New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications

This 10-page report shares conclusions and recommendations from a March 2007 World Health Organization (WHO)/Joint United Nations Programme on HIV/AIDS (UNAIDS) international consultation "Male Circumcision and HIV Prevention: Research Implications for Policy and Programming". The consultation was sparked by the need to examine, and discuss the implications of, a number of observational studies - in particular, 3 randomised controlled trials - indicating that circumcised men have lower levels of HIV infection than uncircumcised men.

A summary of central conclusions and recommendations follows:

1. The research evidence is compelling - male circumcision performed by well-trained medical professionals has been found to be safe, and reduces the risk of acquiring HIV infection by approximately 60%. The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. Thus, male circumcision should be recognised as an efficacious intervention for HIV prevention.
2. Male circumcision does not provide complete protection against HIV - Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Thus, male circumcision should never replace other known methods of HIV prevention and should always be considered as part of a comprehensive HIV prevention package, which includes: promoting delay in the onset of sexual relations, abstinence from penetrative sex and reduction in the number of sexual partners; providing and promoting correct and consistent use of male and female condoms; providing HIV testing and counselling services; and providing services for the treatment of sexually transmitted infections (STIs).
3. Correct communication and messages on male circumcision are critical - Communities, and particularly men opting for the procedure and their partners, require careful and balanced information and education materials that underline that male circumcision is not a "magic bullet" for HIV prevention but, rather, is complementary to other ways of reducing risk of HIV infection. The message that men who resume sexual activity before wound healing may be at higher risk of HIV infection, or if HIV-positive, at higher risk of infecting their sexual partners needs to be strongly conveyed. Further, the difference between male and female circumcision needs to be emphasised: unlike male circumcision, female genital mutilation has no demonstrated medical benefits. In short, messages should be carefully tailored, culturally sensitive, draw on local language and symbols, and be appropriate to the particular level of development and understanding of the population groups for which the messages are designed. Messages should be addressed to both men and women.
4. The socio-cultural context should inform male circumcision programming. The major determinant of circumcision globally is religion; almost all Muslim and Jewish men are circumcised. In addition, substantial numbers of males are circumcised for cultural reasons. Countries and international development partners should make resources available to support community and stakeholder consultations, involving traditional practitioners in places where they perform male circumcision to ensure engagement and participation of all relevant partners in the design of safe male circumcision programmes. Broad community engagement also serves as a means of communicating that male circumcision provides only partial protection against the risk of acquiring HIV. Countries and institutions promoting male circumcision for HIV prevention should ensure that it is promoted and delivered in a culturally appropriate manner that minimises stigma associated with circumcision status.
5. Human rights and legal and ethical principles must guide service delivery - Measures must be in place that ensure that the procedure can be carried out safely, under conditions of informed consent, and without coercion or discrimination. Communities where male circumcision is introduced have a right to clear and comprehensive information about what is known and not known about male circumcision and HIV prevention. Men opting for male circumcision have the right to receive full information on the benefits and risks of the procedure. Where male circumcision is provided for minors, there should be involvement of the child in the decision-making. Before policy makers and programme developers promote male circumcision for specific population groups, they should justify the reasons after conducting an analysis of the ethical and gender implications; this analysis should be conducted in consultation with members of such population groups, stakeholders, and other critical decision makers.
6. The gender implications of male circumcision as an HIV prevention method must be addressed - Policy makers and programme managers should maximise the opportunity that male circumcision programmes afford for education and behaviour change communication (BCC), promoting shared sexual decision-making, gender equality, and improved health of both women and men.
7. Programmes should be designed to maximise the public health benefit - that is, where the population-level impact of male circumcision will be greatest (e.g., in settings where the prevalence of heterosexually transmitted HIV infection is high, the levels of male circumcision are low, and populations at risk of HIV are large). The public health benefits of male circumcision will be realised at different time intervals depending on the age group that is prioritised for circumcision; for instance, boys and young men before sexual debut are a relatively easy group to reach but measurable impact is not likely to be realised for over 10 years. Careful monitoring and evaluation of male circumcision service delivery for possible untoward effects such as increases in unsafe and unprotected sex and increases in sexual violence should be undertaken.
8. Health services need to be strengthened to increase access to safe male circumcision services - Appropriate service delivery models depend on the context and should be determined locally, but, in general, safety depends on the setting, equipment, and expertise of the provider. Strategies should be developed to engage traditional practitioners to improve the safety of their services and counselling on sexual and reproductive health. Integrated approaches to deliver male circumcision services with other essential HIV and sexual health services are most likely to be sustainable in the longer term.
9. Additional resources should be mobilised to finance the expansion of safe male circumcision services.
10. There is currently insufficient evidence of individual or public health benefit to recommend male circumcision for HIV-positive men.
11. Additional research is needed to inform the development, implementation, and monitoring of male circumcision programmes. A consultation will be necessary to delineate global, regional, and national research priorities.