Male circumcision to control HIV infection

The World Health Organization (WHO) and the joint United Nations Program on HIV/AIDS, UNAIDS, have recommended that male circumcision be added to approved interventions to reduce the risk of heterosexually acquired HIV infection in men.

The recommendation follows what was found to be compelling evidence of the benefits of male circumcision, as presented by three trials carried out on African men between the ages of 18 and 24.

One study was held in Kisumu, Kenya where an estimated 26 percent of uncircumcised men are HIV infected by age 25. The majority of the 2,784 HIV negative, uncircumcised men who participated in the study were Luo, an ethnic group that does not traditionally practice circumcision.

Half the men were randomly assigned to circumcision and half the men remained uncircumcised for two years. Participants received free HIV testing and counselling, medical care, tests and treatment for sexually transmitted infections, condoms and behavioural risk counselling during periodic assessments throughout the study.

The clinical trial, which was led by Robert Bailey, a professor of epidemiology at the University of Illinois, found that 47 of the 1,391 uncircumcised men contracted HIV, compared to 22 of the 1,393 circumcised men.

"Our study shows that circumcised men had 53 percent fewer HIV infections than uncircumcised men," said Bailey. "We now have very concrete evidence that a relatively simple surgical procedure can have a very large impact on HIV."

Two other trials, held in Uganda and South Africa, yielded similar results, indicating that circumcision effectively reduced the rate of new HIV infections by 48 to 60 percent.

But experts warn that countries should consider male circumcision as part of a wider HIV prevention package, including HIV testing and counselling services to prevent men developing a false sense of security.

Circumcised men may feel they are protected from becoming HIV infected, Bailey said, and may be more likely to engage in risky behaviour. However, he said, ‘circumcision is by no means a natural condom’, concluding that circumcision will be most effective if it is integrated with other prevention and reproductive health services.

Kenya's director of Medical Services, James Nyikal, cautiously welcomed the recommendation from the WHO and UNAIDS.

"Although male circumcision considerably reduces the risk of HIV/AIDS transmission, there is a high risk of circumcised men becoming complacent and engaging in risky sexual behaviour," he said.

But while Kevin De Cock, director of HIV/AIDS at the WHO, acknowledges that it will be a number of years before the impact of the research is evident on the HIV epidemic, he said that the joint recommendations of the WHO and UNAIDS represent ‘a significant step forward in HIV prevention’.

"Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men," he said.

More information is available from the University of Illinois’ press release and from SciDev.net’s article announcing the WHO/UNAIDS recommendation.