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Based on "compelling evidence," the World Health Organization (WHO) and UNAIDS on Wednesday accepted expert recommendations that adult male circumcision be recognized as an "additional important intervention" to reduce the risk of HIV transmission.
A few months ago, a UNAIDS delegation came to Israel to learn how best to perform adult male circumcision, given this country's great experience in the ritual procedure for voluntary conversion of new immigrants. Israeli experts advised infant circumcision as well, even though it would take years until the infants reached sexual maturity.
Studies suggest that male circumcision in sub-Saharan Africa could prevent 5.7 million new cases of HIV infection and 3 million deaths over 20 years. The evidence presented earlier this month in Montreaux, Switzerland was regarded as very persuasive.
The recommendations "represent a significant step forward in HIV prevention," said Dr. Kevin De Cock, director of the WHO's HIV/AIDS department.
"Countries with high rates of heterosexual HIV infection and low rates of male circumcision now have an additional intervention which can reduce the risk of HIV infection in heterosexual men.
Scaling up male circumcision in such countries will result in immediate benefit to individuals. However, it will be a number of years before we can expect to see an impact on the epidemic from such investment."
There is now strong evidence from three randomized controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda (funded by the US National Institutes of Health) and Orange Farm, South Africa (funded by the French National Agency for Research on AIDS) that male circumcision reduces the risk of heterosexually-acquired HIV infection in men by approximately 60 percent.
This evidence supports the findings of numerous observational studies that have also suggested that the geographical correlation long described between lower HIV prevalence and high rates of male circumcision in some countries in Africa, and more recently elsewhere, is, at least in part, a causal association. Currently, an estimated 665 million men, or 30% of men worldwide, are circumcised.
Male circumcision should always be considered as part of a comprehensive HIV prevention package, said the UN organizations. This includes the provision of HIV testing and counselling 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.
Counselling of men and their sexual partners is necessary to prevent them from developing a false sense of security and engaging in high-risk behaviors that could undermine the partial protection provided by male circumcision.
Furthermore, they said, male circumcision service provision was seen as a major opportunity to address the frequently neglected sexual health needs of men.
"Being able to recommend an additional HIV prevention method is a significant step towards getting ahead of this epidemic," said Catherine Hankins, associate director of UNAIDS's department of policy, evidence and partnerships. "However, we must be clear: Male circumcision does not provide complete protection against HIV. Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners."
Dr. Inon Schenker, senior HIV/AIDS prevention specialist and head of the Israel Multi-Center Research Group on Male Circumcision, welcomed the recommendation, but said the fact that male circumcision can only reduce infection, not completely prevent it, must be highlighted. He also noted that the Jerusalem AIDS Project has already received requests for Israeli support to African countries in this area.
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