Male Circumcision
Based upon the mounting evidence of the effectiveness of male circumcision (MC) in preventing HIV infection, in March 2007 USAID and WHO endorsed MC as a prevention intervention for countries with: (1) generalized epidemics, where transmission is primarily heterosexual; and, (2) low prevalence of male circumcision. To-date, three randomized clinical trials of MC in South Africa, Kenya and Uganda, demonstrated protective effects of at least 50 percent. In fact, given clear evidence of the protective effects of MC in each study, all three studies were ended early so circumcision could be offered to men in the control group.
Male circumcision is the only intervention that does not require continued adherence. Unlike condom use, for example, MC is a one-time procedure that does not depend upon a continuous supply of condoms, partner negotiation or other adherence-related factors. At the same time, MC is a surgical procedure with its own inherent risks. Care must be taken to prevent adverse effects of the procedure. The procedure must be performed by trained personnel in hygienic conditions, and patients must receive appropriate follow-up care. It is also essential that newly circumcised men abstain from sex until the wound has completed healed, usually between 4 to 6 weeks.
The protective benefit of MC for HIV-negative men engaging in heterosexual intercourse is well-documented and considerable. However, two clear messages must accompany efforts to scale up MC services. First, while MC partially protects men against HIV infection, it is not fully protective; it is important that men not view MC as a vaccine that eliminates their susceptibility to HIV. While research trials have not found evidence of increasing risk behaviors among newly circumcised men, behavioral interventions such as correct and consistent condom use remain an important part of a comprehensive HIV prevention strategy. Second, MC helps reduce the risk of a man contracting HIV, but no conclusive evidence indicates that circumcised men are less likely to transmit HIV. Both women and men must be made aware of this distinction, and women should be cautioned not to assume that a circumcised man is HIV-negative.
While the protective benefits for HIV-negative men during heterosexual intercourse are known, it is not known whether MC is protective for men who have sex with men (MSM). A meta-analysis of circumcision status, HIV and MSM found insufficient evidence of an association between circumcision and HIV infection or other STIs. Male circumcision programs must carefully convey the limitations of circumcision’s protective effects with regards to MSM.
Scale up of MC will require widespread acceptance of the practice in traditionally non-circumcising countries, but available data show such acceptance is high. To date, there have been relatively few MC programs outside of research trials; MC programs will need to be monitored in the ‘real world’ to ensure that as programs are scaled-up, sterile conditions are maintained during circumcision, quality counseling is consistently provided, and risk behavior does not increase among recently circumcised men.
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