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The World Health Organization and UNAIDS have published the results of a recent expert symposium on circumcision and AIDS, which insists that “male circumcision now be recognised as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men”—although with certain caveats on the need to ensure the procedures are done safely and appropriately.
The international consultation, held 6-8 March, in Montreux, Switzerland, was attended by participants representing a wide range of stakeholders; including governments; civil society; researchers; funding agencies; implementing partners; and advocates for human rights, women's health, and young people.
The symposium concluded, “There is now strong evidence from three randomised controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda (funded by the US National Institutes of Health) and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.”
It maintains that the evidence examined “supports the findings of numerous observational studies that have also suggested that the geographical correlation long described between lower HIV prevalence and high rates of male circumcision in some countries in Africa, and more recently elsewhere, is, at least in part, a causal association.”
The latest WHO figures estimate that 665 million men—30% of men worldwide—are currently circumcised.
“The recommendations represent a significant step forward in HIV prevention,” said Kevin De Cock, WHO's director of HIV/AIDS. “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.”
The consultation cautioned, “Male circumcision should always be considered as part of a comprehensive HIV prevention package, which includes the provision of HIV testing and counselling services; treatment for sexually transmitted infections; the promotion of safer sex practices; and the provision of male and female condoms and promotion of their correct and consistent use.”
Counselling 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 male circumcision.”
Kim Dickson, head of prevention in WHO's department of HIV/AIDS, told the BMJ, “African health infrastructures are weak, but surgical procedures are routinely carried out within the region. We need to ensure that adequate training, certification, and supervision measures are in place to support roll-out. With these in place it is possible to offer safe services. There are many countries in Africa where circumcision is already available in public health facilities.”
Dr Dickson stressed that “support needs to be provided to governments to provide safe services.” He also pointed out, “Public health messages need to be contextualised within communities and countries and constantly reinforced. Getting the message across is not a once-off exercise, it is an ongoing effort.”