FHI - Male Circumcision

Results from three clinical trials in South Africa, Kenya, and Uganda showed that male circumcision (MC) can reduce HIV incidence in men by 50 to 60 percent.
In March 2007, WHO and UNAIDS endorsed MC as a means of preventing HIV. They highlighted the importance of promoting MC as one strategy within in a comprehensive package of HIV prevention services. Male circumcision programs should communicate messages in a culturally appropriate manner to emphasize that MC provides only partial protection against HIV and that providers must follow up with patients after the procedure. Although MC is an effective prevention intervention, it should not be implemented in isolation. The WHO, UNAIDS, and most experts strongly recommend promoting MC as one component of a comprehensive prevention package that also includes provision of HIV counseling and testing services, treatment for STIs, promotion of safer sex practices, and provision of male and female condoms.
- Circumcision has additional medical benefits: it can prevent inflammation of the glans and the foreskin, lower the risk of penile cancer, and decrease the prevalence of some STIs, especially ulcerative infections like chancroid and syphilis. Circumcised men also find it easier to maintain penile hygiene and do not suffer from health problems associated with the foreskin.
- Research suggests that the biological characteristics of the foreskin make it particularly susceptible to viral entry of HIV. Studies on the pathology of the human penis found that the foreskin contains HIV target cells and Langerhans cells necessary for viral entry. Moreover, the inner foreskin (or the foreskin mucosa) has little to no structural barrier, known as keratin, to prevent the uptake of HIV viral particles.
  - McCoombe SG, Short RV. Potential HIV-1 target cells in the human penis. AIDS 2006;20:1491-95. (abstract)
  - Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002;161(3):867-73. (abstract)
  - Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ 2000;320:1592-1594. (excerpt)

Research shows that MC is acceptable to both men and women. In a review of thirteen studies across nine African countries, levels of acceptability were consistent. An average of 65 percent of uncircumcised men were willing to become circumcised, 69 percent of women favored circumcision for their partners, and 71 percent of men and 81 percent of women were willing to have their sons circumcised. The most reported barriers to acceptability were cost, fear of pain, and concern for safety.
- Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behav 2007;11(3):341-355. (full text)

Moderate implementation costs, high and durable protective effects, and the resulting averted costs of HIV care make MC a cost-effective public health intervention. Safe, voluntary services in places where the prevalence of MC is low and the prevalence of HIV is high, such as southern Africa, could substantially reduce the burden of HIV. Cost-effectiveness of adult MC has also been established in sub-Saharan Africa with high or moderate HIV prevalence, even when MC coverage is low.
- Auvert B, Marseille E, Korenromp EL, et al. Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in sub-Saharan Africa. PLOS One 2008;3(8):e2679. (abstract)
- Khan J, Marseille E, Auvert B. Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 2006;3(12):2349-2358. (full text)
- White RG, Glynn JR, Orroth KK, et al. Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when? AIDS 2008;22:1841-1850. (excerpt)
- Williams B, Lloyd-Smith JO, Gouws E, et al. The potential impact of male circumcision on HIV in sub-Saharan Africa. PLoS Med 2006;3(7):1032-1040. (full text)

The risks involved in MC are generally low when it is performed under safe and sterile conditions, by well-trained providers who are adequately equipped. In addition to training providers, program managers should also carefully monitor and evaluate their services.

More research on MC is needed in several areas: HIV prevalence rates, MC prevalence rates, current circumcision practices (especially with regard to safety), the feasibility of introducing or scaling up programs, and the longer-term social and cultural impact of adult MC as a public health intervention. In general, research questions should focus on how to improve the availability, acceptability, risk disinhibition, quality, and safety of MC as part of comprehensive HIV prevention.

Click here for more information on male circumcision and HIV.

Also see the Clearinghouse on Male Circumcision for HIV Prevention.