Male circumcision and HIV infection

Innovative Methods of Male Circumcision for HIV Prevention-Getting the Right Evidence

World Health Organization recommends that countries with hyperendemic and generalized HIV epidemics implement voluntary medical male circumcision programs for HIV prevention. Innovative methods of male circumcision including devices have the potential to simplify the procedure, reduce time and cost, increase client acceptability, enhance safety, and expand the numbers of providers who may perform circumcision. We describe work led by World Health Organization and supported by global partners to define a pathway for the evaluation of efficacy and safety of male circumcision devices, to set priority criteria, and to establish a process to guide the use of devices in publicly funded voluntary medical male circumcision programs for HIV prevention. A device classification scheme, an expert Technical Advisory Group on Innovations in Male Circumcision, and a formal prequalification program have also guided considerations on safe use of devices. A rigorous approach was deemed appropriate given the intervention is for use among healthy men for public health purposes. The pathway and processes led to coordinated research, better standardization in research outcomes, and guidance that informed the research, introduction and implementation phases. The lessons learnt from this case study can inform evaluation and use of future public health innovations.

Mobilising indigenous resources for anthropologically designed HIV-prevention and behaviour-change interventions in southern Africa

HIV prevention is often implemented as if African culture were either nonexistent or a series of obstacles to overcome in order to achieve an effective, gender-equitable, human rights-based set of interventions. Similarly, traditional or indigenous leaders, such as chiefs and members of royal families, have been largely excluded from HIV/AIDS responses in Africa. This qualitative study used focus group discussions and in-depth interviews with traditional leaders and 'ritual specialists' to better understand cultural patterns and ways of working with, rather than against, culture and traditional leaders in HIV-prevention efforts. The research was carried out in four southern African countries (Botswana, Lesotho, South Africa and Swaziland). The purpose was to discover what aspects of indigenous leadership and cultural resources might be accessed and developed to influence individual behaviour as well as the prevailing community norms, values, sanctions and social controls that are related to sexual behaviour. The indigenous leaders participating in the research largely felt bypassed and marginalised by organised efforts to prevent HIV infections and also believed that HIV-prevention programmes typically confronted, circumvented, criticised or condemned traditional culture. However, indigenous leaders may possess innovative ideas about ways to change individuals' sexual behaviour in general. The participants discussed ways to revive traditional social structures and cultural mechanisms as a means to incorporate HIV-prevention and gender-sensitivity training into existing cultural platforms, such as rites of passage, chiefs' councils and traditional courts.

Exposé of misleading claims that male circumcision will increase HIV infections in Africa

Despite over two decades of extensive research showing that male circumcision protects against heterosexual acquisition of HIV in men, and that includes findings from large randomized controlled trials leading to acceptance by the WHO/UNAIDS and the Cochrane Committee, opponents of circumcision continue to generate specious arguments to the contrary. In a recent issue of the Journal of Public Health in Africa, Van Howe and Storms claim that male circumcision will increase HIV infections in Africa. Here we review the statements they use in support of their thesis and show that there is no scientific basis to such an assertion. We also evaluate the statistics used and show that when these data are properly analyzed the results lead to a contrary conclusion affirming the major role of male circumcision in protecting against HIV infection in Africa. Researchers, policy makers and the wider community should rely on balanced scholarship when assessing scientific evidence. We trust that our assessment may help refute the claims by Van Howe and Storms, and provide reassurance on the importance of circumcision for HIV prevention.

Male circumcision and HIV infection risk

BACKGROUND

Male circumcision is being promoted to reduce human immunodeficiency virus type 1 (HIV) infection rates. This review evaluates the scientific evidence suggesting that male circumcision reduces HIV infection risk in high-risk heterosexual populations.

METHODS

We followed the updated International Consultation on Urological Diseases evidence-based medicine recommendations to critically review the scientific evidence on male circumcision and HIV infection risk.

RESULTS

Level 1 evidence supports the concept that male circumcision substantially reduces the risk of HIV infection. Three major lines of evidence support this conclusion: biological data suggesting that this concept is plausible, data from observational studies supported by high-quality meta-analyses, and three randomized clinical trials supported by high-quality meta-analyses.

CONCLUSIONS

The evidence from these biological studies, observational studies, randomized controlled clinical trials, meta-analyses, and cost-effectiveness studies is conclusive. The challenges to implementation of male circumcision as a public health measure in high-risk populations must now be faced.