Published Articles: Male circumcision and HIV/STI Prevention
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Biological plausibility
Impact on HIV transmission
Acceptability
Programming and technical guidance tools
Reports on consultations on male circumcision and HIV prevention
Advocacy and communication
Cost effectiveness and costing studies
Countries
Useful websites
Archived articles
Biological plausibility
Biological plausibility
Donoval B, Landay AL, Moses S, et al. American Journal of Clinical Pathology, 2006;125:386-391
HIV-1 target cells in foreskins of African men with varying histories of sexually transmitted infections
A seminal study that examines the biologic mechanisms of the foreskin tissue that increases the susceptibility of uncircumcised Kenyan men to HIV-1. Foreskin specimens from 20 men with and 19 men with no history of sexually transmitted infections were examined for HIV-1 target cells. The study concluded HIV-1 targets cells in the foreskin tissue of men as the inner mucosal surface of the human foreskin contains cells that makes it highly susceptible to HIV infection.
Impact on HIV transmission
Impact on HIV transmission
Christine L. Mattson, Richard T. Campbell, Robert C. Bailey, Kawango Agot, J. O. Ndinya-Achola, Stephen Moses. PLoS ONE 3(6), June 2008
Risk compensation is not associated with male circumcision in Kisumu, Kenya. A multi-faceted assessment of men enrolled in a randomised controlled trial
Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants.
Weiss H , Halperin D, Bailey R, et al. AIDS 2008; 22:567-574
Male circumcision for HIV prevention: From evidence to action
In the context of the urgent need for intensified and expanded HIV prevention efforts, the conclusive results of three randomized controlled trials (RCT) showing that male circumcision reduces the risk of HIV acquisition by approximately 60% [2–4] are both promising and challenging. Translation of these research findings into public health policy is complex and will be context specific. To guide this translation, this review estimates the global prevalence and distribution of male circumcision, summarizes the evidence of an impact on HIV incidence, and highlights the major public health opportunities and challenges raised by these findings.
Gray R, Kigozi G, Serwadda D, et al. Lancet 2007, 369 (9562): 657-66
Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomised trial
This article presents the results of the third randomised controlled trial to investigate the effect of male circumcision on HIV incidence in men. 4996 consenting uncircumcised, HIV negative men aged 15-49 years were randomised to receive immediate circumcision or circumcision delayed for 24 months. The analysis shows that male circumcision provides risk reduction of 55-60% against infection. There was no sign of behavioural disinhibition and it is concluded that circumcision can be recommended for HIV prevention in men.
Nagelkerke N, Moses S, de Vlas J, et al. BMC Infectious Diseases, 2007, 7:16
Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa
Two mathematical models are examined to explore this issue: a random mixing model and a compartmental model that distinguishes risk groups associated with sex work. In the compartmental model, two scenarios were developed, one calculating HIV transmission and prevalence in a context similar to the country of Botswana, and one similar to Nyanza Province, in western Kenya.
Williams B, Lloyd-Smith J, Gouws E, et al. PLoS Medicine, 2006; 3(7): e262.
The potential impact of male circumcision on HIV in Sub-Saharan Africa
This publication explores the implications of the 60 per cent protective effect of female-male transmission of HIV-1 observed in the one completed randomized controlled trial, as a public health intervention to control HIV in sub-Saharan Africa. The authors estimate the impact of increasing male circumcision coverage on HIV incidence, HIV prevalence, and HIV-related deaths over the next 10, 20, and 30 years in sub-Saharan Africa. Male circumcision could avert 2.0 (1.1-3.8) million new HIV infections and 0.3 (0.1-0.5) million deaths over the next ten years in sub-Saharan Africa. While the protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years.
Weiss H A, Quigley M, Hayes R. AIDS, 2000; 14:2361-2370
Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis.
A systematic review and meta-analysis of 27 epidemiological studies in sub-Saharan Africa which demonstrated that circumcised men have less than half the risk of acquiring HIV as compared to uncircumcised men (adjusted RR=/0.42, 95% CI: 0.34-/0.54)
Halperin D, Bailey R. Lancet, 1999; 354: 1813-15
Male circumcision and HIV infection: 10 years and counting
The authors argue that there is compelling epidemiological and biological evidence of lower HIV infection rates among circumcised men than uncircumcised men and the need for male circumcision to be considered as part of HIV prevention interventions.
Acceptability
Acceptability
Westercamp N, Bailey R. AIDS and Behavior, 2006; 11 (3): 341-355
Acceptability of male circumcision for prevention strategy of HIV/AIDS in Sub-Saharan Africa: A review.
A review of 13 studies (in nine countries) of the acceptability of MC in sub-Saharan Africa that assesses factors that will influence the uptake of circumcision in traditionally non-circumcising populations. The authors conclude that because the level of acceptability across the nine countries was quite consistent at high levels, additional acceptability studies that pose hypothetical questions to participants are unnecessary. They recommend that pilot interventions be undertaken focusing on making safe male circumcision services available in conjunction with existing HIV prevention strategies and evaluating the safety and acceptability of circumcision.
Scott B, Weiss H, Viljoen J. AIDS Care, 2005; 17(3): 304_/313
The acceptability of male circumcision as an HIV intervention among a rural Zulu population, KwaZulu-Natal, South Africa.
This study explores the acceptability of male circumcision among the rural Zulu around Hlabisa and Mtubatuba, KwaZulu-Natal, South Africa. A cross-sectional convenience sample of 100 men and 44 women was surveyed, and two male focus groups held, to ascertain circumcision preferences within the population. Four in-depth interviews with service providers assessed the feasibility of promoting male circumcision. Fifty-one per cent of uncircumcised men and 68% of women favoured male circumcision of themselves or their partners; while 50% of men and 73% of women would circumcise their sons. For men, the main predictors of circumcision preference pertained to beliefs surrounding sexual pain and pleasure; for women, knowledge about the relationship between male circumcision status and STI acquisition was the key indicator for circumcision preference. The greatest logistical barrier was that circumcision can presently only be carried out by trained hospital doctors.
Halprin D, Fritz K, McFarland W, et al. Sexually Transmitted Diseases, 2005; 4 (32): 238-239
Acceptability of adult male circumcision for sexually transmitted diseases and HIV prevention in Zimbabwe
This paper looks at the acceptability of adult male circumcision in Zimbabwe. It finds that the acceptability level of circumcision in this Harare survey was somewhat lower than in studies from other African countries, where the proportion of men reporting they would like to be circumcised ranged from approximately 60% in Kenya, Uganda, South Africa, and Tanzania to over 80% (after a brief informational session) in Botswana. In considering the feasibility of adult male circumcision as a public health intervention data nonetheless suggests a substantial degree of preexisting knowledge among these Zimbabwean men of various STI prevention and other benefits of circumcision, although only a few directly associated it with HIV/AIDS. Despite the absence of specific educational or promotional efforts, and before knowing the results of current clinical trials of circumcision’s efficacy in preventing HIV, nearly half of the men expressed willingness to undergo the procedure.
Programming and technical guidance tools
Programming and technical guidance tools
WHO
Considerations for implementing Models for optimizing the volume and efficiency of male circumcision services for HIV prevention. February 2010
This document provides guidance to help programmes improve the efficiency of clinical and surgical activities so that they can strengthen their capacity to meet demand for male circumcision services. It addresses clinical techniques, staffing, facility space, client scheduling and flow, commodities management, cost efficiencies, and quality assurance. The options presented are appropriate for a variety of settings, including public facilities, private facilities, outreach locations, and mobile services.
The indicators described in this guide are based on the Male Circumcision Action Framework and provide a mechanism for important feedback for the management of male circumcision programmes.
This guide presents indicators for the creation of demand for and supply of male circumcision services as well as for the maximization of safer sex behaviour.
WHO, UNAIDS
Male Circumcision services package, January 2009
1. Quality assessment toolkit
This toolkit has been developed to assist facility managers and staff to assess the quality of their services. The toolkit can be used by programme and facility managers to guide the set-up of services and to improve current services. It helps to measure progress towards meeting standards and can be used by external assessors to certify or accredit facilities.
2. Quality assurance guide
This guide has been developed to assist national and district programme and health facility managers and providers to establish and implement male circumcision services that meet an internationally agreed level of safety and quality. The guide is complemented by the Male Circumcision Services Quality Assessment Tool Kit, a practical set of tools for assisting facility managers and providers to assess their own performance and the quality of care provided and to define gaps that exist in the provision of male circumcision services. The tools also can be used by national and district managers to conduct external assessments of facilities.
UNAIDS
Technical guidance for Global Fund HIV proposals. February 2009
WHO, UNAIDS
Operational guidance for scaling up male circumcision service for HIV prevention. August 2008
Outlines the policy and programmatic considerations for countries intending to scale up Male circumcision. Provides guidance on what is needed to scale up Male circumcision programmes. Makes reference to other WHO/UNAIDS supporting tools.
This document offers guidance to programme managers and policymakers on how to plan and manage communications to support the scale-up of male circumcision in Eastern and Southern Africa.
When reviewing national HIV prevention policies and programmes in light of the evidence, governments and health-service providers will need to consider the important human rights, legal and ethical issues that arise in the context of male circumcision. These are elaborated in this paper, to assist those involved in introducing or expanding male circumcision services for HIV risk reduction. The paper is divided into two sections:
(i) guidance for decision-makers and programme planners on the huma rights, legal and ethical duties of the State;
(ii) guidance for health-service providers on their ethical and legal duties when offering or conducting male circumcision.
WHO
Country case studies. 2008
Outlines the policy, laws, guidelines, practices (traditional or religious) relating to male circumcision in the Eastern Cape Province, South Africa, Swaziland and Kenya. Including outlining; the main providers of services, reasons for circumcision, other practices/services associated with male circumcision, the costs, associated complications. Describe public and private service availability and access.
Kenya
Swaziland
South Africa
WHO, UNAIDS, JHPIEGO
Manual for male circumcision under local anesthesia. January 2008
This manual offers technical guidance on the provision of safe male circumcision services in resource-limited settings. It provides guidance to providers of male circumcision and programme managers and also addresses broader sexual and reproductive health issues of men. It emphasizes that male circumcision must be provided within the context of other strategies that reduce risk of HIV infection.
Sawires S, Dworkin S, Fiamma A, et al. Lancet, 2007, 369:708-13
Male circumcision and HIV/AIDS: challenges and opportunities
This review outlines 13 contextual issues- challenges and opportunities- that need to be considered before making a decision to implement male circumcision as an HIV prevention strategy. These include questions of personal autonomy, bodily integrity, and human rights; of social and cultural dynamics in specific contexts; and of health system capacity to deliver integrated HIV/AIDS prevention and treatment interventions to the majority of the population.
WHO
Male circumcision information package. March 2007 1 | 2 | 3 | 4 | 5 | all
The package contains a series of introductory information notes on male circumcision in the context of HIV prevention, and gives references to other resources that offer more detailed information on the subject. The contents will be periodically updated when policy recommendations are issued, or as new evidence is published and additional experience with provision of male circumcision services is documented.
WHO, UNAIDS
Male circumcision and HIV prevention: policy and programme implications. March 2007
The report details the conclusions and recommendations of a WHO/UNAIDS Technical Consultation held in Montreux Switzerland, March 6-8, 2007 which on reviewing all available evidence including the Uganda and Kenya trials, recommended that countries include male circumcision as part of a comprehensive HIV Prevention package.
WHO, UNAIDS
Male circumcision: Situation analysis toolkit summary, November 2007
The toolkit provides a framework and tools that a country can use to undertake a qualitative and quantitative situational analysis to inform decision making on programming for male circumcision. The toolkit is available electronically on CD-ROM, web format and in print.
Reports on consulatations on male circumcision and HIV prevention
Reports on consulatations on male circumcision and HIV prevention
Country experiences in the scale-up of male circumcision in the Eastern and Southern Africa Region: Two years and counting. A sub-regional consultation. Windhoek, Namibia, June 9-10 2009
Two years since the initial United Nations recommendations a sub-regional consultation was held in Windhoek, Namibia from 9 to 10 June 2009 with the overall objective of reporting progress, sharing experiences, exchanging ideas and to forge collaborations in the male circumcision efforts.
UNAIDS,CAPRISA
Social science perspectives on male circumcision for HIV prevention. January 2007
The report of a meeting convened by UNAIDS and CAPRISA at the University of Kwa Zulu-Natal in January 2007, to explore the socio-cultural aspects related to the proposal to scale up male circumcision services in high prevalence settings. It underscores the need for multi-disciplinary research to understand local contexts and meanings of male circumcision.
Country consultations on male circumcision and HIV prevention. September 2006
Reports of consultation meetings held between July and September 2006 in five countries, Lesotho, Kenya, Swaziland, Tanzania and Zambia, to discuss the evidence on the HIV protective effect of male circumcision and the implications for the development of HIV prevention programmes and male sexual and reproductive health services. The meetings were attended by stakeholders from government, private, traditional, donor, NGO sectors and the UN.
Regional consultation on male circumcision and HIV in Sub Saharan Africa. September 2006
Report of a regional meeting held in Nairobi, September 2006, to examine the knowledge and epidemiological evidence on the linkages between safe male circumcision and HIV; review the issues raised in the five country consultations and identify support needed by countries to develop policies and programmes on safe male circumcision in the case where the randomised controlled trials reconfirmed the protective effect of male circumcision. The meeting was attended by the five consulting countries and a range of regional and international stakeholders, including the UN, NGOs; and research and academic institutions and donor agencies and foundations.
Advocacy and communication
UNAIDS, WHO
Progress in male circumcision scale-up. Country implementation update. July 2009
Advocacy and communication
Thirteen southern and eastern African countries with high HIV prevalence, low levels of male circumcision and heterosexual epidemics have been included in this table. The information about each country was provided by countries, partners, and UN agencies, mostly from discussions at a sub-regional meeting that took place in Windhoek, Namibia on June 9-10 2009.
In their article "Male Circumcision is not the 'vaccine' we have been waiting for", Green et al. claim that the incorporation of male circumcision as an additional HIV prevention strategy is based on 'incomplete evidence, and is premature and ill-advised'. The authors attempt to refute a prior article with a similar title published in the same journal, which urged immediate action to implement safe male circumcision servics based on the scientific evidence for HIV prevention and otehr aspects of reproductive health. The authors respond to the various claims in the paper by Green et al., according to their main allegations.
UNICEF, UNAIDS, WHO
Male circumcision: Africa's unprecedented opportunity. March 2007
There is strong consensus and excitement in the scientific community about the potential of the male circumcision. A high-leve WHO/UNAIDS Technical Consultation issued a powerful set of conclusions and recommendations on male circumcision in March 2007, with health experts and other stakeholders calling for prioritising male circumciison in high HIV prevalence countries - where most infections occur due to heterosexual transmission and where relatively few men are circumcised.
UNAIDS Secretariat, UNICEF, UNFPA, WHO, World Bank
Internal UN briefing note on male circumcision and HIV prevention. June 2006
Outlines the UN policy position; the policy implications of the evidence; the UN work plan activities which include development of tools, modelling of the impact of MC on HIV, and consultation meetings of stakeholders at country and regional level.
UNAIDS, WHO, UNFPA, UNICEF, World Bank
Statement on Kenyan and Ugandan trial findings regarding male circumcision and HIV of December 2006.
Press Statement released by WHO, UNFPA, UNICEF, the World Bank, the UNAIDS Secretariat after the announcement by the US National Institute of Health that the two trials had been stopped, stating that male circumcision reduces the risk of becoming infected with HIV, but does not provide complete protection.
http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html
UNAIDS Secretariat, UNICEF, UNFPA, WHO, World Bank
Update to internal UN briefing note on male circumcision and HIV prevention of June 2006.
This update was made after the Data and Safety Monitoring Board (DSMB) of the two male circumcision trials in Kenya and Uganda analyzed the interim results on 27 and 28 June 2006 and recommended continuation of the trials. It emphasizes that the final results of the two ongoing trials will be important to clarify the relationship between male circumcision and HIV in a variety of social and cultural contexts.
ANRS, INSERM, NICD, U Versailles
Breaking news in the science of HIV/AIDS prevention: Adult male circumcision reduces risk of HIV infection (press release). July 2005
Press statement released by the Orange Farm Study investigators' team at the Third Conference of the International AIDS Society on the Pathogens and Treatment of HIV.
| Cost effectiveness and costing studies |
Olalekan A. Uthman, Taiwo Aderemi Popoola, Mubashir M. B. Uthman, Olatunde Aremu. PLoS ONE 5(3): e9628. doi: 10.1371/ journal. pone. 000962. March 2010
Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in Sub-Saharan Africa: a systematic review
There is conclusive evidence from observational data and three randomized controlled trials that circumcised men have a significantly lower risk of becoming infected with the human immunodeficiency virus (HIV). The aim of this study was to systematically review economic evaluations on adult male circumcision (AMC) for prevention of heterosexual acquisition of HIV in men.
Agnes Binagwaho, Elisabetta Pegurri, Jane Muita, Stefano Bertozzi. PLoS Med 7(1): e1000211. doi:10.1371/journal. pmed.1000211. January 2010
Male circumcision at different ages in Rwanda: A cost-effectiveness study
There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice.
The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence.
USAID
The potential cost and impact of expanding male circumcision in 14 African countries. December 2009
Scaling up male circumcision programmes in 14 selected countries in Eastern and Southern Africa could prevent more than 4 million adult HIV infections during 2009 to 2025, result in cumulative net savings of US$20.2 billion over the same time period, and require almost 12 million male circumcisions to be performed in the peak year (2012). Between 2015 and 2025, the number of male circumcisions required drops to between 4 and 5 million annually and eventually declines further and stabilizes at about 3 million newborn circumcisions annually.
WHO, UNAIDS
Progress in male circumcision scale-up: country implementation update. December 2009
This report provides an overview of progress in malecircumcision programme scale-up in all the thirteen priority countries according to the key elements. Information for each country has been contributed by country programme managers, UN Agency focal persons withincountries, technical supportagencies and other key stakeholders through regular progress reports, collaborative consultations, meetings and discussions.
Kahn J, Marseille E, Auvert B. PLos Medicine, 2006 ; 3 (12): e517
Cost-effectiveness of male circumcision for HIV prevention in a South African setting. December 2006
This paper presents the results of the first randomized, controlled intervention trial to test the hypothesis that male circumcision may provide protection against HIV-1 infection. A total of 3,274 uncircumcised men in South Africa, aged 18–24 years, were randomized to a control or an intervention group with follow-up visits at 3, 12, and 21 months for HIV testing, physical examination and interviews. The trial was stopped early as an analysis demonstrated that male circumcision provides 60-75 per cent protection against acquiring HIV infection.
| Countries |
Botswana
Safe male circumcision. Additional strategy for HIV prevention. A national strategy
Tanzania
Male circumcision situation analysis
Zambia
Male circumcision strategy and implementation plan 2010-2020
Kenya
Nyanza Update: Quarterly provincial newsletter on the Voluntary Medical Male Circumcision Programme
| Useful Websites |
This website is a clearinghouse for sharing of authoritative information about the role of male circumcision in HIV prevention. The information has been reviewed by technical experts from around the world and provides evidence-based guidance to support the delivery of safe male-circumcision services as one component in a comprehensive approach to HIV prevention services.
| Archived articles [click to enter] |