During a meeting with UNAIDS Executive Director, Michel Sidibé, the Premier of KwaZulu Natal, Dr Zweli Mkhize highlighted that progress made in the province has begun to turn around the AIDS epidemic in the South African Province which has been most affected by HIV.

KwaZulu Natal has made remarkable progress in expanding access to antiretroviral treatment as well as in reducing new HIV infections. From 2011 to the beginning of 2013 more than 300 000 men have undergone medical male circumcision decreasing their risk of HIV infection. Although it remains high, the overall HIV prevalence among 15-24 years old dropped from 31% in 2009 to 25.5% in 2011.

Mr Sidibé applauded the Premier for his personal vision and leadership in the implementation of decentralised HIV prevention, treatment and care programmes that have yielded visible results. He noted that, if current efforts are expanded, KwaZulu Natal can be on-track to reach the targets set out in the 2011 United Nations General Assembly Political Declaration on HIV/AIDS.

Despite these gains, KwaZulu Natal remains South Africa’s most affected province with an antenatal HIV prevalence of more than 40% in two of its districts and more than 1.6 million people living with HIV in 2011.

According to Mr Sidibé, if South Africa is to achieve real progress, the national AIDS response should continue with its current approach of integrating political and traditional leadership, scientific researchers and active engagement of communities.

Quotes

UNAIDS Executive Director, Mr. Michel Sidibé (right) receives a token from His Majesty King Goodwill Zwelethini.
Credit: UNAIDS/A.Debiky

During his seven-day visit to South Africa, the UNAIDS Executive Director, Michel Sidibé had the opportunity to meet His Majesty King Goodwill Zwelethini, in his home province of Kwazulu Natal.

The King is a key figure in the response to HIV in the Province, home to the Zulu nation. In what was lauded as a bold move, in mid-2009 the King called for Zulu men and boys to undergo medical male circumcision (MMC) in a bid to protect themselves against HIV. Studies have shown that MMC can reduce the sexual transmission of HIV by approximately 60%.

At the time of the King’s announcement it was mainly Xhosa, Sotho, Ndebele and Shangaan people who underwent traditional circumcision as part of a boy’s initiation into manhood.

Traditional circumcision among Zulu men was banned in the time of King Shaka.

However, now over two centuries later the current King of the Zulus has revived the practice of circumcision to try to save the lives of his people. The King’s decision was motivated by the disproportionate impact of HIV on the Zulu people.

Mr Sidibé commended the King on his vision and leadership around HIV, particularly on male medical circumcision and on his continued personal engagement in the response to HIV.

Thanking Mr Sidibé for his support to South Africa’s AIDS response and calling for the need for strong partnerships the King said, “The health of the nation can only improve if we create a permanent, unified front against the epidemic…..I am on the winning side but without support of the outside world I cannot win this war.”

ROME/GENEVA, 20 July 2011—The Joint United Nations Programme on HIV/AIDS (UNAIDS) strongly welcomes new results confirming that scaling-up adult male circumcision works to prevent HIV in men. The study, which was carried out in the township of Orange Farm in South Africa, resulted in a 55% reduction in HIV prevalence and a 76% reduction in HIV incidence in circumcised men.

The results were announced today in Rome at the 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention by the French National Agency for Research on AIDS and Viral Hepatitis. It is the first time a study has shown that male circumcision roll-out is effective at community level in preventing HIV.

“Science is proving that we are at the tipping point of the epidemic,” said Michel Sidibé, Executive Director of UNAIDS. “Urgent action is now needed to close the gap between science and implementation to reach the millions of people who are waiting for these discoveries. Scaling up voluntary medical male circumcision services rapidly to young men in high HIV prevalence settings will help reach the 2015 goal of reducing sexual transmission of HIV by 50%.”

During the study, free circumcision services offered to all men over 15 years of age resulted in 20 000 circumcisions over a three-year period.  From 2007 to 2010 the percentage of circumcised men increased from 16% to 50% among men between the ages of 15 and 49 years, peaking at 59% in young men aged 15 to 24 years. Community-based surveys reveal no changes in sexual behaviour. The total population of the township of Orange Farm is estimated to be around 110 000.

Many African countries are strongly supporting the scale-up of male circumcision. Kenya has taken the lead, providing voluntary male circumcision to 290 000 men over the past three years, mostly in the province of Nyanza. As reported today at the Rome conference, the men who were circumcised did not increase their risk behaviour. In Tanzania, where the government announced plans to circumcise at least 2.8 million men and boys between the ages of 10 and 34 over a five-year period, a rapid results campaign in early 2011 saw more than 10 000 boys and men circumcised over six weeks.

His Majesty King Mswati III of Swaziland, together with the Swazi Ministry of Health and the US President’s Emergency Plan for AIDS Relief, has recently launched a plan to provide voluntary medical male circumcision to the 152 800 men living in Swaziland between the ages of 15-49 years. Swaziland has the highest HIV prevalence rate in the world, estimated at 26% of adults aged 15-49 years. A statement released by the US Embassy in Swaziland estimated that the circumcision plan could avert nearly 90,000 new HIV infections and save more than US$ 600 million over the next decade.     

These results and announcements follow other recent scientific breakthroughs in HIV prevention: the HPTN 052 trial announced in May showed that early initiation of antiretroviral therapy can reduce the risk of transmission to an uninfected partner by 96%; the Partners PrEP and TDF2 studies announced last week show that a daily antiretroviral tablet taken by people who do not have HIV infection can reduce their risk of acquiring HIV by up to 73%; in November 2010, the iPrEx trial among men who have sex with men reported a 44% reduction in HIV acquisition among HIV negative men who took a daily antiretroviral tablet; and the CAPRISA gel study results announced in July 2010 showed that an antiretroviral gel—when used as a vaginal microbicide—was 39% effective in reducing a woman’s risk of becoming infected with HIV during sex.

UNAIDS stresses that despite the recent scientific discoveries there is still no single method which is fully protective against HIV. To reach UNAIDS vision of Zero new HIV infections, UNAIDS strongly recommends a combination of HIV prevention options. These include correct and consistent use of male and female condoms, waiting longer before having sex for the first time, having fewer partners, medical male circumcision, avoiding penetrative sex and ensuring that as many people as possible in need of antiretroviral therapy have access to it.

Joy Ndugutse, co-founder of Gahaya Links, showed UNAIDS Executive Director Michel Sidibé a selection of handicrafts produced by women in Rwanda for the North American market.

In 2004, two sisters in Rwanda started a “trade-not-aid” initiative that produces high-end handicrafts. From a humble beginning with just 20 artisans in the remote village of Gitarama, Gahaya Links has since expanded its network to more than 5000 weavers nation-wide.

Most of the employees at Gahaya Links are women who lost husbands and children in the 1994 Rwandan genocide. Many are HIV-positive. The income earned through their work ensures they can provide food, education, and healthcare for their families.

“This is development in practice,” said UNAIDS Executive Director Michel Sidibé during a visit to the Gahaya Links head office in Kigali on Tuesday. “It is a success story for restoring the dignity of people living with HIV,” he added. In a guided tour of the project, Mr Sidibé saw first-hand the range of handicrafts on offer, including brightly-coloured woven baskets and crocheted glass-beaded necklaces.

Gahaya Links organizes sessions on HIV prevention for its employees and teams with national partners and health centres to ensure that women have access to antiretroviral treatment and care. The programme fosters an environment of support, cooperation and mutual trust for people living with HIV.

Joy Ndugutse, co-founder of Gahaya Links, told Mr Sidibé that the project transforms the lives of women living with HIV. “These women are now stronger and more confident,” she said, adding that many others could benefit from such support.

Gahaya Links collaborates closely with Same Sky, a New York-based company founded by social entrepreneur Francine Le Frak that markets the Rwandan handicrafts for a North American market. Proceeds are reinvested into expanding the business to other world regions and employing more women artisans.

PrePex: A potential new tool for HIV prevention

While in Kigali, Mr Sidibé visited the Nyamata hospital, a public facility serving a population of approximately 300 000 people. The hospital was chosen as a site for a safety study of a new, non-surgical method of male circumcision called “PrePex.”

“The most interesting thing about PrePex is that it doesn’t require going to the operating theatre,” said Dr. Agnes Binagwaho Permanent Secretary in the Ministry of Health of Rwanda. “It can be done from any clean environment. It is also cost-effective and does not require highly trained staff—any well-trained person can do it,” she added.

Studies have shown that adult male circumcision reduces the risk of HIV transmission from women to men by about 60%. Existing techniques for male circumcision require highly trained health professionals and surgical settings.

During his tour of the hospital, Mr Sidibé commended health authorities in Rwanda for their work on this groundbreaking study. “PrePex marks a revolution in the framework of accelerating HIV prevention,” he said. If larger studies confirm that PrePex is safe and effective, PrePex could be approved as a medical device that would triple the number of male circumcisions that health facilities conduct daily.

Male circumcision among heterosexual men in high HIV prevalence and low male circumcision settings is beneficial and cost effective, says a new article in the open access journal PLoS Medicine.

The report is based upon the findings of a series of meetings, convened by UNAIDS, the World Health Organization (WHO), and the South African Centre for Epidemiological Modelling and Analysis (SACEMA). These meetings reviewed published and unpublished modelling work to estimate the long-term population impact and cost-effectiveness of male circumcision programmes through mathematical modelling approaches.

Six models were considered by the expert group, which was led by Dr. Catherine Hankins, Chief Scientific Advisor at UNAIDS. The models predicted that, using a 10 year time horizon, one new HIV infection would be averted for every five to 15 men newly circumcised. For the most successful interventions, where almost all men are circumcised, HIV incidence could be reduced by 30% to 50% over the same period, with prevalence trends also following this decrease.

The estimated costs per adult male circumcision are between $30 and $60, depending on the programme setting, with neonatal circumcision costing about one-third this amount. The models estimate costs per infection averted of between $150 and $900 in high HIV prevalence settings over a 10-year time horizon.

All the models indirectly confirmed that the most favourable cost-effectiveness ratios will be seen where HIV incidence is highest. By comparison, estimates of discounted lifetime treatment costs typically exceed $7,000 per HIV infection if only first-line treatment is provided, and twice as much if second-line treatment is available. Thus, circumcising sexually active males of any age is likely to be cost saving.

While several studies have confirmed that male circumcision performed by well-trained medical professionals reduces the risk of men acquiring HIV through female-to-male transmission by approximately 60%, a major concern raised in discussions around male circumcision, is that it does not directly protect women from HIV. However, women do benefit indirectly from reduced HIV prevalence in circumcised male sexual partners as male circumcision programmes scale up.

Male circumcision does not replace other prevention measures. Because it provides partial protection, it should be combined with strategies such as delaying the onset of sexual relations, abstaining from penetrative sex, reducing the number of sexual partners, using male and female condoms correctly and consistently, learning your HIV status, and getting treatment for sexually transmitted disease.

Male circumcision may have minimal impact on reducing HIV transmission among men who have sex with men.

The site is a clearinghouse for the generation and sharing of authoritative information about the role of male circumcision in HIV prevention.
Credit: malecircumcision.org

A new web site on male circumcision for HIV prevention was launched today by the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the AIDS Vaccine Advocacy Coalition (AVAC), and Family Health International (FHI).

The site — www.malecircumcision.org — is designed to be a clearinghouse for the generation and sharing of authoritative information about the role of male circumcision in HIV prevention. The information has been reviewed by technical experts from around the world and provides evidence-based guidance to support the delivery of safe male-circumcision services as one component in a comprehensive approach to HIV-prevention services.

“The Clearinghouse will be continually updated with emerging information on country progress in expanding access to safe male circumcision services, including lessons learned in implementation,” said Dr. Catherine Hankins, Chief Scientific Adviser to UNAIDS. “Providing access to tools and guidance, the Clearinghouse is an essential website aid for all those working on male circumcision for HIV prevention,” she added.

UNAIDS led the preparatory UN work plan on male circumcision and supports WHO as the lead for UN implementation support for the introduction or expansion of safe, voluntary male circumcision services. UNAIDS recommends that male circumcision always be considered as part of a comprehensive HIV prevention package. Key UNAIDS materials on male circumcision are included on the new web site.

“The Clearinghouse will serve as the ‘one-stop-shopping’ site for the most recent news, research, and resources on the use of male circumcision to prevent HIV, says Dr. Kim Eva Dickson, medical officer for HIV prevention in the health sector, WHO. “We want to attract the attention of the international public-health community—including scientists, civil-society groups, policy makers, health providers and programme managers.”

Resources include:

• A browsable database of hundreds of scientific abstracts and full-text articles
• An inventory of research activities on male circumcision
• Tools and guidelines for provider training and programme scale-up
• Evidence-based protocols and guidelines
• A compendium of better and best practices
• An opportunity to sign up for an RSS feed on news related to male circumcision
• A global mechanism for exchanging and integrating information on male circumcision programmes and associated services

“Circumcising men is among the most promising public health tools to reduce new HIV infections in areas most affected by the epidemic,” said Al Siemens, PhD, CEO of Family Health International.

“We are proud to have helped produce such a practical and evidence-based resource for health professionals interested in improving men’s access to high quality male circumcision services as a component of comprehensive HIV prevention efforts.”

15th Conference on Retroviruses
and Opportunistic Infections took place in
Boston 4-6 February 2008. Credit: CROI

The annual Conference on Retroviruses and Opportunistic Infections (CROI) began in 1994 as a small meeting of scientists studying HIV and clinicians treating people with HIV. It is now one of the most important annual HIV gatherings and provides a forum for basic scientists, clinical investigators, and global health researchers to present, discuss, and critique their investigations into the epidemiology and biology of human retroviruses and the diseases they produce.

The 15th CROI concluded in Boston on 6 February and while announced trial results were not encouraging, many significant topics were discussed. The absence of a scientific breakthrough in HIV vaccine development underscores the need to scale-up existing prevention and treatment strategies.

HSV-2 trial - No observed reduction in risk

Disappointing results were announced from trials to see if ongoing treatment of the virus that causes herpes in humans, herpes simplex virus type 2 (HSV-2), would reduce the risk of HIV transmission. HIV-negative people with HSV-2 were asked to take medication to suppress outbreaks of herpes. However, the trial results showed no difference in rates of HIV infection between individuals who had taken the medication and those who hadn’t.

Scientific data shows a link between HSV-2 infection and susceptibility to acquiring HIV infection and there are other on-going trials exploring different aspects of this link, so researchers remain cautiously hopeful about this avenue of research.

Male circumcision

Previously-released data from the studies of male circumcision in Uganda which were stopped in December 2006 were presented by trial investigator Maria Wawer. One trial explored whether circumcising a HIV-positive man reduced the risk of HIV transmission to his HIV-negative female partner. Results showed a trend towards increased HIV transmission from men to their female partners. This trend was more notable, although still not statistically significant, when the men resumed sex before their wound had healed completely.

While this data is not new, its presentation at CROI gave an opportunity for discussion and analysis of its implications. Advocates stressed the necessity for all male circumcision programmes to directly address women’s increased vulnerability to infection by sex with a recently-circumcised, HIV-positive man.

UNAIDS Chief Scientific Adviser Dr Catherine Hankins said, “This underlines the importance of considering male circumcision as part of a comprehensive prevention package which includes couple counselling and post-surgery advice involving both partners. Couples should consider a mutual commitment to abstinence until the wound is healed completely.”

UNAIDS guidelines recommend that all men undergoing male circumcision should be clearly instructed and supported to abstain from sexual intercourse until certified wound healing, which normally can take up to six weeks, to avoid increasing the risk of both acquiring and transmitting HIV.

Most importantly, individuals must understand that male circumcision does not afford complete protection against HIV infection and that it must not replace other prevention strategies such as correct and consistent use of male and female condoms, reduction in the number of sexual partners, avoidance of penetration, and treatment of sexually transmitted infections.

Vaccines

Last September there was a disappointing failure in Merck’s adenovirus- based HIV vaccine candidate. The consensus from experts at CROI was that it was important for scientists to go back to the drawing board of basic science to get a better understanding of the workings of the virus and the responses of the human immune system. There was a call for increased investment into basic scientific research and less emphasis on expensive clinical trials, although clearly both are needed.

There is a growing acceptance that the search for the elusive HIV vaccine is set to continue for some time. This underscores the need to scale-up existing prevention and treatment strategies and highlights the importance of improving people’s access to sexual health information, access to HIV testing and counselling services and to male and female condoms.

Other interesting topics under discussion at CROI included improved screening for TB, ensuring adequate representation of women in HIV trials, aging and AIDS, and paediatric and adolescent HIV care.

Experts from across the world are gathering this week in Montreux in Switzerland to review the results of recent trials establishing that male circumcision reduces by almost 60% the risk of men to acquire HIV during vaginal sex. These results announced in December 2006 and detailed in recent publications in The Lancet sparked interest and debate in the world of HIV. Is male circumcision as significant an advance as some of its proponents have claimed?

Dr Kim Dickson, from the HIV Department of the World Health Organization is a recognized and respected figure in the field of reproductive health and HIV. She currently coordinates the joint WHO/UNAIDS working group on male circumcision and HIV prevention as well as the Inter-agency Task Team on male circumcision and HIV prevention. She has kindly agreed to tell us more about the meeting and its expected outcomes.

Unaids.org: Dr Dickson, you coordinate the joint WHO/UNAIDS working group on male circumcision and HIV prevention. Can you tell us why WHO and UNAIDS are convening this meeting on male circumcision?

KD: When the US National Institutes of Health decided, in December 2006, to stop the two trials they were funding in Kenya and Uganda on male circumcision and HIV, it became clear that we needed to assess male circumcision as a potential public health intervention in the response to AIDS. The trials, as detailed in the results recently published in The Lancet, confirmed many previous observational studies which suggested that male circumcision significantly reduced the risk of men in acquiring HIV during vaginal sex.

It was important that the World Health Organization and the Joint United Nations Program on HIV/AIDS review the research results and consider what they mean for HIV prevention policy and programming in countries. It was decided to convene a meeting to bring around the table as many stakeholders as possible to look at and discuss many of the issues that male circumcision can raise, and, if possible, give guidance and recommendations for Member States and other stakeholders.

Unaids.org: How many participants are joining in this meeting and what do they represent?

KD: We invited the trials' investigators to present their methodology and their results. We also invited other scientists, from different disciplines such as social science, human rights and communications to ask the investigators questions which were not necessarily in the scope of their trials. We also have 16 representatives from Member States, and 11 from the civil society, including women’s health advocates and a representative from the Global Network of People Living with HIV, to present their own reading of the results and also to raise the issues that they face in their countries and in the context of their activities.

We paid special attention to invite people representing different positions. Last, but not least, we also have eight funding agencies and six implementing partners joining in the discussions. Overall, we are expecting almost 80 participants in Montreux. No need to say that we expect intense discussions that will touch upon many difficult issues.

Unaids.org: What do you expect as the outcomes of this meeting?

KD: The first and immediate outcome resides in the debate that is going to take place this week. This is the first time ever that such a wide range of stakeholders exchange views and discusses the consequences of male circumcision as an additional prevention method in the response to AIDS. At this stage, we cannot pre-empt the outcome. Maybe we will conclude the meeting with more questions than we began with- though I am hoping that at least some questions will be answered and that we will be able to make some recommendations.

The meeting will also identify what we need to do next in order to move forward. In any case, there will be a meeting report which we will make public shortly after the meeting.

Finally, I want to emphasize again and again that our objective is to examine male circumcision as an additional prevention method which should always be part of a comprehensive package which includes, among other elements, the correct and consistent use of male and female condoms, the delay in sexual debut and the reduction of sexual partners. The meeting will discuss how we can strengthen our communications so as not to undermine other prevention methods if we are to scale up male circumcision services.

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 as an alternative. People must understand that male circumcision does not provide complete prevention and they should be encouraged to use more than one of the prevention choices available to them.

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.

In the second of a special three-part series on the issue of male circumcision and its links to the reduction of HIV acquisition, unaids.org considers current research findings.

It’s a subject that hits headlines, fuels discussions, sparks debate and causes some of the men in the room to wince and cross their legs. Male circumcision and its links to HIV is one of the most talked about issues within the AIDS response over the last years, with latest research findings driving potential change in the way male circumcision is practiced and implemented for the future in relation to HIV prevention.

In scientific circles, the perceived links between male circumcision and HIV infection are nothing new. For years, AIDS researchers have observed that many African tribes that circumcise boys or young men had lower HIV rates than those that do not, and that Africa's Islamic nations, where circumcision is near universal, had far fewer AIDS cases than predominantly Christian ones.

Now, trials in Kenya, Uganda and South Africa have all shown that male circumcision significantly reduces a man’s risk of acquiring HIV. The three sets of trials have shown circumcised men are up 50 to 60% less likely to acquire HIV during heterosexual intercourse.

Research findings

The first research proof came in 2005, when a study in South Africa, supported by the French agence nationale de recherches sur le sida (ANRS) and known as the 'Orange Farm Intervention Trial', was stopped early in the face of evidence that the men who had been randomly assigned to be circumcised were getting 60% fewer HIV infections than the men assigned to the control group.

In December 2006, on the recommendation of their Data and Safety Monitoring Board (DSMB), two similar studies in Uganda and Kenya were halted early by the United States National Institutes of Health (NIH) because the interim results showed a significant effect of male circumcision in preventing HIV acquisition in men.

The trial carried out in Kisumu, Kenya by researchers from the University of Nairobi, University of Illinois at Chicago, the University of Manitoba, and RTI International involving 2,784 men aged 18 to 24 showed a 53% reduction of HIV infections in circumcised men compared to uncircumcised men.

In Uganda, the trial, carried out in Rakai by researchers from Makerere University, the Uganda Virus Research Institute, Johns Hopkins University, and Columbia University New York, involved 4996 men aged 15 to 49 years old and showed that adult male circumcision reduced by 51% the risk of becoming infected with HIV.

Dr. Anthony Fauci, director of the NIH's National Institute of Allergy and Infectious Diseases, said the institute ended both trials early and offered circumcision to all men involved in them. The trials began in 2005 and were due to go until mid-2007.

The biology

Male circumcision involves the surgical removal of the foreskin, the tissue covering the head of the penis. Previous research shows that removing the foreskin is associated with a variety of health benefits including lower rates of urinary tract infections in male infants who are circumcised and reduced risk of certain inflammations and health problems associated with the foreskin.

Scientists say male circumcision probably reduces the risk of HIV infection because it removes tissue in the foreskin that is particularly vulnerable to the virus, and because the area under the foreskin is easily scratched or torn during sex. “Uncircumcised men may also be more vulnerable to sexually transmitted diseases, which in turn increase the risk of contracting HIV, because the region under the foreskin provides a moist, dark place in which germs can thrive,” said UNAIDS Chief Scientific Adviser, Dr Catherine Hankins.

No ‘magic bullet’

The results of the trials in South Africa, Uganda and Kenya indicate that in certain settings, adult male circumcision could become an important addition to an HIV prevention strategy for men. “The trials indicate that male circumcision can lower both an individual's risk of infection and hopefully the rate of HIV spread through the community," NIH’s Dr Fauci said.

But experts— including the United Nations bodies working on the issue—caution that circumcision is no cure-all. Male circumcision does not provide complete protection against HIV infection; it only lessens the chances that a man will acquire the virus.

Circumcision is "not a magic bullet, but a potentially important intervention," said Dr. Kevin M. De Cock, director of the World Health Organization’s AIDS department.

“Men and women must understand that circumcised men can still become infected with the virus and if HIV-positive, can infect their sexual partners,” said UNAIDS’ Dr Hankins

“ Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive HIV prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and abstaining from penetrative sex”, she said.

Safety, sanitation and communication

To ensure safe and clean operations, male circumcision should only be performed by well-trained practitioners in sanitary settings under conditions of informed consent, confidentiality, proper counseling and safety. “If male circumcision is to be promoted, this should be done in a culturally appropriate manner and people should be provided sufficient and correct information on HIV prevention to prevent them from developing a false sense of security and engaging in risky behavior,” said Dr Hankins.

These considerations and others in relation to the AIDS response, including the fact that male circumcision has the potential to be an expensive intervention, that more research is needed to address whether male circumcision reduces risk of transmitting HIV-particularly for female partners, and the different ethical and human rights issues raised by male circumcision, will form discussions of the United Nations consultation on male circumcision that will take place in Geneva from 5 March. Here, WHO, the UNAIDS Secretariat and their partners will review the detailed trial findings and will, if deemed appropriate, then define specific policy recommendations for expanding and/or promoting male circumcision.

“Male circumcision is a complicated issue which involves sometimes difficult discussion on issues of culture, tradition, religion, ethnicity, human rights and gender. The consultation will provide an excellent arena for moving the discussion and policy forward within the United Nations,” said Dr Hankins.

Male Circumcision: context, criteria and culture (Part 1)
Male Circumcision and HIV: the here and now (Part 2)
Moving forwards: UN policy and action on male circumcision (Part 3)