Male circumcision should be recognized as an additional important step in curbing heterosexually acquired HIV in men after trials showed that the procedure cut the risk of infection by up to 60 per cent, the United Nations health agency said today. Modelling studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new HIV cases and 3 million deaths over 20 years, the UN World Health Organization (WHO) added, summarizing the findings of an experts meeting it convened earlier this month together with the Joint UN Programme on HIV/AIDS (UNAIDS). But circumcision should only be considered as part of a comprehensive prevention package that includes treatment for sexually transmitted infections, promotion of safer sex practices and provision and correct use of male and female condoms. "The recommendations represent a significant step forward in HIV prevention," Kevin De Cock, Director of WHO's HIV/AIDS Department, said. "Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men. "Scaling up male circumcision in such countries will result in immediate benefit to individuals. However, it will be a number of years before we can expect to see an impact on the epidemic from such investment," he added.


Three randomized controlled trials in Kenya, Uganda and South Africa provide strong evidence that male circumcision cuts the risk of heterosexually acquired HIV infection in men by about 60 per cent, supporting numerous observational studies showing that the correlation between lower HIV prevalence and high rates of male circumcision in some countries in Africa is, at least in part, a causal association.


Currently 665 million men, or 30 per cent of men worldwide, are estimated to be circumcised. But counselling of men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behaviours that could undermine the partial protection provided by circumcision, WHO stressed. "Being able to recommend an additional HIV prevention method is a significant step towards getting ahead of this epidemic," Catherine Hankins, Associate Director of UNAIDS Department of Policy, Evidence and Partnerships, said. "However, we must be clear: male circumcision does not provide complete protection against HIV. "Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners," she added.


The risks involved in male circumcision are generally low, but can be serious if it is undertaken in unhygienic settings by poorly trained providers or with inadequate instruments. Wherever the service is offered, training and certification of providers as well as careful evaluation of programmes will be needed. A significant public health impact is likely to occur most rapidly if male circumcision is first provided where the incidence of heterosexually acquired HIV is high, and countries with generalized heterosexual HIV epidemics but low male circumcision rates should consider urgently scaling up access to the procedure. In view of the large potential public health benefit, countries should also consider providing the services free of charge or at the lowest possible cost to the client. The experts' meeting, held 6-8 March in Montreux, Switzerland, was attended by a wide range of stakeholders, including governments, civil society, researchers, human rights and women's health advocates, young people, funding agencies and implementing partners.