BioEd Online

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.