Programme on HIV and AIDS (UNAIDS) announce recommendations from expert
consultation on male circumcision for HIV prevention
28 March 2007
Paris/Geneva: In response to the urgent need to reduce the number of new HIV
infections globally, WHO and the Joint United Nations Programme on HIV and AIDS
(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
recognised as an additional important intervention to reduce the risk of
heterosexually acquired HIV infection in men. The international consultation
which was held 6 to 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 and 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 randomised controlled trials
undertaken in Kisumu, Kenya, Rakai District, Uganda (funded by the United
States (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
* 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 for Department of Policy, Evidence and Partnerships
at UNAIDS. "However, we must be clear that 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
healthcare programmes, including other HIV and AIDS interventions. In order to
both maximise 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 minimises
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.
Maximising 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, generalised 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 prioritised 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 three 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
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 incentive partners
engaging in homosexual or heterosexual anal intercourse
* 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.
For further information, please contact:
In Paris:
Anne Winter
Mobile: +41 79 440 6011
E-mail: wintera@who.int
In Geneva:
Iqbal Nandra
Tel.: +41 22 791 5589
Mobile: +41 79 509 0622
E-mail: nandrai@who.int
UNAIDS
Yasmine Topor
Tel.: +41 22 791 3501
Mobile: +41 76 512 8853
E-mail: topory@unaids.org
Issued by: Department of Health
28 March 2007
Source: Department of Health (http://www.doh.gov.za/)
