New recommendations out on HIV & circumcision
Global policies are being updated with the recent issuance of recommendations from an expert consultation on male circumcision for HIV prevention.1 But what impact do the recommendations have on your practice?
An international expert consultation convened in March 2007 by the World Health Organization (WHO) and the UNAIDS Secretariat issued a recommendation that male circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. The consultation was held following publication of evidence from three randomized, controlled trials undertaken in Kisumu, Kenya; Rakai District, Uganda; and Orange Farm, South Africa, show that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.2-4
In making the recommendations, global experts noted that male circumcision should be part of a comprehensive HIV prevention package that includes the provision of HIV testing and counseling services, treatment for sexually transmitted infections, the promotion of safer sex practices, and the provision of male and female condoms and promotion of their correct and consistent use.
Being able to recommend an additional HIV prevention method is a significant step toward getting ahead of the HIV epidemic, said Catherine Hankins, associate director of UNAID's Department of Policy, Evidence, and Partnerships, in a joint statement on the new recommendations at a WHO/UNAIDS press conference. However, the message must be clear that male circumcision does not provide complete protection against HIV, she states. (Download the expert consultation at www.who.int.)
What is the U.S. impact?
What are the implications of the global guidance for the U.S. population? At press time, the Centers for Disease Control and Prevention (CDC) was scheduled to hold a consultation in late April to begin developing U.S. recommendations and outline research needs, states Jennifer Ruth, CDC spokeswoman.
There are significant differences in the United States to be considered before recommendations can be made, explains Ruth. Africa and the United States are experiencing very different HIV epidemics. Africa has a generalized epidemic with most transmission through heterosexual sex, while in the United States, the epidemic is primarily among men who have sex with men (MSM), she notes. The African trials do not provide data on how circumcision affects the most common routes of transmission in the United States: male-to-male and male-to-female, observes Ruth.
"CDC will be evaluating the potential role of circumcision in the U.S. as we continue to support a combination of evidence-based HIV prevention strategies," she says. "We are currently working with our public health partners to evaluate the potential value, risks, and feasibility of circumcision to prevent HIV in the U.S."
Ward Cates, MD, MPH, president of research at Family Health International in Research Triangle Park, NC, presented information on the male circumcision studies during his talk on new approaches to HIV prevention at the recent Contraceptive Technology conference in Washington, DC.5 There is a different situation in this country compared to the settings where the three African randomized, controlled trials occurred, he says. "First, most men in this country are circumcised," Cates observes. "Second, the overall incidence of HIV in the U.S. is quite low in the general population; however, it is higher in selected populations."
What can U.S. clinicians do now? Cates encourages clinicians to follow CDC guidelines in assisting patients to find out their HIV infection status. The CDC issued recommendations in late 2006 that voluntary HIV screening become a routine part of medical care for all patients ages 13 to 64.6 Patients should be encouraged to learn the infection status of their sexual partners as well, he suggests.
If you are using the "A-B-C approach" (Abstain, Be faithful, and use Condoms) when talking about HIV risk reduction, expand your alphabet to include the full A to Z of risk reduction strategies, says Cates.
CDC continues to support a combination of approaches to reduce HIV infection, supported by the best available science, states Ruth. As the agency proceeds with the development of public health recommendations for the role of circumcision in preventing HIV transmission in the United States, Ruth says individual men may wish to consider circumcision as an additional HIV prevention measure, but must recognize that circumcision:
- has only proved effective in reducing HIV risk of infection through insertive vaginal sex;
- confers only partial protection and should be considered only with other proven prevention measures;
- does carry risks and costs that must be considered in addition to potential benefits.
References
- World Health Organization/UNAIDS. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Conclusions and Recommendations. Montreux, Switzerland; March 2007. Accessed at: www.who.int.
- 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; 369:643-656.
- Gray H, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: A randomized trial. Lancet 2007; 369:657-666.
- 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:e298.
- Cates W. New approaches to HIV prevention. Presented at the Contraceptive Technology conference. Washington, DC; March 2007.
- Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings. MMWR 2006; 55(RR-14):1-17; quiz CE1-4.
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