Voluntary medical male circumcision for HIV prevention
- Medical male circumcision reduces the risk of female-to-male sexual transmission of HIV by approximately 60%.
- Since 2007, WHO and UNAIDS have recommended voluntary medical male circumcision as an additional important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision, where the public health benefits will be maximized. Fourteen countries in eastern and southern Africa with this profile have initiated programmes to expand male circumcision.
- Medical male circumcision offers excellent value for money in such settings. It saves costs by averting new HIV infections and reducing the number of people needing HIV treatment and care.
- A one-time intervention, medical male circumcision provides men life-long partial protection against HIV as well as other sexually transmitted infections. It should always be considered as part of a comprehensive HIV prevention package of services and be used in conjunction with other methods of prevention, such as female and male condoms.
Male circumcision is surgical removal of the foreskin - the retractable fold of tissue that covers the head of the penis. The inner aspect of the foreskin is highly susceptible to HIV infections. Trained health professionals can safely remove the foreskin of infants, adolescents and adults (medical male circumcision).
Compelling evidence for recommendations
In 2007, WHO and UNAIDS issued recommendations on medical male circumcision as an additional HIV prevention strategy based on strong and consistent scientific evidence. Three randomized controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda, and Orange Farm, South Africa have shown that medical male circumcision reduces the risk of sexual transmission of HIV from women to men by approximately 60%.
The most recent data from Uganda show that in the five years since the Uganda trial was completed, high effectiveness has been maintained among the men who were circumcised, with a 73% protective effect against HIV infection.
Maximizing public health benefit
WHO and UNAIDS recommended the intervention be added in countries with high HIV prevalence, generalized heterosexual HIV epidemics, and low levels of male circumcision where the intervention is likely to have the greatest public health impact. Fourteen priority countries with this profile are striving to scale up voluntary medical male circumcision: Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.
Medical male circumcision for HIV prevention offers excellent value for money. Recent modelling studies found that reaching 80% coverage among men 15 - 49 years old in the priority countries – by performing approximately 20 million circumcisions - would cost US$1.5 billion and would result in net savings of US$16.5 billion by 2025 due to averted treatment and care costs. Achieving, and maintaining, 80% coverage through 2025 would avert 3.4 million new HIV infections.
A comprehensive prevention package of services
Male circumcision is a proven intervention that offers partial protection against sexually acquired HIV in men. WHO and UNAIDS recommend that it should always be considered as part of a comprehensive HIV prevention package which includes:
- HIV testing and counselling;
- Correct and consistent use of female or male condoms;
- Treatment for sexually transmitted infections; and
- Promotion of safer sexual practices, such as avoidance of penetrative sex.
Provision of antiretroviral treatment for people living with HIV who are eligible for treatment should also be considered as part of a combination prevention package to reduce HIV transmission in couples where one partner has HIV.
In line with global goals such as Millennium Development Goal 6 to halt and reverse the spread of HIV and the WHO Global Health Sector Strategy on HIV/AIDS, a five-year Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa 2012-2016 was developed by WHO and UNAIDS with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank and in consultation with national ministries of health. The framework calls for an intensified response by countries and partners to ‘catch up’ with men 15 to 49 years old who were not previously circumcised and to establish sustainable services for infants and adolescents for the longer term. The framework promotes country ownership, a combination of approaches and strategic, coordinated action.
By the end of 2011, more than 1.3 million voluntary medical male circumcisions had been performed for HIV prevention, with nearly a doubling of the number from 2010 to 2011. Despite the recent increased pace, focused efforts are needed to achieve the number of medical male circumcisions for maximum public health impact on HIV and AIDS. Key challenges include strengthening advocacy at all levels, exploring innovative approaches to service delivery including the use of medical devices for adult circumcision, improving supply chain logistics and use of limited human resources, and creating demand for services.