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On March 28, 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that HIV prevention programs and policies recognize male circumcision as an additional, important strategy to prevent men from acquiring HIV from infected female partners.[1] Recent studies have demonstrated that circumcision offers men considerable—though not complete—protection against acquiring HIV through heterosexual intercourse.[2,3,4]

Male circumcision is the surgical removal of all or part of the foreskin (the tissue that covers the head of the penis).[5,6] This fact sheet discusses recent studies on male circumcision, biological mechanisms by which the practice may reduce men’s risk of heterosexually acquired HIV infection, global prevalence of male circumcision, and recommendations for HIV prevention programs and policies.

Study Findings

• Since the 1980s, many studies have shown that circumcised men have a lower prevalence of HIV infection than do uncircumcised men.[6]
• The first randomized controlled trial, conducted in South Africa, showed male circumcision to provide a 61 percent protective factor against males’ acquiring HIV through heterosexual intercourse.[2]
• Two more studies, in Uganda and Kenya, showed that male circumcision provided a 51 to 53 percent protective factor against heterosexually acquired HIV.[3,4]

Biological Mechanisms

Experts have considered several possible mechanisms to explain how circumcision may decrease males’ vulnerability to heterosexually acquired HIV.

• The inner mucosal surface of the foreskin contains a high concentration of cells that HIV-targets—cells such as Langerhans and CD4+T cells. Removing the foreskin greatly reduces the number of available target cells through which HIV could invade a man’s body.[3]
• HIV and other pathogens may survive for some time on the protected, damp, inner surface of the foreskin. Eliminating this environment reduces the pathogens’ ability to survive.[6,7]
• Abrasions and inflammation of the delicate foreskin tissue during sexual intercourse may facilitate HIV’s invasion of the body. Circumcision eliminates the foreskin and closes off this pathway for the virus.[6,7]
• In addition, studies link male circumcision to a lower prevalence of syphilis and some other sexually transmitted infections (STIs) that cause genital ulcers and also increase the risk of HIV infection. For example, a study in Tanzania found circumcised men to have half as many syphilis infections as their uncircumcised counterparts.[8]

Prevalence of Male Circumcision around the World

• About 30 percent (665 million) of all human males have been circumcised.[9] Virtually all Islamic and Jewish men are circumcised; in fact 68 percent of circumcised men are Islamic.[10]
• In many societies, circumcision is a rite of passage to manhood.[10] In Judaism, circumcision is usually performed shortly after birth while Moslem males may undergo circumcision at any age between birth and puberty.[10]
• In northern Africa and most of western Africa, nearly all males are circumcised.[9] By contrast, male circumcision varies greatly in south and central Africa; only 15 percent of Botswana’s males are circumcised compared to more than 80 percent of Angola’s and Madagascar’s males.[9]
• Male circumcision is almost universal in the Middle East and Central Asia as well as in Bangladesh, Indonesia, and Pakistan. In India, about 120 million males are circumcised, usually for religious and cultural reasons.[9]
• Male circumcision is relatively rare throughout Central and South America (prevalence of less than 20 percent).[9]

Implications for the Future
Public health experts anticipate a rise in the demand for male circumcision. WHO and UNAIDS assert that the greatest potential public health impact may be realized in settings where HIV prevalence in the general population exceeds 15 percent, where the epidemic is primarily one of heterosexual transmission, and where more than 80 percent of males are uncircumcised.[1]

At the same time, promoting male circumcision as a method for preventing HIV requires: 1) good counseling; 2) safe services; 3) a human rights approach; and 4) culturally appropriate services.[1]

• Counseling—Men and women need to be counseled that:
  • The procedure does not provide complete protection against HIV.[1,11] Circumcised men should continue to be abstinent or, if they choose to have sex, to remain in a mutually monogamous relationship and/or to use condoms.
  • Newly circumcised men must avoid sexual intercourse for six weeks to allow the incision to heal completely. Having sexual intercourse prior to complete healing can actually increase a man’s risk of HIV infection.[1,11]
  • In addition, men must understand that sexual activity before the wound has healed can lead to surgical complications.[11]
• Service safety—Programs must take all necessary steps to assure the client’s well-being:
  • The procedure must be performed in clean surroundings, with trained personnel using sterilized instruments.[1,11]
  • Counseling services must be a part of the package.[1,11]
  • Men should be encouraged to return for follow-up if they experience any complications, especially infection or uncontrolled bleeding.[1,11]
• Human rights—Planners must take an approach to offering male circumcision that acknowledges the human rights of the client:
  • Every adult male who is considering circumcision for himself should be able to give informed consent.[1]
  • Where a minor is the prospective client, counselors must take extra time to ensure that the minor and his parents understand the procedure and that the young male consents to it.[1]
  • When an infant is to undergo the procedure, his parents must be fully informed.
• Cultural appropriateness—Since WHO and UNAIDS recommend male circumcision as an HIV prevention method especially for countries where 80 percent or more of the male population is uncircumcised, offering this service calls for especial care.
  • Communities should be fully informed and involved in the design and implementation of circumcision programs.[1]
  • HIV prevention should include ongoing community-wide educational programs with regard to all methods to prevent HIV.[1]
  • UNAIDS and WHO recommended that: countries should consider scaling up access to male circumcision services as a priority for adolescents, young men, and (as indicated by local epidemiology and other considerations) older men at high risk of HIV.[11]

Finally, UNAIDS and WHO acknowledge the need for additional research on:

• Implications of male circumcision on male-to-female HIV transmission;
• The effect of male circumcision for men who have sex with men; and
• Appropriate mechanisms for offering low cost and safe male circumcision services.[1,11]

Male circumcision does not completely protect against HIV. Instead, it should be offered as part of comprehensive HIV prevention. UNAIDS and WHO project that, if adopted successfully as an additional HIV prevention method, male circumcision could be responsible for the prevention of 5.7 million new cases of HIV over the next 20 years.[11]

References

1. WHO, UNAIDS. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications: Conclusions and Recommendations. [Technical Consultation] 2007; http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf.
2. Auvert B et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Medicine 2005; 2:e298; doi:10.1371/journal.pmed.0020298.
3. Bailey RC et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007; 369: 643-56.
4. Gray RH et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657-66.
5. WHO et al. Information Package on Male Circumcision and HIV Prevention [Insert 1]; http://www.who.int/hiv/mediacentre/infopack_en_1.pdf; accessed 3/7/2007.
6. UNAIDS, WHO. Male Circumcision and HIV: Recent Developments;http://data.unaids.org/pub/FactSheet/2007/20061229
   _mc_fs_en.pdf?preview=true; accessed 4/5/2007.
7. WHO et al.Information Package on Male Circumcision and HIV Prevention [Insert 4; http://www.who.int/hiv/mediacentre/infopack_en_4.pdf; accessed 3/29/2007.
8. Todd J et al. Risk factors for active syphilis and TPHA seroconversion in a rural African population. Sex Transm Inf 2001; 77:37-45; http://sti.bmj.com/cgi/content/full/77/1/37.
9. WHO et al. Information Package on Male Circumcision and HIV Prevention [Insert 2]; http://www.who.int/hiv/mediacentre/infopack_en_2.pdf; accessed 3/29/2007.
10. UNAIDS. Male Circumcision: Context, Criteria, and Culture
    [Part 1]; http://www.unaids.org/en/MediaCentre/Press
    Materials/FeatureStory/20070226_MC_pt1.asp; accessed 4/5/2007.
11. WHO. WHO and UNAIDS Announce Recommendations from Expert Consultation on Male Circumcision for HIV Prevention. [News Release] Paris/Geneva; 2007; http://www.who.int/hiv/mediacentre/news68/en/index.html; accessed 3/29/2007.

Written by Kathy Osborn
2007 © Advocates for Youth