Information Package on Male Circumcision and HIV Prevention
Insert 1
Introduction
Male circumcision is the surgical removal of all or part of the foreskin of the penis. It is one of the
oldest and most common surgical procedures worldwide, undertaken for religious, cultural, social
or medical reasons. Male circumcision has now been assessed as a potential means to limit the
spread of HIV.
Data from a range of observational epidemiological studies, conducted since the mid-1980s, showed
that circumcised men have a lower prevalence of HIV infection than uncircumcised men. Three randomized controlled trials have been conducted which make it possible to separate a direct protective effect of male circumcision from behavioural or social factors that may be associated with both
circumcision status and risk of HIV infection. These trials have been conducted in Orange Farm,
South Africa ; Kisumu, Kenya ii and Rakai District, Uganda iii. The results of these trials showed that
following circumcision, the incidence of HIV infection was reduced in men by more than half.
This information package has been prepared for the use of policy makers and programme
managers who may be facing an increased demand for male circumcision services and who wish
to determine the place of male circumcision within a comprehensive HIV prevention programme.
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 provide 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.
Since male circumcision is now shown to be effective in reducing the risk of HIV infection for men,
care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection. Male circumcision must be considered as just one
element of a comprehensive HIV prevention package that includes the correct and consistent use
of condoms, reductions in the number of sexual partners, delaying the onset of sexual relations,
avoidance of penetrative sex, and testing and counselling to know one’s HIV serostatus.
Action is required to improve the safety of male circumcision practices in many countries and to
ensure that health care providers and the public have up-to-date information on the health benefits and risks of male circumcision. Male circumcision is a voluntary surgical procedure and health
care providers must ensure that men and young boys are given all the necessary information to
enable them to make free and informed choices either for or against getting circumcised.
This information package is the result of collaborative work between members of the Interagency
Task Team (IATT) on Male Circumcision which is composed of the United Nations Children’s Fund
(UNICEF) the United Nations Population Fund (UNFPA), the World Health Organization (WHO),
the World Bank and the Joint United Nations Programme on HIV/AIDS (UNAIDS). It is a compilation of work undertaken by a large group of clinical and public health experts.
For further information on male circumcision go to:
http://www.who.int/hiv/topics/malecircumcision/en/index.html
http://www.who.int/reproductive-health/hiv/index.html
Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2(11):e298.
ii
Bailey C, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007;369: 643-56.
iii Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomized trial. Lancet 2007;369:657-66.
Information Package on Male Circumcision and HIV Prevention
Insert 2
The Global Prevalence of Male Circumcision
Global estimates in 2006 suggest that about 30% of males – representing a total of approximately
665 million men – are circumcised. Other common determinants of male circumcision are ethnicity, perceived health and sexual benefits, and the desire to conform to socio-cultural norms.
Male circumcision is common in many African countries and is almost universal in North Africa
and most of West Africa. In contrast it is less common in southern Africa; country to country and
within country variation is greatest in this region i. Self-reported prevalence in several countries is
around 15% (Botswana, Namibia, Swaziland, Zambia, Zimbabwe); but substantially higher in others (Malawi 21%, South Africa 35%, Lesotho 48%, Mozambique 60%, and Angola and Madagascar
more than 80%). Prevalence in central and eastern Africa varies from 15% in Burundi and Rwanda,
to over 70% in Ethiopia, Kenya and the United Republic of Tanzania. In sub-Saharan Africa age at
circumcision varies from infancy to the late teens or early twenties. Male circumcision in Africa is
undertaken for mainly religious and cultural reasons.
Male circumcision is almost universal in the Middle East and Central Asia and in Bangladesh,
Indonesia and Pakistan ii,iii. In addition there are an estimated 120 million circumcised men in
India iv. In all these countries, male circumcision is undertaken primarily for religious and cultural
reasons. There is little non-religious circumcision in Asia, with the exception of the Republic of
Korea and the Philippines where circumcision is routine and widespread v.
During the 20 th century, male circumcision gained popularity for perceived health benefits and
social reasons in North America, New Zealand and Europe vi,vii. Neonatal and childhood male circumcision rates in the United States of America rose to about 80% in the 1960s with prevalence
remaining high (between 76%-92%) todayviii. In contrast, Australia ix, Canada x, and the United
Kingdom xi have seen a decline in male circumcision. In Central and South America male circumcision is uncommon (less than 20%)xii,xiii.
Examination of the prevalence of male circumcision shows that the major determinant of circumcision globally is religion, but that significant numbers of males are circumcised for cultural reasons.
In sub-Saharan Africa tradition and cultural identity play as important a role as religion during
male circumcision practices. Historically, in various parts of the world there have been increases
and decreases in the popularity of non-religious male circumcision. These trends often result from
changes in perceptions of the health benefits or cultural beliefs associated with the practice, indicating that the cultural determinants of male circumcision can evolve.
Information Package on Male Circumcision and HIV Prevention
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Global Map of Male Circumcision Prevalence at Country Level
i
Measure DHS. Demographic and health surveys. http://www.measuredhs.com/ (accessed on 22 Jan 2007).
ii
Hull TH, Budiharsana M. Male circumcision and penis enhancement in Southeast Asia: matters of pain and pleasure. Reprod Health Matters 2001;9:60-67.
iii Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC. Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis
2006;6:172.
iv US Department of State. International Religious Freedom Report for 2004. http://www.state.gov/g/drl/rls/irf/2004/index.htm. (accessed 22 Jan 2007).
v
Pang MG, Kim DS. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 2002;89:48-54.
vi Hutchinson J. On the influence of circumcision in preventing syphilis. Med Times Gazette 1855; 32: 542-543.
vii Clifford M. Circumcision: it’s advantages and how to perform it. 1893, London: J. & A. Churchill.
viii Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol 2005;173:978-81.
ix Richters J, Smith AM, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;17: 547-54.
x
Wirth JL. Current circumcision practices: Canada. Pediatrics 1980;66:705-8.
xi Gairdner D. The fate of the foreskin, a study of circumcision. BMJ 1949;2:1433-37.
Dave SS, Fenton KA, Mercer CH, et al. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 2003;79:499-500.
xii Brinton LA, Reeves WC, Brenes MM, et al.The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989;44:99-203.
xiii Castellsague X, Peeling RW, Franceschi S, et al. Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men. Am J Epidemiol 2005;162:907-16.
Information Package on Male Circumcision and HIV Prevention
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Health Benefits and Associated Risks
Male circumcision involves the surgical removal of the foreskin, the tissue covering the head of the
penis. In adult men, a four to six week period is required to fully heal the wound. Healing is usually
complete after about one week when circumcision is performed for babies.
Research shows that removing the foreskin is associated with a variety of health benefits i,ii,iii:
• Studies have found lower rates of urinary tract infections in male infants who are circumcised iv.
• Circumcision prevents inflammation of the glans (balanitis) and the foreskin (posthitis).
• Men who are circumcised do not suffer health problems associated with the foreskin such as
phimosis (an inability to retract the foreskin) or paraphimosis (swelling of the retracted foreskin
causing inability to return it to its normal position).
• Circumcised men find it easier to maintain penile hygiene. Secretions can easily accumulate in the
space between the foreskin and glans making it necessary for an uncircumcised man to retract
and clean the foreskin regularly.
• Two studies now suggest that female partners of circumcised men have a lower risk of cancer of
the cervix, which is caused by persistent infection with high-risk oncogenic (cancer-inducing)
types of human papillomavirusv.
• Circumcision is associated with a lower risk of penile cancervi,vii.
• Circumcised men have a lower prevalence of some sexually transmitted infections, especially
ulcerative diseases like chancroid and syphilis viii,ix.
In numerous observational studies lower levels (prevalence) of HIV infection have been found in
circumcised men compared to uncircumcised men and three randomized controlled trials in South
Africa Kenya and Uganda have demonstrated a lower risk of acquiring HIV infection in circumcised men compared to those who remain uncircumcised x,xi,xii.
The likely biological explanation for the higher levels of sexually transmitted infections, including
HIV infection, seen in men who are not circumcised is that the inner mucosal surface of the foreskin is only thinly keratinized xiii and is therefore susceptible to minor trauma and abrasions which
facilitate entry of pathogens. The area under the foreskin is a warm, moist environment which may
enable pathogens to replicate, especially when penile hygiene is poorxiv. Circumcision does not
guarantee complete protection from any of the infections cited above and is medically indicated
as treatment for only a few conditions – most commonly for phimosis.
Male circumcision, as with any surgical procedure, carries a risk of post-operative infection. In
inexperienced hands, penile mutilation and even death can occur. The surgery can lead to excessive bleeding, haematoma (the formation of a blood clot under the skin), meatitis (inflammation of
the opening of the urethra), and increased sensitivity of the glans penis for the initial months after
the procedure. In addition, adverse reactions to the anaesthetic used during the circumcision may
occur.
The safety of male circumcision clearly depends on the setting and expertise of the provider. When
circumcision is performed in a clinical setting, under aseptic conditions, by well trained, adequately equipped health care personnel the level of risk is low. Among adults the operation is more
complex and the complication rates for clinical circumcision are between 2 and 4 per 100 procedures. Few of these complications are serious. Neonatal circumcision is a relatively simple, quick
procedure; fewer than 1 in 500 procedures results in complications and these are usually minor.
Information Package on Male Circumcision and HIV Prevention
Insert 3
Male circumcision for religious or traditional reasons frequently takes place in a non-clinical setting
although, in some cultures, an increasing proportion takes place in clinicsxv,xvi. Circumcisions
undertaken in unhygienic conditions by inexperienced providers with inadequate instruments, or
with poor after-care, can result in very serious complications, including death. For example, among
50 patients admitted to hospital with post-circumcision complications in Nigeria and Kenya
between 1981 and 1988, 80% had been circumcised by unqualified traditional surgeonsxvii.
Action is required to improve male circumcision practices in many regions and to ensure that
health care providers and the public have up-to-date information on the health risks as well as the
benefits of safe male circumcision. Many boys and men wishing to be circumcised do not have
access to safe circumcision services or to post-circumcision care if they suffer from complications. Health authorities need to monitor the practice and to ensure that health-care practitioners
are properly trained and licensed to perform the procedure safely.
Since male circumcision has now been shown to be effective in reducing the risk of HIV infection,
care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection. Male circumcision must be considered as just one
element of a comprehensive HIV prevention package that includes the correct and consistent use
of condoms, reductions in the number of sexual partners, delaying the onset of sexual relations,
avoidance of penetrative sex, and testing and counselling to know one’s HIV serostatus.
Male circumcision also raises human rights issues, as is generally the case with medical and
health procedures. In line with internationally accepted ethical and human rights principles, no
surgical intervention should be performed on anyone if it results in adverse outcomes in terms of
health or the integrity of the body, and where there is no expectation of health benefit. Nor should
any surgical intervention be performed on anyone without informed consent, or the consent of the
parents or guardians when a child is not capable of providing consent.
Detailed information on the procedures for male circumcision can be found in the forthcoming
Manual on Male Circumcision under Local Anaesthesia prepared jointly by WHO, UNAIDS, and
JHPIEGO (2007). The manual provides technical guidance on clinical and programmatic
approaches to male circumcision in an appropriate human rights framework. It also addresses
broader issues of sexual and reproductive health of men and emphasizes that male circumcision
must be set within the context of other strategies for reducing the risk of HIV infection.
i
Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect
2006;82:101-109.
ii
Singh-Grewal D, Macdessi J, Craig j. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch
Dis Child 2005;90:853-8.
iii
Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 1998;74:368-73.
iv
Wiswell TE, Hachey WE. Urinary tract infection s and the uncircumcised state. Clin Pediatr 1993;32:130-34.
v
Agarwal SS, Sehgal A, Sardana S, et al. Role of male behaviour in cervical carcinogenesis among women with one lifetime sexual partner. Cancer 1993;72:166-169.
vi
American Academy of Pediatrics. Report of the task force on circumcision. Pediatrics 1989; 84: 388-91.
vii
Dodge OG, Kaviti JN. Male circumcision among the peoples of East Africa and the incidence of genital cancer. East Afr Med J 1965;42:98-105.
viii Nasio JM, Nagelkerke NJ, Mwatha A, et al. Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV-1 and circumcision status. Int J STD AIDS 1996; 7:410-14.
ix
Cook LS, Koutsky LA, and Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84:197-201.
x
Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2(11):e298.
xi
Bailey C, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007;369: 643-56.
xii
Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomized trial. Lancet 2007;369:657-66.
xiii McCoombe SG, Short RV. Potential HIV-1 target cells in the human penis. AIDS 2006;20:1491-95.
xiv Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83(Suppl 1):34-44.
xv
Doyle D. Ritual male circumcision: a brief history. J R Coll Physicians Edinb 2005;35(3): 279-85.
xvi Bailey RC. Egesah O. Assessment of clinical and traditional male circumcision services in Bungoma District, Kenya: Complication rates and operational needs; April 2006.
http://www.aidsmark.org/resources/pdfs/mc.pdf (accessed 22 Jan 2007).
xvii Magoha GA. Circumcision in various Nigerian and Kenyan hospitals. East Afr Med J 1999;76:583-86.
Information Package on Male Circumcision and HIV Prevention
Insert 4
Male Circumcision as an HIV Prevention Method
Numerous observational studies indicate that circumcised men have lower levels of HIV infection
than uncircumcised men. Throughout the world, HIV prevalence is generally lower in populations
that traditionally practice male circumcision than in populations where most men are not circumcisedi. Until the three randomized controlled trials in South Africa ii, Kenya iii and Uganda iv were completed, it was unclear to what extent this was the result of a biological effect of male circumcision, or
the result of cultural or social factors that can accompany high rates of male circumcision.
A systematic review and meta-analysis of 28 published studies found that circumcised men are
two- to three-fold less likely to be infected by HIV than uncircumcised men, with differences most
pronounced in men highly exposed to HIV infection v.A sub-analysis of 10 African studies found a
3.4-fold lower incidence of HIV infection among men considered to be at high risk of becoming
infected.
The geographic regions in subSaharan Africa where men are more
commonly circumcised overlap with
25.8
Zimbabwe
Botswana
25.1
areas of lower HIV prevalence. Low
19.9
Namibia
Zambia
19.1
prevalence of male circumcision and
18.5
Swaziland
high prevalence of genital herpes,
Malawi
14.9
14.2
MC Prevalence <20%
Mozambique
which is more common in uncircumRwanda
12.8
11.6
Kenya
cised men, emerged as the principal
MC Prevalence >80%
Congo
7.6
determinant for the differences in HIV
4.9
Cameroon
Gabon
4.3
rates found in sub-Saharan Africa.
4.1
Nigeria
Liberia
3.7
The bar chart figure 1 shows that
3.2
Sierra Leone
countries in sub-Saharan Africa with
Ghana
2.4
2.1
Benin
relatively low rates of male circumciGuinea
2.1
sion (<20%) have a higher HIV prevalence when compared to countries
with high (>80%) rates of male circumcision. Countries in West Africa where male circumcision is
common have HIV prevalence levels well below those of countries in eastern and southern Africa,
despite other risk factors for high rates of heterosexual HIV transmission, such as multiple concurrent sexual partners, inconsistent condom use, and high prevalence of other STIs.
Figure 1 – African Countries HIV and Male Circumcision Prevalence
0
5
10
15
20
25
30
Figure 2 – Asian Countries HIV and Male Circumcision Prevalence
0.0
0.5
1.0
1.5
Cambodia
2.5
3.0
2.6
Thailand
1.5
Myanmar
1.2
India
0.9
Papua New Guinea
0.6
Viet Nam
2.0
0.3
China
0.1
Indonesia
0.1
Philippines
0.1
Pakistan
0.0
Bangladesh
0.0
MC Prevalence <20%
MC Prevalence >80%
HIV prevalence in the south and
southeast Asian countries where
nearly all men are circumcised
(Bangladesh, Indonesia, Pakistan
and Philippines) remains extremely
low, despite similar patterns of risk
factors for HIV and other STIs found
elsewhere in the region (figure 2).
Information Package on Male Circumcision and HIV Prevention
Insert 4
The South Africa Orange Farm trial, which enrolled 3274 uncircumcised men aged 18 to 24 years
showed a 61% protection against HIV acquisition. The trial in Kisumu, Kenya, of 2784 HIV-negative
men aged 18 to 24 years showed a 53% reduction of HIV acquisition in circumcised men relative
to uncircumcised men. The trial of 4996 HIV-negative men aged 15 to 49 years in Rakai, Uganda,
showed that HIV acquisition was reduced by 51% in circumcised men. The trials involved adult,
HIV-negative heterosexual male volunteers assigned at random to either undergo circumcision
performed by trained medical professionals in a clinic setting or wait until after the end of the trial
to be circumcised. All participants were extensively counselled in HIV prevention and risk reduction techniques and were provided with condoms.
An observational study in Uganda suggests that male circumcision may also protect against male-tofemale transmission of HIV. Among 47 couples in which the circumcised male partner was infected
with HIV, none of the female partners became infected in two years. By contrast, 26 of the 147 women
who were partners of uncircumcised men with HIV infection became infected with the virusvi. A further
randomized trial to assess the impact of male circumcision on the risk of HIV transmission to female
partners is currently underway in Uganda with results expected in 2008.
There are several biological explanations why male circumcision may reduce the risk of HIV infection for men:
• By removing foreskin, circumcision reduces the ability of HIV to penetrate the skin of the penis
due to keratinization or toughening of the inner aspect of the remaining foreskin vii.
• The inner part of the foreskin contains many special immunological cells, such as Langherhans
cells, that are prime targets for HIVviii,ix. Some of these are removed with the foreskin, while the
remaining cells become less accessible to the HIV virus due to the keratinization described
above.
• Ulcers, which are characteristic of some sexually transmitted infections and which can facilitate
HIV transmission, often occur on the foreskin. By removing the foreskin, the likelihood of acquiring
these infections is reduced.
• The foreskin may suffer abrasions or inflammation during sex that could facilitate the passage
of HIV.
Male circumcision reduces the risk of HIV infection, but it only provides partial protection.
Circumcised men are not immune to the virus. Male circumcision must not be promoted alone, but
alongside other methods to reduce the risk of HIV – including avoidance of unsafe sexual practices, reduction in the number of sexual partners, and correct and consistent condom use.
i
Auvert B, Buve A, Ferry B, et al. Ecological and individual level analysis of risk factors for HIV infection in four urban populations in sub-Saharan Africa with different levels of HIV
infection. AIDS 2001;15:S15-30.
ii
Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2(11):e298.
iii Bailey C, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 2007;369: 643-56.
iv Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomized trial. Lancet 2007;369:657-66.
v
Weiss HA, Quigley M, Hayes R. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000;14:2361-70.
vi Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team . AIDS 2000;14:2371-81.
vii Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Path
2002;161: 876-873.
viii Soilleux EJ, Coleman N. Expression of DC-SIGN in human foreskin may facilitate sexual transmission of HIV. J Clin Pathol 2004;57:77-78.
ix Hussain LA, Lehner T. Comparative investigation of Langerhans cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunology 1995;85:475-484.