
Their recommendations were mostly influenced by the results of three randomized controlled trials conducted in Kisumu in Kenya, Rakai District in Uganda and Orange Farm in South Africa where results showed male circumcision reduced the risk of heterosexually acquired HIV infection in men by about 60%. The trials were stopped early because the evidence was so compelling and it was important to let the world know and start moving toward applying the lessons learned.
These trials echo results from observational studies on African and other communities that found strong links between lower HIV rates and high percentages of circumcised males.
The way ahead however is not easy and there are many potential pitfalls.
Apart from the obvious one of money, the implementation of such a strategy needs careful consideration. One area that will need sensitive handling is to avoid coercion and ensure that ethical procedures such as informed consent and respect for cultural values are followed.
Also, it is important that education and advice form an important part of the process, and the suggestion is that all males considering circumcision and their partners are offered counselling that also stresses the importance of correct condom use and safe sex practice.
There is a danger that if the programme does not roll out properly, the message will become distorted into one that makes men believe circumcision will be enough to stop them becoming infected. It won’t. It is only part of a mix of precautions that they will have to accept and practise in order to dramatically alter their HIV infection risk.
Catherine Hankins, Associate Director, Department of Policy, Evidence and Partnerships at UNAIDS emphasized that male circumcision was just one of a number of important things that together form a comprehensive strategy. “We must be clear”, she said, “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.”
Another consideration is that health services in the areas that most need this intervention, such as sub-Saharan Africa, are not strong.
It is important that the introduction of new strategies does not disrupt systems that are already in place. If male circumcision is to provide long term, sustainable benefits to a community already struggling to implement healthcare, then it should be integrated with existing services, said the WHO and UNAIDS spokespeople.
Male circumcision is a procedure that is relatively safe but it does carry risks. Health professionals need to be trained and certified in appropriate safety and hygiene, the right equipment has to be provided, and operations monitored to ensure standards are met.
The maximum public health benefit will be felt if male circumcision is offered in areas with a high prevalence of heterosexually acquired HIV infection and low numbers of circumcised males.
Studies using computer models suggest that in sub-Saharan Africa male circumcision could prevent 5.7 million new infections of HIV and 3 million deaths from AIDS over 20 years.
Estimates suggest that 665 million men worldwide are circumcised; this is 30 per cent of the world’s male population.
There is no evidence that male circumcision reduces HIV infection rates in women, nor in men who have sex with men.
Reports on the Kenyan and Ugandan trials were published in the 23rd February 2007 edition of the Lancet.
Written by: Catharine Paddock
Writer: Medical News Today