Male circumcision should never pre-empt other HIV prevention measures, UN warns

United Nations health agencies have given a guarded welcome to United States trials in Africa showing that male circumcision halves the risk of HIV infection in men in heterosexual relations, warning that it should never pre-empt other preventive measures such as the use of condoms.

Proper guidelines “will be necessary to prevent people from developing a false sense of security and, as a result, engaging in high-risk behaviours which could negate the protective effect of male circumcision,” they said in a joint statement.

They plan to quickly draw up guidelines after examining the implications, particularly in sub-Saharan Africa and elsewhere with high HIV prevalence and low male circumcision levels, taking into account cultural and human rights aspects and the need to ensure that circumcisions are performed safely by well-trained practitioners in sanitary settings.

“Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection,” they said. “Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners.

“Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling,” they added.

The statement was issued by the UN World Health Organization (WHO), UN Population Fund (UNFPA), UN Children’s Fund (UNICEF), the Joint UN Programme on HIV/AIDS (UNAIDS) and World Bank.

Noting that the trials’ results will likely heighten interest in male circumcision from governments, non-governmental institutions and the general public, the agencies said they would define specific policy recommendations for promoting male circumcision after a detailed review of the findings.

The recommendations will take into account cultural and human rights considerations; the risk of complications from the procedure performed in various settings; the potential to undermine existing protective behaviours and strategies; and the fact that the ideal and well-resourced conditions of a randomized trial are often not replicated in other settings.

To support countries or institutions that decide to scale up male circumcision, the agencies are developing technical guidelines on ethical, rights-based, clinical and programmatic approaches.

They are also drawing up ‘rapid assessment toolkits’ for determining circumcision prevalence and acceptability; identifying key providers; estimating costs; and monitoring numbers of circumcisions performed, their safety, and their potential impact on sexual behaviour.