Male circumcision, HIV prevention and communication challenges

02 February 2007

Trials in Kenya, Uganda and South Africa have now all shown that male circumcision significantly reduces a man’s risk of acquiring HIV. Three sets of trials have shown circumcised men are between 48% and 60% less likely to acquire HIV during heterosexual intercourse.

The evidence for the protective effect of male circumcision has been building over the past few years, but the latest findings conclusively confirm suggestions from previous observational studies. To put this in context, after many years of research there is still no sign of an HIV vaccine on the horizon with anything approaching the 50-60% efficacy rate of male circumcision. So the results are significant and raise important questions about how we best use circumcision in the response to HIV.

Of course, the results don’t mean male circumcision is a new panacea for preventing HIV: the trials only confirm that it reduces risk of female-to-male sexual transmission in high prevalence, largely heterosexual epidemics. Not all HIV transmission is through heterosexual intercourse, injecting drug users sharing needles for example and we don’t know as yet the extent to which male circumcision reduces transmission to female partners or in sex between men. But the findings strongly show that male circumcision could help limit the size of HIV epidemics significantly in countries where there is high prevalence of HIV throughout the general population[3]. This could massively reduce the levels of ill health and death associated with HIV in these countries.

Researchers’ models estimate that male circumcision could avert 2 million new HIV infections and 300,000 deaths over the next ten years in sub-Saharan Africa. Another 3.7 millions infections and 2.7 million deaths could be averted in the ten years after that. This would make male circumcision equivalent to a vaccine or increased condom use that reduced transmission in both directions by 37%[4].

The World Health Organization and UNAIDS are holding consultations to examine the results of the circumcision trials to date and their implications for countries, particularly those in sub-Saharan Africa and elsewhere with high HIV prevalence and low levels of male circumcision[5]. They are also planning to provide technical guidance and rapid assessment toolkits to countries thinking about instituting male circumcision programmes[6].

A challenging prevention message

Male circumcision for HIV prevention presents considerable communication challenges. Translating these complex findings into information that individuals and families can use for decision making is not straightforward: the positive impact of male circumcision will be greatest if the majority of HIV negative men in high prevalence settings voluntarily choose to undergo circumcision (in a similar way to vaccination programmes); but the protective effect for the individual HIV negative man will be limited if they don’t reduce their exposure to HIV by consistent condom use or partner reduction. We already know from anecdotal evidence that the mistaken belief by circumcised men that they are not at risk of infection can lead to increased HIV risk taking – through unprotected sex or an increase in partners, which could negate the protective effect of male circumcision. Research both supports and contradicts this view, but the dangers are clear.

The results are also likely to inform the decisions that are made by sero-discordant couples, particularly around family planning and the use of male circumcision as a risk reduction strategy if they want to start a family. Again there are complex communication issues here for positive prevention that need to be addressed, which also reinforce the importance of integrating HIV and sexual and reproductive health messages.

Culture and religion add another layer of complexity. In many communities, circumcision, or the lack of it, is related to rites of passage and religious and tribal identity. How this new knowledge is communicated will need great sensitivity and an understanding of local meaning given to male circumcision, particularly in communities where there is continued suspicion about both the origins of the virus and the measures proposed to prevent it.

However, we should not underestimate the ability of communities to assess and interpret information to their own circumstances – as we have seen in the roll out of antiretroviral programmes. With clear information and support, communities in the south have been able to understand and adhere to complex drug regimes at least as well as those on treatment in the north.

And despite concern that adult male circumcision would be unacceptable, in a number of countries in southern Africa we are already seeing men voluntarily seeking the procedure. In Swaziland, there is an 18-month waiting list for male circumcision and the demand for circumcision is already increasing in Lesotho, Botswana and South Africa.

It seems that men in high prevalence settings are already making decisions about circumcision and NGOs and CBOs working at the community level have an important role to play in sensitizing people to the issues and facts, and the importance of continued condom use and other prevention measures. The Alliance and other organisations have a clear role in developing tools and resources to help NGOs and CBOs do this effectively.

Overcoming practical concerns

Adult male circumcision is usually safe when performed correctly, but is not without risk; it can also be painful and the person must avoid sex for about six weeks post-operatively to allow for healing, otherwise serious complications can occur and their risk of HIV infection could increase. Trial results so far are based on the procedure being carried out in sterile clinical environments by trained medical personnel. Although in sub-Saharan Africa male circumcision is often performed on an out-patient basis under anaesthetic, many men continue to be circumcised by traditional and religious practitioners[7]. The potential role of religious and traditional practitioners in male circumcision intervention programmes needs careful consideration. WHO, UNAIDS, the Alliance and others need to give this serious consideration in the months ahead, and in the development of technical guidance and rapid assessment toolkits.

Trials results are also based on knowledge of HIV status. In non-trial settings, access to and uptake of HIV testing is extremely low due to both lack of testing services and low up-take by men. Ensuring that both access and up-take are addressed will be critical to the implementation of male circumcision services. It is also possible that knowledge of and access to circumcision services could improve HIV testing rates for heterosexual men.

What we need now are programmes that pilot a comprehensive male circumcision package with excellent pre and post-operative care – where male circumcision is offered alongside HIV testing services, community engagement, communication of the risks and benefits, and prevention education to counteract the potential for increased risk-taking. Given other health benefits associated with male circumcision – such as hygiene, reduced incidence of some sexually transmitted infections, particularly HPV infection and its impact on cervical cancer, male circumcision could be set within a broader men’s sexual health programme. Operations research would help influence future models of intervention.

Acting on the evidence

The results of these trials offer hope for the reduction of the HIV burden in some of the most affected countries, particularly in southern Africa. Cultural, communication and surgical complexities are no excuse for inaction. But the key to successful prevention work still depends on mobilising communities and giving them access to information so they can make informed choices. Safe male circumcision should be one part of a comprehensive range of prevention services available to communities.

As we have seen with other aspects of the HIV response, such as providing condoms, antiretroviral treatment and prevention of mother to child transmission, these are only effective when they are provided through, and with the full engagement of communities

What do these results mean for women? Although findings from the Rakai trial[8] [9] suggest male circumcision also reduces HIV transmission from men to women, further research is required to understand this better, and this research must be prioritised. The impact of male circumcision on women negotiating safe sex also needs close attention. Alongside research on male circumcision, the work to find effective female-controlled HIV prevention methods must also remain a global priority.

Next steps

In the history of the HIV epidemic, the results of these trials are as important as the results of the Paediatric AIDS Clinical Trials Group study which showed a two-thirds reduction of mother to child transmission of HIV through a complex regimen of zidovudine to mother and infant. It took more than six years before we had resource appropriate services available in developing countries. Sadly, most women still do not have access to comprehensive prevention of mother to child transmission services. It’s important that we don’t wait so long before translating these new circumcision findings into appropriate and safe programmes.

The Alliance will be focusing time and energy over the months ahead to understand all the issues male circumcision raises for communities in high prevalence countries, to make sure these issues are discussed at community level, and to help ensure full community participation. We will be working with the key researchers and actors in this area to develop an understanding of effective strategies for male circumcision so we can support communities to prepare – in the same way we have supported community preparedness and engagement for roll out of antiretroviral treatment.

We will also need to continue our work with the research community to ensure that the possible protective effect of male circumcision for men who have sex with men, and other vulnerable populations living in low and concentrated epidemics and in different cultural contexts is better understood. We plan to carry out consultation with affected communities to gather information about the personal and social meanings of these findings and the HIV information and education implications. We will be publishing a position paper and strategy in March/April on how circumcision should complement existing Alliance programming, which will be circulated with The Loop.

Let us know what you think

The Loop is keen to hear what you think of the circumcision debate. Is male circumcision already a part of your programming? What do you think of its relevance to your work, your community and the epidemic you face?

We will be bringing you more articles on circumcision throughout the year in the Loop, and would like to hear your views to help inform our wider consultation plans.

Email theloop@aidsalliance.org, putting 'circumcision' in your email subject line, by Monday 26 February .

[1] Adult Male Circumcision Significantly Reduces Risk of Acquiring HIV: Trials in Kenya and Uganda Stopped Early

[2] Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298.

[3] Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000 14(15): 2361-70. Review.

[4] The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa

[5] Alcorn K, Two circumcision studies halted after circumcised men's HIV risk halved

[6] Statement on Kenyan and Ugandan trial findings regarding male circumcision and HIV

[7] Halperin, DT, Bailey, RC. Male circumcision and HIV infection: 10 years and counting, The Lancet, Volume 354, Issue 9192 , 20 November 1999, Pages 1813-1815

[8] U.S. National Institutes of Health. Trial of Male Circumcision: HIV, Sexually Transmitted Disease (STD) and Behavioral Effects in Men, Women and the Community. 2006.

[9] Circumcision and HIV Transmission: The Cutting Edge. Tom Quinn, NIAID, NIH and Johns Hopkins Univ, Baltimore, MD, US MP3 Podcast from the CROI Conference, February 2006.