WHO and UNAIDS announce recommendations from expert consultation
on male circumcision for HIV prevention
PARIS/GENEVA, 28 MARCH 2007 --
In response to the urgent need to reduce the number of new HIV
infections globally, the World Health
Organization (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 from
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, World Health Organization. "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, an estimated 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."
Health services need strengthening to provide quality services
safely 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 provided
with full adherence to medical ethics and human rights rinciples,
including informed consent, confidentiality, and absence of coercion.
Maximizing the public health benefit
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. Modeling
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.
More research needed to further inform programme development
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.
http://www.who.int/hiv/mediacentre/news68/en/index.html
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