Information Package on Male Circumcision and HIV Prevention

Transcription

1 Insert Introduction Male circumcision is the surgical removal of all or part of the foreskin of the penis. It is one of the oldest and most common surgical procedures worldwide, undertaken for religious, cultural, social or medical reasons. Male circumcision has now been assessed as a potential means to limit the spread of HIV. Data from a range of observational epidemiological studies, conducted since the mid-980s, showed that circumcised men have a lower prevalence of HIV infection than uncircumcised men. Three randomized controlled trials have been conducted which make it possible to separate a direct protective effect of male circumcision from behavioural or social factors that may be associated with both circumcision status and risk of HIV infection. These trials have been conducted in Orange Farm, South Africa i ; Kisumu, Kenya ii and Rakai District, Uganda iii. The results of these trials showed that following circumcision, the incidence of HIV infection was reduced in men by more than half. This information package has been prepared for the use of policy makers and programme managers who may be facing an increased demand for male circumcision services and who wish to determine the place of male circumcision within a comprehensive HIV prevention programme. The package contains a series of introductory information notes on male circumcision in the context of HIV prevention, and gives references to other resources that provide more detailed information on the subject. The contents will be periodically updated when policy recommendations are issued, or as new evidence is published and additional experience with provision of male circumcision services is documented. Since male circumcision is now shown to be effective in reducing the risk of HIV infection for men, care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection. Male circumcision must be considered as just one element of a comprehensive HIV prevention package that includes the correct and consistent use of condoms, reductions in the number of sexual partners, delaying the onset of sexual relations, avoidance of penetrative sex, and testing and counselling to know one s HIV serostatus. Action is required to improve the safety of male circumcision practices in many countries and to ensure that health care providers and the public have up-to-date information on the health benefits and risks of male circumcision. Male circumcision is a voluntary surgical procedure and health care providers must ensure that men and young boys are given all the necessary information to enable them to make free and informed choices either for or against getting circumcised. This information package is the result of collaborative work between members of the Interagency Task Team (IATT) on Male Circumcision which is composed of the United Nations Children s Fund (UNICEF) the United Nations Population Fund (UNFPA), the World Health Organization (WHO), the World Bank and the Joint United Nations Programme on HIV/AIDS (UNAIDS). It is a compilation of work undertaken by a large group of clinical and public health experts. For further information on male circumcision go to: i Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 265 Trial. PLoS Med 2005;2():e298. ii 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: iii 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:

2 Insert 2 The Global Prevalence of Male Circumcision Global estimates in 2006 suggest that about 30% of males representing a total of approximately 665 million men are circumcised. Other common determinants of male circumcision are ethnicity, perceived health and sexual benefits, and the desire to conform to socio-cultural norms. Male circumcision is common in many African countries and is almost universal in North Africa and most of West Africa. In contrast it is less common in southern Africa; country to country and within country variation is greatest in this region i. Self-reported prevalence in several countries is around 5% (Botswana, Namibia, Swaziland, Zambia, Zimbabwe); but substantially higher in others (Malawi 2%, South Africa 35%, Lesotho 48%, Mozambique 60%, and Angola and Madagascar more than 80%). Prevalence in central and eastern Africa varies from 5% in Burundi and Rwanda, to over 70% in Ethiopia, Kenya and the United Republic of Tanzania. In sub-saharan Africa age at circumcision varies from infancy to the late teens or early twenties. Male circumcision in Africa is undertaken for mainly religious and cultural reasons. Male circumcision is almost universal in the Middle East and Central Asia and in Bangladesh, Indonesia and Pakistan ii,iii. In addition there are an estimated 20 million circumcised men in India iv. In all these countries, male circumcision is undertaken primarily for religious and cultural reasons. There is little non-religious circumcision in Asia, with the exception of the Republic of Korea and the Philippines where circumcision is routine and widespread v. During the 20 th century, male circumcision gained popularity for perceived health benefits and social reasons in North America, New Zealand and Europe vi,vii. Neonatal and childhood male circumcision rates in the United States of America rose to about 80% in the 960s with prevalence remaining high (between 76%-92%) today viii. In contrast, Australia ix, Canada x, and the United Kingdom xi have seen a decline in male circumcision. In Central and South America male circumcision is uncommon (less than 20%) xii,xiii. Examination of the prevalence of male circumcision shows that the major determinant of circumcision globally is religion, but that significant numbers of males are circumcised for cultural reasons. In sub-saharan Africa tradition and cultural identity play as important a role as religion during male circumcision practices. Historically, in various parts of the world there have been increases and decreases in the popularity of non-religious male circumcision. These trends often result from changes in perceptions of the health benefits or cultural beliefs associated with the practice, indicating that the cultural determinants of male circumcision can evolve.

3 Insert 2 Global Map of Male Circumcision Prevalence at Country Level i Measure DHS. Demographic and health surveys. (accessed on 22 Jan 2007). ii Hull TH, Budiharsana M. Male circumcision and penis enhancement in Southeast Asia: matters of pain and pleasure. Reprod Health Matters 200;9: iii Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC. Male circumcision, religion, and infectious diseases: an ecologic analysis of 8 developing countries. BMC Infect Dis 2006;6:72. iv US Department of State. International Religious Freedom Report for (accessed 22 Jan 2007). v Pang MG, Kim DS. Extraordinarily high rates of male circumcision in South Korea: history and underlying causes. BJU Int 2002;89: vi Hutchinson J. On the influence of circumcision in preventing syphilis. Med Times Gazette 855; 32: vii Clifford M. Circumcision: it s advantages and how to perform it. 893, London: J. & A. Churchill. viii Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol 2005;73: ix Richters J, Smith AM, de Visser RO, et al. Circumcision in Australia: prevalence and effects on sexual health. Int J STD AIDS 2006;7: x Wirth JL. Current circumcision practices: Canada. Pediatrics 980;66: xi Gairdner D. The fate of the foreskin, a study of circumcision. BMJ 949;2: Dave SS, Fenton KA, Mercer CH, et al. Male circumcision in Britain: findings from a national probability sample survey. Sex Transm Infect 2003;79: xii Brinton LA, Reeves WC, Brenes MM, et al.the male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 989;44: xiii Castellsague X, Peeling RW, Franceschi S, et al. Chlamydia trachomatis infection in female partners of circumcised and uncircumcised adult men. Am J Epidemiol 2005;62:907-6.

4 Insert 3 Health Benefits and Associated Risks Male circumcision involves the surgical removal of the foreskin, the tissue covering the head of the penis. In adult men, a four to six week period is required to fully heal the wound. Healing is usually complete after about one week when circumcision is performed for babies. Research shows that removing the foreskin is associated with a variety of health benefits i,ii,iii : Studies have found lower rates of urinary tract infections in male infants who are circumcised iv. Circumcision prevents inflammation of the glans (balanitis) and the foreskin ( posthitis). Men who are circumcised do not suffer health problems associated with the foreskin such as phimosis (an inability to retract the foreskin) or paraphimosis (swelling of the retracted foreskin causing inability to return it to its normal position). Circumcised men find it easier to maintain penile hygiene. Secretions can easily accumulate in the space between the foreskin and glans making it necessary for an uncircumcised man to retract and clean the foreskin regularly. Two studies now suggest that female partners of circumcised men have a lower risk of cancer of the cervix, which is caused by persistent infection with high-risk oncogenic (cancer-inducing) types of human papillomavirus v. Circumcision is associated with a lower risk of penile cancer vi,vii. Circumcised men have a lower prevalence of some sexually transmitted infections, especially ulcerative diseases like chancroid and syphilis viii,ix. In numerous observational studies lower levels (prevalence) of HIV infection have been found in circumcised men compared to uncircumcised men and three randomized controlled trials in South Africa Kenya and Uganda have demonstrated a lower risk of acquiring HIV infection in circumcised men compared to those who remain uncircumcised x,xi,xii. The likely biological explanation for the higher levels of sexually transmitted infections, including HIV infection, seen in men who are not circumcised is that the inner mucosal surface of the foreskin is only thinly keratinized xiii and is therefore susceptible to minor trauma and abrasions which facilitate entry of pathogens. The area under the foreskin is a warm, moist environment which may enable pathogens to replicate, especially when penile hygiene is poor xiv. Circumcision does not guarantee complete protection from any of the infections cited above and is medically indicated as treatment for only a few conditions most commonly for phimosis. Male circumcision, as with any surgical procedure, carries a risk of post-operative infection. In inexperienced hands, penile mutilation and even death can occur. The surgery can lead to excessive bleeding, haematoma (the formation of a blood clot under the skin), meatitis (inflammation of the opening of the urethra), and increased sensitivity of the glans penis for the initial months after the procedure. In addition, adverse reactions to the anaesthetic used during the circumcision may occur. The safety of male circumcision clearly depends on the setting and expertise of the provider. When circumcision is performed in a clinical setting, under aseptic conditions, by well trained, adequately equipped health care personnel the level of risk is low. Among adults the operation is more complex and the complication rates for clinical circumcision are between 2 and 4 per 00 procedures. Few of these complications are serious. Neonatal circumcision is a relatively simple, quick procedure; fewer than in 500 procedures results in complications and these are usually minor.

5 Insert 3 Male circumcision for religious or traditional reasons frequently takes place in a non-clinical setting although, in some cultures, an increasing proportion takes place in clinics xv,xvi. Circumcisions undertaken in unhygienic conditions by inexperienced providers with inadequate instruments, or with poor after-care, can result in very serious complications, including death. For example, among 50 patients admitted to hospital with post-circumcision complications in Nigeria and Kenya between 98 and 988, 80% had been circumcised by unqualified traditional surgeons xvii. Action is required to improve male circumcision practices in many regions and to ensure that health care providers and the public have up-to-date information on the health risks as well as the benefits of safe male circumcision. Many boys and men wishing to be circumcised do not have access to safe circumcision services or to post-circumcision care if they suffer from complications. Health authorities need to monitor the practice and to ensure that health-care practitioners are properly trained and licensed to perform the procedure safely. Since male circumcision has now been shown to be effective in reducing the risk of HIV infection, care must be taken to ensure that men and women understand that the procedure does not provide complete protection against HIV infection. Male circumcision must be considered as just one element of a comprehensive HIV prevention package that includes the correct and consistent use of condoms, reductions in the number of sexual partners, delaying the onset of sexual relations, avoidance of penetrative sex, and testing and counselling to know one s HIV serostatus. Male circumcision also raises human rights issues, as is generally the case with medical and health procedures. In line with internationally accepted ethical and human rights principles, no surgical intervention should be performed on anyone if it results in adverse outcomes in terms of health or the integrity of the body, and where there is no expectation of health benefit. Nor should any surgical intervention be performed on anyone without informed consent, or the consent of the parents or guardians when a child is not capable of providing consent. Detailed information on the procedures for male circumcision can be found in the forthcoming Manual on Male Circumcision under Local Anaesthesia prepared jointly by WHO, UNAIDS, and JHPIEGO (2007). The manual provides technical guidance on clinical and programmatic approaches to male circumcision in an appropriate human rights framework. It also addresses broader issues of sexual and reproductive health of men and emphasizes that male circumcision must be set within the context of other strategies for reducing the risk of HIV infection. 2 i Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis. Sex Transm Infect 2006;82:0-09. ii Singh-Grewal D, Macdessi J, Craig j. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 2005;90: iii Moses S, Bailey RC, Ronald AR. Male circumcision: assessment of health benefits and risks. Sex Transm Infect 998;74: iv Wiswell TE, Hachey WE. Urinary tract infection s and the uncircumcised state. Clin Pediatr 993;32: v Agarwal SS, Sehgal A, Sardana S, et al. Role of male behaviour in cervical carcinogenesis among women with one lifetime sexual partner. Cancer 993;72: vi American Academy of Pediatrics. Report of the task force on circumcision. Pediatrics 989; 84: vii Dodge OG, Kaviti JN. Male circumcision among the peoples of East Africa and the incidence of genital cancer. East Afr Med J 965;42: viii Nasio JM, Nagelkerke NJ, Mwatha A, et al. Genital ulcer disease among STD clinic attenders in Nairobi: association with HIV- and circumcision status. Int J STD AIDS 996; 7:40-4. ix Cook LS, Koutsky LA, and Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 994; 84: x Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 265 Trial. PLoS Med 2005;2():e298. xi 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: xii 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: xiii McCoombe SG, Short RV. Potential HIV- target cells in the human penis. AIDS 2006;20: xiv Cold CJ, Taylor JR. The prepuce. BJU Int 999;83(Suppl ): xv Doyle D. Ritual male circumcision: a brief history. J R Coll Physicians Edinb 2005;35(3): xvi Bailey RC. Egesah O. Assessment of clinical and traditional male circumcision services in Bungoma District, Kenya: Complication rates and operational needs; April (accessed 22 Jan 2007). xvii Magoha GA. Circumcision in various Nigerian and Kenyan hospitals. East Afr Med J 999;76:

6 Insert 4 Male Circumcision as an HIV Prevention Method Numerous observational studies indicate that circumcised men have lower levels of HIV infection than uncircumcised men. Throughout the world, HIV prevalence is generally lower in populations that traditionally practice male circumcision than in populations where most men are not circumcised i. Until the three randomized controlled trials in South Africa ii, Kenya iii and Uganda iv were completed, it was unclear to what extent this was the result of a biological effect of male circumcision, or the result of cultural or social factors that can accompany high rates of male circumcision. A systematic review and meta-analysis of 28 published studies found that circumcised men are two- to three-fold less likely to be infected by HIV than uncircumcised men, with differences most pronounced in men highly exposed to HIV infection v.a sub-analysis of 0 African studies found a 3.4-fold lower incidence of HIV infection among men considered to be at high risk of becoming infected. Figure African Countries HIV and Male Circumcision Prevalence Zimbabwe Botswana Namibia Zambia Swaziland Malawi Mozambique Rwanda Kenya Congo Cameroon Gabon Nigeria Liberia Sierra Leone Ghana Benin Guinea MC Prevalence <20% MC Prevalence >80% The geographic regions in sub- Saharan Africa where men are more commonly circumcised overlap with areas of lower HIV prevalence. Low prevalence of male circumcision and high prevalence of genital herpes, which is more common in uncircumcised men, emerged as the principal determinant for the differences in HIV rates found in sub-saharan Africa. The bar chart figure shows that countries in sub-saharan Africa with relatively low rates of male circumcision (<20%) have a higher HIV prevalence when compared to countries with high (>80%) rates of male circumcision. Countries in West Africa where male circumcision is common have HIV prevalence levels well below those of countries in eastern and southern Africa, despite other risk factors for high rates of heterosexual HIV transmission, such as multiple concurrent sexual partners, inconsistent condom use, and high prevalence of other STIs. Figure 2 Asian Countries HIV and Male Circumcision Prevalence Cambodia Thailand Myanmar India Papua New Guinea Viet Nam China MC Prevalence <20% HIV prevalence in the south and southeast Asian countries where nearly all men are circumcised (Bangladesh, Indonesia, Pakistan and Philippines) remains extremely low, despite similar patterns of risk factors for HIV and other STIs found elsewhere in the region (figure 2). Indonesia Philippines Pakistan Bangladesh MC Prevalence >80%

7 Insert 4 The South Africa Orange Farm trial, which enrolled 3274 uncircumcised men aged 8 to 24 years showed a 6% protection against HIV acquisition. The trial in Kisumu, Kenya, of 2784 HIV-negative men aged 8 to 24 years showed a 53% reduction of HIV acquisition in circumcised men relative to uncircumcised men. The trial of 4996 HIV-negative men aged 5 to 49 years in Rakai, Uganda, showed that HIV acquisition was reduced by 5% in circumcised men. The trials involved adult, HIV-negative heterosexual male volunteers assigned at random to either undergo circumcision performed by trained medical professionals in a clinic setting or wait until after the end of the trial to be circumcised. All participants were extensively counselled in HIV prevention and risk reduction techniques and were provided with condoms. An observational study in Uganda suggests that male circumcision may also protect against male-tofemale transmission of HIV. Among 47 couples in which the circumcised male partner was infected with HIV, none of the female partners became infected in two years. By contrast, 26 of the 47 women who were partners of uncircumcised men with HIV infection became infected with the virus vi. A further randomized trial to assess the impact of male circumcision on the risk of HIV transmission to female partners is currently underway in Uganda with results expected in There are several biological explanations why male circumcision may reduce the risk of HIV infection for men: By removing foreskin, circumcision reduces the ability of HIV to penetrate the skin of the penis due to keratinization or toughening of the inner aspect of the remaining foreskin vii. The inner part of the foreskin contains many special immunological cells, such as Langherhans cells, that are prime targets for HIV viii,ix. Some of these are removed with the foreskin, while the remaining cells become less accessible to the HIV virus due to the keratinization described above. Ulcers, which are characteristic of some sexually transmitted infections and which can facilitate HIV transmission, often occur on the foreskin. By removing the foreskin, the likelihood of acquiring these infections is reduced. The foreskin may suffer abrasions or inflammation during sex that could facilitate the passage of HIV. Male circumcision reduces the risk of HIV infection, but it only provides partial protection. Circumcised men are not immune to the virus. Male circumcision must not be promoted alone, but alongside other methods to reduce the risk of HIV including avoidance of unsafe sexual practices, reduction in the number of sexual partners, and correct and consistent condom use. 2 i Auvert B, Buve A, Ferry B, et al. Ecological and individual level analysis of risk factors for HIV infection in four urban populations in sub-saharan Africa with different levels of HIV infection. AIDS 200;5:S5-30. ii Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 265 Trial. PLoS Med 2005;2():e298. iii 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: iv 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: v Weiss HA, Quigley M, Hayes R. Male circumcision and risk of HIV infection in sub-saharan Africa: a systematic review and meta-analysis. AIDS 2000;4: vi Gray RH, Kiwanuka N, Quinn TC, et al. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team. AIDS 2000;4: vii Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus- infection of human foreskin and cervical tissue grown in explant culture. Am J Path 2002;6: viii Soilleux EJ, Coleman N. Expression of DC-SIGN in human foreskin may facilitate sexual transmission of HIV. J Clin Pathol 2004;57: ix Hussain LA, Lehner T. Comparative investigation of Langerhans cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunology 995;85: