Male Circumcision and HIV Prevention

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Recent research suggests that male circumcision may be a cost-effective means of reducing HIV infection rates, especially in generalized epidemics where more than one percent of the population is living with HIV/AIDS.

In December 2006, the National Institutes of Health (NIH) released findings from two studies measuring the effects of male circumcision in reducing the risk of HIV transmission among men who have heterosexual intercourse. The studies, which examined nearly 8,000 men ages 18-24 in in Kisumu, Kenya and Rakai, Uganda, found that male circumcision reduced men's risk of contracting HIV from vaginal intercourse by as much as 53 percent. These studies corroborated findings from an earlier study in South Africa, which reported reductions as high as 60 percent.

New research raises questions as to whether male circumcision provides any protection to female partners, and early results from a trial of newly circumcised men indicate that HIV-negative female partners may have an increased risk of infection if they have sexual intercourse before the surgical wound has fully healed.

These research findings and gaps underscore the need to proceed carefully when considering male circumcision programs and policies as protection against HIV infection.

A 50-60% REDUCTION IN INFECTION IS NOT 100%

Public health messages must emphasize that male circumcision does not provide complete protection against HIV, and continue to promote safe sexual behavior and effective use of all prevention tools (see below). Circumcised men—and their partners—must be clearly informed of the risks of sexual intercourse before their surgical wounds have healed.

INVESTMENT IN COMPREHENSIVE PREVENTION MUST CONTINUE

Prevention of HIV transmission overall must be the primary goal, including through:

• HIV counseling and testing,
• male and female condoms,
• comprehensive sexuality education,
• programs and policies to promote gender equality and safe sex,
• clean needles and harm reduction,
• post-exposure prophylaxis,
• cervical barrier methods, microbicides, and vaccines as they become available.

MALE CIRCUMCISION MUST BE VOLUNTARY

Services must be confidential and based on informed, free choice, and should be provided at lowest possible cost. Sensitivity to the cultural and religious context surrounding male circumcision is also important.

SAFE AND SANITARY CONDITIONS ARE ESSENTIAL

Those who perform the procedure must be trained, have and use sterile equipment, follow informed consent procedures, and provide patients with follow-up care and comprehensive information, including about after care and condom use.

COMPETING RESOURCE NEEDS MUST BE CAREFULLY WEIGHED

Trained personnel and limited resources must not be diverted from equally pressing priorities. These include sexual and reproductive health services, which remain underfunded and out of reach for many women and girls.

CIRCUMCISION PROGRAMS PROVIDE AN IMPORTANT OPPORTUNITY TO EDUCATE MEN ON SEXUAL AND REPRODUCTIVE RIGHTS AND HEALTH

Services for male circumcision and related programs should, for example, discourage marriages of young girls to older men, promote zero tolerance for sexual coercion and violence against girls and women, and encourage men to respect and support the health rights and needs of their partners. Men and their partners must be supported to abstain from sex for at least one month following the operation.

MORE RESEARCH IS NEEDED TO ASCERTAIN IMPACTS ON THE SEXUAL PARTNERS (FEMALE AND MALE) OF CIRCUMCISED MEN

Researchers in Zimbabwe and Uganda recently found that male circumcision had little influence on a female partner's risk of HIV infection. Studies have not fully assessed the impact of male circumcision on the sexual partners of the men being monitored; nor on circumcised men who have non-vaginal sex (with men or women). Results of a trial on the longer-term impacts of male circumcision are expected in 2008.

For more information:

Studies on male circumcision and HIV transmission www3.niaid.nih.gov/news/newsreleases/2006/AMC12_06.htm
www.who.int/mediacentre/news/statements/2006/s18/en/index.html
www.aidsvaccineclearinghouse.org/pdf/MC/Rakai_Release_Mar6.pdf

How male circumcision protects against HIV infection
www.bmj.com/cgi/content/full/320/7249/1592

Policy recommendations and implications
http://www.who.int/mediacentre/news/releases/2007/pr10/en/print.html
http://data.unaids.org/pub/FactSheet/2007/20061229_MC_FS_en.pdf

Position papers on male circumcision in HIV/AIDS prevention
www.avac.org/pdf/a_new_way_to_prevent_hiv_pre_publication_copy.pdf
www.worldaidscampaign.info/index.php/en/campaigns/key_constituencies/
youth/africa_youth_common_position_on_male_circumcision_and_hiv_prevention

Implications for the United States
www.cdc.gov/hiv/resources/factsheets/circumcision.htm

Additional background and updates
www.aidsvaccineclearinghouse.org/MC/index.html

Women and HIV/AIDS
www.iwhc.org/withwomenworldwide/index.cfm

Page last updated 10/11/07.