March 29, 2007 -- Circumcised men are up to 60% less likely to get HIV, and now the World Health Organization and the UNAIDS program recommend adult surgery to slow the AIDS pandemic.
The recommendation comes only weeks after the WHO and UNAIDS officials asked an expert panel for advice. The advice is based on three clinical trials suggesting that circumcised men are 50% to 60% less likely than uncircumcised men to get HIV during heterosexual sex.
Circumcised men can and do get infected with the AIDS virus. There is, yet, no evidence that male circumcision protects women. But widespread circumcision would have a major impact on the AIDS pandemic, says Catherine Hankins, MD, chief scientific officer for the UNAIDS.
"This is an exciting development. It is only partial protection for men -- still, it is not to be scoffed at. We have not had good news like this in quite a long time," Hankins said at a WHO/UNAIDS news conference.
Ronald Gray, MD, professor of reproductive epidemiology at Johns Hopkins University in Baltimore, led a clinical trial of male circumcision in Uganda. He was also a member of the WHO/UNAIDS expert panel.
"This is unique. We have never before used surgery for prevention of infectious disease," Gray tells WebMD. "We are going to have a steep learning curve. But all the evidence is it will have a substantial impact on the AIDS epidemic over the next 10 to 20 years."
Male Circumcision Does Not Replace Safe Sex
Circumcision will have a major impact only if properly implemented, warns Kevin De Cock, MD, director of HIV/AIDS for the WHO.
"Male circumcision should now be considered as an additional strategy for HIV prevention in the context of comprehensive prevention programs," De Cock said at the news conference. "This is important protection but incomplete protection. It is an additional rather than a replacement strategy."
The key WHO/UNAIDS recommendations:
- Countries should implement free or low-cost male circumcision programs if a high percentage of their population is uncircumcised, if HIV is widespread, and if HIV spread is predominantly heterosexual. Most such nations are in southern Africa and, to a lesser extent, in eastern Africa.
- Circumcision programs initially should target sexually active men -- that is, young men and adolescents.
- Circumcision should be part of a comprehensive AIDS risk-reduction program. "It does not replace promotion of safer sex, delay of onset of sexual relations, abstinence, reduction of penetrative sex, reduction in number of partners, and provision of male and female condoms with education on their use," Hankins said.
- Medical ethics and human rights must be respected. This included informed consent, confidentiality, and lack of coercion.
- Circumcision must be provided by trained personnel in a hygienic manner, with medical follow-up to prevent and treat complications.
- After circumcision, men must abstain from sexual relations for at least six weeks after surgery, to ensure that their wounds have healed.
- Circumcision must be offered in ways that do not offend cultural norms.
- Circumcision is not advised for men already infected with HIV, but circumcision should not be denied to HIV-positive men who want the procedure.
Who Will Pay?
The recommendations have one major drawback: money. Although WHO and UNAIDS say they will provide technical support to any nation that wishes to start a circumcision program, details on funding such programs remain vague.
The WHO and UNAIDS say only that funding must not come at the expense of funding for other health care programs or HIV prevention programs.
"Money is going to be the key. If additional resources brought to bear, we can have very substantial effects on the AIDS epidemic in East and Central Africa," Gray says. "These are not cheap resources. There are the costs of training, the costs of equipment and supplies, the costs of all the complexities of providing surgeries and providing postsurgical care and managing any problems that arise."
If money is not forthcoming, the recommendations may do more harm than good. Men in areas with high HIV prevalence are very much aware of the news that circumcision lowers HIV risk.
"There is a lot of anecdotal evidence that men already are lining up asking for circumcision," Gray says. "And if we do not provide safe services, they will seek unsafe services."
The same message comes from Kim Dickson, MD, medical officer at the WHO department of HIV/AIDS.
"In certain countries we have reports of interest by men for male circumcision services," Dickson said at the news conference. "Yes, if safe services are not in place, then there will be practitioners who will provide unsafe services. The thing that must be done is to set up safe circumcision services with trained practitioners."
Despite this major obstacle, Gray is highly optimistic.
"It is doable," he says. "This one-time procedure is likely to confer very long -- perhaps lifelong -- reduction in HIV risk."
Meanwhile, studies are under way to determine whether male circumcision reduces women's HIV risk and whether circumcision offers protection to homosexual men.