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Published online: 28 March 2007; | doi:10.1038/news070326-10
UN advice: circumcise to prevent HIVInternational health agencies sing praises of surgical procedure.John Whitfield 
| Should health clinics in Africa advise circumcision? WHO/Rapelang Radebe |
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The
United Nations (UN) has recommended circumcision as a means of reducing
the risk of HIV infection in heterosexual men. The announcement should
pave the way for African governments to incorporate the practice into
their AIDS-prevention strategies.
"The
evidence is now really quite conclusive that male circumcision is
effective in preventing HIV infection in heterosexually exposed males,"
says Kevin De Cock, director of the World Health Organization's (WHO)
department of HIV/AIDS. "The effectiveness is approaching 60%."
The
practice could be particularly effective in southern and eastern
Africa, where HIV is common, circumcision rates are low and
transmission is mainly heterosexual, he adds.
"This
is an exciting development," says Catherine Hankins, chief scientific
adviser at UNAIDS. "We haven't had news like this for an extremely long
time." If governments can devise action plans, international agencies
are willing to provide funding and technical support, she says.
But,
she adds, circumcision must be added to the package of HIV-prevention
measures, such as sex education and condoms, rather than be seen as a
replacement.
"Individual
countries have to take these recommendations and consider them," says
Kim Dickson, a medical officer working on HIV prevention at the WHO.
"Countries will engage in their own consultations to make decisions on
how they roll this out, and whether this is relevant to them." They
will need to address questions about how to target such programmes,
provide training and equipment, ensure proper hygiene, and consider
issues of consent and public attitudes to the practice.
Kindest cut
Researchers
have been studying the effects of circumcision on disease transmission
for some 20 years. By 2006 the evidence of its usefulness against HIV
seemed overwhelming (see 'Time for the chop').
In the wake of this, the WHO and UNAIDS convened a meeting of about 70
researchers, policy-makers, and representatives of funding agencies,
human rights groups and patient advocacy groups in Montreux,
Switzerland from 6-8 March to discuss potential recommendations.
"We
were really struck by the remarkable consistency of the data," says de
Cock. "It's very unusual." And with a cost of around US$50-100 per
person, he adds, circumcision appears to be as cost effective, if not
more so, than many other interventions
Still
uncertain is whether circumcising HIV-positive men reduces transmission
to their female partners, and whether circumcision reduces the
transmission risk from anal sex. Preliminary data from Uganda suggest
that men with an unhealed circumcision wound are more at risk of
transmitting the virus to their female partners.
Another
major uncertainty, says Hankins, is whether the young, sexually active
men most at risk of HIV will queue up for circumcision. The prevalence
of the practice, and attitudes towards it, vary widely between and
within countries.
But
they can also change rapidly. There are reports of African men seeking
circumcision after hearing about the successes of earlier trials. And
South Korea went from nearly no circumcision to more than 60% between
the mid-1980s and mid-1990s.
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