Now that three separate clinical trials have shown that male circumcision reduces the risk of HIV infection, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) today recommended that the procedure become part of prevention programs aimed at high-risk heterosexual men.
Over the past 2 years, randomized, controlled clinical trials conducted separately in Kenya, Uganda, and South Africa have shown that circumcision reduced a heterosexual man's risk of becoming infected with HIV by 51% to 60%. These findings backed more than 40 epidemiological reports that found a correlation between HIV prevalence and low rates of male circumcision. "We're in the unusual situation where we had the epidemiological information before the trials," notes epidemiologist Kevin De Cock, who heads the WHO's HIV/AIDS program. "It's the epidemiological version of the cart before the horse."
It is especially urgent that countries with a high prevalence of heterosexual transmission and low levels of male circumcision implement this intervention, says De Cock. Although WHO and UNAIDS did not specify which countries meet those criteria, a study published in BMC Infectious Diseases in December 2006 found that in 51 developing countries--8 of which were in sub-Saharan Africa, the region hardest-hit by HIV--fewer than 20% of men and boys had been circumcised.
Catherine Hankins, chief scientific adviser at UNAIDS, emphasizes that the recommendations say male circumcision should augment, rather than replace, other prevention strategies. "This is an exciting development, but it is partial protection for men," says Hankins. Also, no evidence exists that male circumcision reduces the rate at which HIV-infected men transmit the virus to their female or male sexual partners. The recommendations specifically target men, not newborns, children, or adolescent males.
De Cock and Hankins both stress that male circumcision carries risks and must be performed in hygienic conditions by properly trained healthcare workers. If men who become circumcised begin having more unprotected sex and more sexual partners, they also can override any benefit that the circumcision offers. "This is not a magic bullet situation," says Hankins.
The recommendations were drafted after WHO and UNAIDS held a technical consultation 6-8 March in Montreux, Switzerland, with some 70 participants, including public health officials, researchers, funders, human rights advocates, and HIV-infected people. "Believe me, people have strong ideas about this subject," says De Cock, noting that concerns ranged from how to incorporate traditional healers within circumcision promotion programs to cultural and social considerations. As for who will pay for the $50 to $100 procedure, De Cock says that several major funders of HIV prevention have announced that they are willing to help countries launch appropriate programs.