HIV This Week

Weiss HA, Halperin D, Bailey RC, Hayes RJ, Schmid G, Hankins CA. Male circumcision for HIV prevention: from evidence to action? AIDS. 2008 Mar 12; 22( 5): 567-74.

The conclusive results of three randomized controlled trials (RCT) showing that male circumcision reduces the risk of HIV acquisition by 58% (95% CI 43–69%) are both promising and challenging. To guide the translation of these research findings into public health policy, Weiss and colleagues estimate the global prevalence and distribution of male circumcision, summarize the evidence of an impact on HIV incidence, and highlight the major public health opportunities and challenges raised by these findings. The authors estimate that 30–34% of adult men are circumcised worldwide. Overall, an estimated 68% of circumcised men are Muslim and 1% are Jewish, with coverage almost universal in the Middle East, north Africa, Pakistan, Bangladesh, and Indonesia. The results of the RCTs confirmed the findings of a previous meta-analysis of 15 observational studies that circumcised men had a large, highly statistically significant reduced risk of HIV acquisition (risk reduction 58%, 95% CI 46–66%). Further, the high density of HIV target cells that are relatively accessible to HIV infection in the inner foreskin provides a plausible biological mechanism that could explain the increased risk of HIV in uncircumcised men. Several countries are planning to introduce or expand safe male circumcision programmes, including Kenya, Zambia, Swaziland and Rwanda, and international funding agencies are backing this strategy. National policies, however, are needed to maximize the safety, efficiency, and availability of male circumcision service provision. Challenges include potential behaviour change following male circumcision (risk compensation), predicting the potential population-level epidemic impact and cost-effectiveness of male circumcision, knowing the impact on female partners, and knowing the impact for men who have sex with men. In summary, male circumcision provides a much needed addition to the current HIV prevention armamentarium. It is not a new, untested or unknown technology, but possibly the oldest, and certainly the most common, surgical procedure known. The evidence from the trials is conclusive, and the challenges to implementation must now be faced.

Editors’ note:This editorial review constitutes an overview of why male circumcision is currently on the policy agenda of a number of countries, particularly those in southern and eastern Africa with a high HIV prevalence overall or among sub-populations. The WHO/UNAIDS position on male circumcision for HIV prevention may be found at http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf.