World Health Organisation (WHO) and Joint United Nations Programme on HIV/AIDS (UNAIDS)

This 41-page report reviews the determinants, prevalence, safety, and acceptability of male circumcision in sub-Saharan Africa. The report states that there is conclusive evidence that circumcised men have a significantly lower risk of becoming infected with the human immunodeficiency virus (HIV) and that demand for safe, affordable male circumcision is expected to increase rapidly. The report was therefore compiled to assist country-level decision-makers and offers information about the sociocultural and medical determinants of circumcision, as well as the risks of the procedure, in the context of comprehensive HIV prevention programming. In relation to communication, the study stresses that communication strategies need to be embedded within wider HIV prevention frameworks to ensure that men do not adopt riskier sexual behaviour based on the false assumption that circumcision provides them with immunity to HIV infection.

In the first section, the publication looks at the religious, cultural, and social determinants of male circumcision and estimate the global and regional prevalences. In the second section, it offers a summary of the medical aspects of the procedure, including medical indications for circumcision, surgical methods used and the complications of circumcision carried out in clinical and non-clinical settings. The third section focuses on the public health implications of the fact that male circumcision reduces risk of HIV infection, including a summary of the acceptability of adult male circumcision in currently non-circumcising populations in sub-Saharan Africa with high incidence of HIV.

Researchers looked at 13 studies conducted throughout southern and eastern Africa to access the acceptability of male circumcision. According to the report, there are three main barriers to update with fear of excessive pain cited as the primary barrier to uptake. Concerns about safety, specifically that the procedure would lead to infection, bleeding, and possible mutilation, as well as concerns regarding costs were also cited as barriers.

The report notes that these barriers may be overcome through effective communication strategies and refers to a Botswana study that showed acceptability levels of about 80% among both male and female respondents who were told about the health benefits and risks associated with the procedure. Protection against sexually transmitted infections, including HIV, improved hygiene, and perception about increased sexual pleasure associated with circumcision were common factors that increased acceptability within surveyed populations.

However, the report suggests that communication strategies need to go beyond just getting men and their partners to accept and undergo the procedure. According to the authors, while public health messaging may emphasis that male circumcision does not eliminate the risk of HIV, this message remains difficult to communicate and data from South African trial sites showed that circumcised men reported higher levels of HIV risk behaviours, including unprotected sex and engaging in multiple concurrent partnerships. However the report points to data from Kenya that showed no significant increase in risky behaviour among circumcised men and argues that this demonstrates the essential role that counselling plays in risk reduction.

The report concludes by cautioning that care must be taken to place male circumcision provision within existing HIV prevention packages that include intensive counselling on issues such as partner reduction, concurrent partnerships and consistent condom-use. Authors also advocate for more research into the behaviours of men pre- and post-circumcision that may help develop appropriate communications strategies.

WHO website on September 25 2009.