WHO/UNAIDS recommendations on male circumcision for HIV prevention

[Guest guest]

[Moderators note: WHO/UNAIDS Technical Consultation Male Circumcision

and HIV Prevention: Research Implications for Policy and Programming

Montreux, 6- 8 March 2007. Conclusions and Recommendations is

available from the following url.

http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf ]

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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 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

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 principles,

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