The World Health Organization (WHO) and UNAIDS are to recommend that circumcision programmes should become part of HIV prevention programmes in countries seriously affected by HIV, following an expert consultation earlier this month.
But experts warned that circumcision must not be relied upon as the sole means of protection against HIV, and Dr Kevin De Cock of the World Health Organization’s HIV department said that it will take “a number of years” before money spent on circumcision programmes will translate into any slowing of the epidemic.
Circumcision provides “important but incomplete protection” against HIV, said Dr De Cock, and is an “important but additional strategy” for HIV prevention programmes.
“It is partial protection for men, it’s not to be scoffed at. We haven’t had news like this in a long time,” said Catherine Hankins of UNAIDS. “But it does not replace the need for promotion of safer sexual practices.”
“High HIV prevalence, low circumcision prevalence countries with high rates of heterosexual transmission should consider adopting circumcision as a priority,” said Dr De Cock. “We are primarily talking about the countries of southern and eastern Africa.”
“The first consideration should be to scale-up circumcision for adolescents and young sexually active men. Although circumcision in babies and young children is an important consideration, it will take 15 to 20 years to see the benefits.”
“Scale up will take a long time and for this to have a population-level effect, coverage will have to be very high – we’re talking about [rolling this out over] the next ten to twenty years,” Dr De Cock went on.
Asked whether circumcision should be recommended for all HIV-negative men, not just men in countries with high HIV prevalence, Catherine Hankins said: “For individual men there can be a real benefit immediately.”
Widespread changes in cultural attitudes would be needed, said Kim Dickson of WHO. However, it was important that any changes did not affect the human rights of males.
“It’s very important that we don’t create a new stigma around circumcision status,” said Catherine Hankins. “In the case of adolescents, it’s important that parents and health care providers recognise their evolving capacity to assent or withhold consent for the procedure.”
Spokespersons for WHO and UNAIDS stressed that it would be up to individual countries to decide how to implement circumcision programmes. Once national assessments have been conducted, said Catherine Hankins, “PEPFAR, the Global Fund and the World Bank have all indicated they would be willing to fund.”
WHO and UNAIDS are recommending that circumcision should be provided at no cost or at the lowest possible cost, and that it should be performed by medically trained personnel in order to reduce the risk of complications.
The evidence for circumcision
There is now strong evidence from three randomised 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%.
It has also been shown to reduce the risk of HIV transmission from HIV-positive men to their uninfected female partners by around one-third. in one study, although Dr Kevin de Cock stressed that more data were needed before the procedure could be recommended for HIV-positive men.
A similar degree of reduction in risk has been seen in population studies comparing the risk of HIV acquistion between circumcised and uncircumcised men, and regions of Africa in which circumcision is widely practiced tend to have much lower HIV prevalence.
“Many epidemiologists comment that they are very struck by the consistency of all the data, both epidemiological and clinical,” said Kevin de Cock, noting that results in clinical trials often fail to be attained in the field due to implementation problems.
“Here we are in the unusual situation of having real-world epidemiologic data before the clinical trial data.”
Recent evidence from the Rakai circumcision study suggests that men with multiple partners may get the greatest benefit from circumcision, partly because it reduced the risk of ulcerative sexually transmitted infections. However the study also showed that the protective effect grew over time, possibly due to the hardening of the skin on the head and shaft of the penis after circumcision.
Evidence from another study carried out in Kenya also suggests that circumcision does not result in an increase in risky sex over time, a concern that has been raised by researchers, advocates and politicians reacting to early study results. In addition, epidemiological modelling based on the South African Orange Farm study has shown that even if condom use among circumcised men fell dramatically, mass circumcision would still reduce the HIV infection rate over time.
Epidemiological modelling has suggested that mass implementation of circumcision could avert up to 5.7 million HIV infections and 3 million AIDS deaths by 2026.
Further details
The recommendations and other background material can be obtained from the WHO website.