Feature Story

In the final part of a special series on the issue of male circumcision and its links to the reduction of HIV acquisition, www.unaids.org discusses expected upcoming action and developments from the United Nations on male circumcision through a special interview with UNAIDS Chief Scientist, Dr Catherine Hankins

From 6-8 March 2007, public health experts from the World Health Organization, UNAIDS and other partner organizations will gather in Montreux, Switzerland, to discuss the topical and often thorny issue of male circumcision and its links to HIV prevention, and to define future United Nations guidance to countries on the policy and programming implications of recent research findings.

As the consultation approaches, UNAIDS’ Chief Scientific Adviser, Dr Catherine Hankins gives a preview of the different issues that may be raised, and an insight into considerations for potential outcomes and action for the United Nations.

Unaids.org: Dr Hankins, you’ve been involved in the issue of male circumcision and its impact on HIV for many years—how do the current findings corroborate scientists’ claims that there is a link between circumcision and reduced HIV infections?

CH: For many years, researchers and scientists have noted that parts of Sub-Saharan Africa where circumcision is common, such as countries in West Africa, have much lower levels of HIV infection, while those in southern Africa, where circumcision is rare, have the highest. Before the availability of data from these three randomised controlled trials, multiple observational studies indicated that male circumcision carried with it a reduced risk of HIV infection. The latest findings from the three trials indicate that male circumcision provides a protective benefit against HIV infection of 50% to 60%

A further trial, led by researchers at Johns Hopkins University, to assess the impact of male circumcision on the risk of HIV transmission to female partners is currently under way in Uganda, with results expected in 2008.

Unaids.org: What is the United Nations doing about this latest evidence that male circumcision reduces risk of HIV acquisition?

CH: Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the United Nations agencies involved in this work absolutely underline that it does not provide complete protection against HIV infection- we need to make sure that men and women understand that circumcised men can still become infected with the virus and if HIV-positive, can infect their sexual partners.

Next week, WHO, the UNAIDS Secretariat and their partners will review the trial findings in detail at a consultation which will define specific recommendations for expanding and/or promoting male circumcision. These recommendations will need to take into account a number of key issues including the cultural and human rights considerations associated with promoting male circumcision; the risk of complications from the procedure performed in various settings; the potential of male circumcision to undermine or to work in synergy with existing protective behaviours and prevention strategies that reduce the risk of HIV infection; and the financial and human resource implications of male circumcision in different service delivery settings.

In order to support countries or institutions that decide to scale up male circumcision services, with our partners we are developing technical guidance on ethical, rights-based, clinical and programmatic approaches to male circumcision. We are also developing guidance on training, standard setting and certification procedures.

Unaids.org: What are some of the key concerns about increasing male circumcision practice that will be discussed at the consultation?

CH: A number of thorny issues arise related to promoting male circumcision as a public health intervention for HIV prevention. Adult male circumcision has a higher risk of adverse effects than infant male circumcision, and should be undertaken by trained health workers in safe, adequately equipped and sanitary conditions with appropriate pre and post-surgical counselling and follow-up. There is a real need to ensure that male circumcision interventions for health benefits are differentiated from female genital mutilation which the UN opposes and is considered to have no health benefits and potentially severe consequences for women and girls.

We also have to take into account the cultural issues- within cultures and faith traditions in which male circumcision is not considered acceptable, promoting it may or may not prove challenging. Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’- it doesn’t provide total protection and it doesn’t mean people can stop taking the safe sex precautions they were already using, such as use of male or female condoms, delaying sexual debut, avoiding penetrative sex and decreasing the number of sexual partners. We must continue to promote combination prevention and ensure that male circumcision is perceived as an additional benefit but one that should be in combination with other strategies to prevent sexual transmission of HIV. We don’t want increased risk behaviour to offset the benefits.

If the United Nations moves forward with guidance to countries on male circumcision as a public health intervention for HIV prevention, it will be promoted as an ‘additional’ intervention to current HIV prevention packages; not an alternative.

Effective communication on male circumcision will be critical and will be an opportunity to reinforce messages on the need for a comprehensive approach to prevention that encourages people to use more than one of the prevention choices available to them.

Unaids.org: Would male circumcision be part of the HIV prevention response for all settings?

Countries with high HIV prevalence and low male circumcision levels may be among the first to consider the potential for male circumcision to play a role in their HIV prevention programming. Other countries may decide to provide male circumcision services to particular populations who could benefit from the additional protection that male circumcision can afford.

The UN and its partners are fully aware that male circumcision may raise cultural and religious issues – it should never be imposed and, if it is promoted, must be done in a culturally acceptable manner in settings where it is not traditionally practised.

CH: Like all types of surgery, circumcision is not without risk. Circumcision by unqualified individuals under unsanitary conditions with poorly maintained or sub-optional equipment can lead to serious, immediate and long-term complications, or even death. Where health professionals have been trained and equipped to perform safe male circumcisions, however, the rate of post-operative complications is less than 5% and the large majority of these resolve with simple, appropriate post-operative care.

Anecdotal accounts of serious complications, including penile amputation and death after male circumcision in traditional settings have been reported. It is difficult to give overall figures for adverse events in all settings, in part because well-documented studies of complication rates in low-and-middle income countries are rare.

Unaids.org: Is there a need to improve male circumcision practices?

CH: Absolutely. Action is required now to improve circumcision practices in many regions, and to ensure that health-care providers and the public have up-to-date information on the health risks and benefits of male circumcision. Many boys and men wishing to be circumcised do not have access to safe circumcision services nor to post-circumcision care if they do suffer from complications. Regardless of the HIV prevention benefits, it is now increasingly important to make existing practices safer. Where circumcision is legal, authorities need to ensure that practitioners are properly trained and licensed to do this procedure. Monitoring should also be done to ensure that procedures are performed safely and that untrained practitioners do not continue to perform unsafe circumcisions.

Unaids.org: Does male circumcision raise human rights issues?

CH: Yes, as is the case with all medical and health procedures. In line with internationally accepted ethical and human rights principles, UNAIDS and WHO are of the view that no surgical intervention should be performed on anyone if it results in adverse outcomes in terms of health or the integrity of the body, and where there is no expectation of health benefit. Nor should any surgical intervention be performed on anyone without informed consent, or the consent of the parents or guardians when a child is not capable of providing consent.

As male circumcision involves surgery and removal of a part of the body, it should only be performed under these conditions: a) participants are fully informed of the possible risks and benefits of the procedure; b) participants give their fully informed consent; and c) the procedure can be performed under fully hygienic conditions by adequately trained and well equipped practitioners with appropriate post-operative follow-up.

Unaids.org: What effect on the HIV epidemic might we expect if male circumcision were commonly practised where it currently is not?

An international group of experts have carried out a mathematical modelling exercise on the impact on HIV incidence of a programme of universal male circumcision in sub-Saharan Africa, assuming the programme worked as it had in Orange Farm, South Africa and that all men would be circumcised within 10 years. The model predicts that 5.7 million infections and 3 million deaths would be prevented over 20 years among both men and women. There are many unknowns within this model but it does predict that male circumcision would provide a significant, potential benefit, similar to a partially effective vaccine. Importantly though, the model also shows that male circumcision alone cannot eliminate the HIV epidemic in sub-Saharan Africa.

Unaids.org: Could male circumcision eliminate the risk of HIV infection?

CH: No. Male circumcision alone certainly does not prevent men from becoming infected with HIV. Nor does it prevent women from being infected with HIV by men who have been circumcised. Circumcision needs to be seen as one of the range of methods to reduce the risk of HIV—including avoidance of penetrative sex, delaying sexual debut, reduction in the number of sexual partners, and correct and consistent male or female condom use. Male circumcision reduces the risk of HIV infection during vaginal intercourse, but is unknown whether it would have an effect on other routes of sexual HIV transmission: the receptive partner in anal intercourse may not have a reduced risk due to the circumcision status of his or her partner and, if male, will not have a reduced risk due to his own circumcision status. It is also not known whether male circumcision reduces the risk of HIV infection for the insertive partner during anal intercourse. Male circumcision has no effect in the case of HIV transmission through injecting drug use.

Unaids.org: Given all these considerations, is it likely the UN will recommending that adult men become circumcised as a way to protect themselves from HIV?

CH: This is what will be discussed at the consultation, and the partners expect to release information about the discussions and possible next steps at the end of the week’s meeting.

In any and all cases for future direction and action, the UN and its partners will certainly underline that male circumcision does not provide complete protection from HIV. It should therefore never replace other known effective preventive methods, such as delay in onset of sexual activity, abstinence from penetrative sex, correct and consistent use of condoms, and reductions in the number of sexual partners.

It’s very important that we stress that circumcised men, if HIV positive, can still infect their sexual partners if they do not use condoms during penetrative sexual intercourse.