WHO, UNAIDS Recommend Male Circumcision To Help Reduce Spread of HIV/AIDS
The World Health Organization and UNAIDS on Wednesday recommended that male circumcision be made available in countries highly affected by HIV/AIDS to help reduce transmission of the virus through heterosexual sex, the Washington Post reports. According to the Post, the recommendations were released in response to growing evidence that routine male circumcision could reduce a man's risk of contracting HIV (Timberg, Washington Post, 3/29). According to final data from two NIH-funded studies conducted in Uganda and Kenya published in the Feb. 23 issue of the journal Lancet, routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65% (Kaiser Daily HIV/AIDS Report, 3/7). The agencies on Wednesday recommended that circumcision be offered in addition to other prevention programs, including HIV testing and counseling, treatment for other sexually transmitted infections, promotion of safer-sex practices and condom distribution. The agencies said that the procedure only should be performed by trained, certified providers in "sanitary settings with adequate equipment and with appropriate counseling and other services." In addition, male circumcision should be offered at no cost or at the lowest possible price, the agencies said (UNAIDS/WHO release, 3/28). Officials also said that men who have sex before the circumcision wounds have healed, which generally takes several weeks, might increase the risk of contracting HIV or transmitting the virus to their partner (Washington Post, 3/29). Preliminary results from a study being conducted in Uganda and presented earlier this month to UNAIDS and WHO officials found that HIV-positive men undergoing circumcision might be more likely to transmit the virus to their female partners if they have sex before the circumcision wounds have healed (Kaiser Daily HIV/AIDS Report, 3/7).
Cost, Donor Funding
UNAIDS did not set a goal for the number of circumcisions that should be performed in the next several years, and the agency did not estimate costs associated with male circumcision programs, the San Francisco Chronicle reports. Officials said that countries will need to determine "whether and how" to implement the recommendations, while larger donor organizations -- including the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. government -- are prepared to fund them, the Chronicle reports (Russell, San Francisco Chronicle, 3/29). Several donor organizations -- including the Global Fund and the President's Emergency Plan for AIDS Relief -- "have already indicated" that they are willing to cover the cost of male circumcisions if countries ask for money and can show that the procedures will be performed safely and with appropriate counseling, the New York Times reports (McNeil, New York Times, 3/29). Advocates say expanding circumcision programs "would be logistically daunting but possible and affordable" because they would reduce the need for some future treatments, the Post reports. The cost of performing male circumcision -- including training, personnel, facilities and supplies -- is about $50 to $100 per procedure. Ambassador Mark Dybul, who serves as the U.S. global AIDS coordinator and administers PEPFAR, said that the U.S. would "support safe male circumcision services ... as a part of an expanded approach to reduce HIV infections."
Implementation, Next Steps
According to the Post, focus on the implementation of male circumcision programs has been centered on sub-Saharan Africa, where public health infrastructures largely are underdeveloped. Health officials in Africa generally have said that they are waiting for guidance from WHO before expanding access to male circumcision (Washington Post, 3/29). According to WHO, implementing circumcision programs in sub-Saharan Africa could prevent about 5.7 million new HIV cases and three million deaths during the next two decades. "If you combine this with other modalities -- condom usage, responsible behavior, knowing the HIV status of your partner -- this is a big addition to that armamentarium," Anthony Fauci, director of NIH's National Institute of Allergy and Infectious Diseases, said. According to the Los Angeles Times, WHO is encouraging countries to provide access to no-cost male circumcision and initially to target adults (Chong, Los Angeles Times, 3/29). Countries in Southern and East Africa, where HIV rates are high and circumcision rates are low, should consider adopting male circumcision as "an important and urgent" health priority, with the target group being boys and men ages 13 to 30, Kevin De Cock, director of WHO's HIV/AIDS Department, said (San Francisco Chronicle, 3/29). In addition, the agencies said it is critical for men to know that even if they are circumcised, they can still contract HIV and transmit it to their partners. Therefore, circumcised men should continue to practice abstinence, have fewer sex partners and use condoms, the agencies said (New York Times, 3/29). UNAIDS and WHO experts said additional research is required to assess the impact of male circumcision on sexual HIV transmission from men to women; the risks and benefits of the procedure for HIV-positive men; the protective benefit of the procedure for men who have sex with men; and the resources needed and the most effective means to expand such services. In addition, they said that research to determine whether "there are modifications in perceptions and HIV risk behavior over the longer term" in men who are circumcised and in their communities "will also be essential" (UNAIDS/WHO release, 3/28).
The recommendations are available online.
NPR's "All Things Considered" on Wednesday reported on the recommendations. The segment includes comments from De Cock and Ron Gray, a professor of reproductive epidemiology at the Johns Hopkins Bloomberg School of Public Health (Wilson, "All Things Considered," NPR, 3/28). Audio of the segment is available online.