Male circumcision should be promoted in developing countries as a major means of HIV prevention.

Felipe Meja Master of Science in International Health Reproductive Health and HIV/AIDS Introduction According to UNAIDS for its AIDS epidemic 2009 report, the total number of people living with HIV in 2008 was 33.4 million, among them 15.7 million of are women and 2.1 million children under 15 years old. The same data reported 2.7 million new infections due to HIV in 2008 and 2.0 million deaths due to AIDS. Sub-Saharan Africa has the largest amount of people living with HIV accounting for 22.4 million with an adult prevalence of 5.2%. Of over 7400 new HIV infections a day in 2008, 97% are in low- and middle-income countries, 6200 are in adults (15-49 years old), 48% women. Comparing to 2001, there has been a reduction in the total new cases by 0.5 million.i Even considering that the new cases have decreased over the years between 2001 and 2008, HIV/AIDS remains as an important cause of mortality and morbidity in the world especially in the poorest regions. Due to its continue spread, developing new methods or extending existing ones which can protect large populationa against new infections are still urgent. Male circumcision has been analyzed for the past years as a possible procedure to protect men on HIV infection. Indeed, three studies made in South Africaii, Kenyaiii and Ugandaiv have shown that it reduces the probability of getting infected by 50% making it as a possible tool for a national policy in developing countries. However, male circumcision programs depend on different factors which must be under analysis according to particular cases. Efforts similar to the mentioned above has been carried out previously for antiretroviral treatments, showing that the integration with national policies, the civil society, all non-governmental organizations and other different stakeholders as well as qualified health facilities and medical products supply are required to achieve success. It is also important to stress that in non-endemic regions, male circumcision programs may not be significantly. However, for endemic places as it is in Sub Saharan Africa, the possible results may be greater. It was estimated for 2007 that in rural KwaZulu-Natal, South Africa, male circumcision would prevent an estimated 35 000 new HIV infections in the 25 million men with the previous knowledge that most of them were circumcised.v Peoples acceptability: In most of the countries in Sub Saharan Africa, male circumcision is common practice. Some studiesvi have shown that 61% of men are willing to be circumcised and 81% of couples are willing to circumcise their male children. However, for regions where this is an uncommon practice, this intervention has more challenges and ethical in regarding to social, cultural and religious issues must be addressed carefully. Male circumcision Prevalence The prevalence of male circumcision does not necessarily depend on the presence of religious activities or a specific cultural basis as it is in some countries in Africa. Indeed, it does not depend also on differences between developed and not developed countries. In USA more than 80% of new born were circumcised in late 1970, 48% Canada and 24% UK. Yet USA has one of the highest prevalence of

male circumcision as a routine procedure with 84 to 89% in the 80s. vii In developing countries where male circumcision is a common practice for social or non social reasons, it is important to establish what the prevalence is in order to set a base line for a future intervention. Information, Communication, Education (IEC): How to disseminate the information among the targeted people and integrate it to the other preventive programs? Considering that the protective effect has been estimated as 50% as mentioned above, the messages which want to get attention for the future circumcised men must make clear that male circumcision is not always effective. So, it implies that the education among the population of interest must be aware of other preventions tools and behaviors such as condoms, non promiscuous behaviors, etc. WHO and UNAIDS must focus on the messages that recent circumcised men should restart sexual activity only after six weeks.viii Should the information only go straight to men or should involve also their partners? Should women be aware about male circumcision effectiveness? Moral Hazard In this concern, it is possible to question: will the knowledge of being circumcised reduce the willingness to use condom? Will it increase the probability of risky behaviors? In the trial carried out in Ugandaix there is no evidence which suggest such moral hazard. Although, male circumcision counseling must consider this possible effect in any case. Religious and cultural issues: In places where communities practice male circumcision among their believes and who are reluctant to HIV/SIDA campaigns, male circumcision may be a possible bridge of dialogue to persuade them and to integrate them into safer practices and achieve cultural and community acceptance. When to circumcise? Whom? Some trials show that the effectiveness of male circumcision decreases with agex, others have shown that male circumcision in new born or neonatal is safer and has less cost comparing to adolescent and adultsxi. So, for male circumcision program seems to be better to do it at this age in places where this procedure is not common especially considering that there are less risks associated to circumcisions made in health facilities than in non clinical settingsxii. Looking at this point, this kind of intervention seems to be similar to vaccination where the risk group is not already exposed. It is also important to investigate whether the male circumcisions made by trained health professionals and people from the communities have the same effectiveness. Male circumcisions risks: As it was mentioned, possible complications in male circumcision procedures can come out depending on: age of the patient, training of the personnel who perform it , instruments used and quality assurance of the procedures such as sterility among others. In the trial made in South Africa, 3.8% of the men circumcised by trained personnel developed complications afterwards.xiii Male circumcision which takes place in traditional areas where it is a common practice due to social or religious factors, as in Africa, are related to high incidence of complications.xiv This is similar to the complications reported for developed countries where male circumcision is common.xv

Integration with other programs/procedures/products: There is no doubt that in case a male circumcision program is implemented; it must be parallel with other prevention activities such as condom promotion and delivery, awareness campaigns, counseling family planning, HIV tests, etc. Vertical vs Horizontal approach: Should an intervention like this require a vertical approach as it has been done for HIV/AIDS program interventions? Or is it possible to integrate it into the neonatal care routine activities? These questions should be formulated along with the next consideration: Although achieving high rates of circumcision might be beneficial, it should not be at the cost of other disease prevention strategieseg, antenatal care, malaria control, or nutrition. Since an internationally agreed-upon public health goal is for all women to give birth in health facilities, offering male circumcision to babies in clinics would at least not divert national resources from current efforts to build systems, and might be a strategy that has multiple benefits xvi It also has to be studied how many surgeries are needed to prevent one new case of HIV positive which depends on contextual factors as well as epidemiological. How cost effective for specific settings would have an intervention such as this one? Conclusion Even considering the probable beneficial effects of male circumcision to prevent new cases of HIV, public health authorities must consider the social cultural context of the place under interest, the resources available, the trained available personnel, the male willingness, the possible clinical complications and the respective awareness among the population, political and social implications. The question ultimately is: Is anything acceptable if it leads to a successful result?

Unaids. (2009). AIDS epidemic update December 2009. Available: http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp . Last accessed 25 Feb 2010. ii Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298. iii Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 64356. iv Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 65766. v Welz T, Hosegood V, Jaffar S, Batzing-Feigenbaum J, Herbst K, Newell ML. Continued very high prevalence of HIV infection in rural KwaZulu-Natal, South Africa: a population-based longitudinal study. AIDS 2007 Jul 11;21(11):1467-72. vi Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS Behavior 2007;11(3):341-355. vii Bonner K. Male circumcision as an HIV control strategy: Not a Natural Condom. Reproductive Health Matters, 2001 ; 9, 18, pp. 143-155. viii WHO/UNAIDS Male Circumcision for HIV Prevention: Research Implications for Policy and Programming WHO/UNAIDS Technical Consultation 68 March 2007 Conclusions and Recommendations (Excerpts). Reproductive Health Matters 2007;15(29): pp. 1114 ix Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 65766. x Bonner K. Male circumcision as an HIV control strategy: Not a Natural Condom. Reproductive Health Matters, 2001 ; 9, 18, pp. 143-155. xi Schoen EJ, Colby CJ, To TT. Cost analysis of neonatal circumcision in a large health maintenance organization. J Urol 2006; 175:111115. xii Bonner K. Male circumcision as an HIV control strategy: Not a Natural Condom. Reproductive Health Matters, 2001 ; 9, 18, pp. 143-155. xiii Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298. xiv Sharif R Sawires, Shari L Dworkin, Agns Fiamma, Dean Peacock, Greg Szekeres, Thomas J Coates Male circumcision and HIV/AIDS: challenges and opportunities The Lancet, Volume 369, Issue 9562, 24 February 2007-2 March 2007, Pages 708-713 xv Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369: 64356. xvi Sharif R Sawires, Shari L Dworkin, Agns Fiamma, Dean Peacock, Greg Szekeres, Thomas J Coates Male circumcision and HIV/AIDS: challenges and opportunities The Lancet, Volume 369, Issue 9562, 24 February 2007-2 March 2007, Pages 708-713