Male circumcision (MC) programs and services are directly related to achieving Millennium Development Goal #6 combat HIV/AIDS and indirectly to #5 improve maternal health.  In 2007, an expert panel convened by WHO and UNAIDS reviewed research results on MC and HIV transmission and recommended that MC be added to comprehensive HIV packages in countries with predominantly heterosexual epidemics (WHO, 2010a). Adult MC is considered a cost-effective and potentially cost-saving method of HIV prevention and, based on five economic evaluations, the reported cost per HIV infection averted ranged from US $174 to US$2,808 over 10 to 20 years (Uthman, et al., 2010).  The Bill and Melinda Gates Foundation has encouraged rapid scale-up of MC as an inexpensive and effective intervention for HIV prevention.  A new grant to South Africa from the Global Fund to Fight AIDS, Tuberculosis and Malaria will help expand access to medical MC for HIV prevention in underserved areas.

The growing support for MC programs and services is based on solid evidence from international studies linking MC with reduced risk in men for infection from HIV and several other sexually transmitted infections (STIs).  Analyses from three randomized clinical trials demonstrated reductions in men’s risk for HIV infection ranging from 55 percent in Uganda to 60 percent in Kenya, and 76 percent in South Africa (CDC, 2008). Furthermore, MC is being shown to provide sustained protection against heterosexually acquired HIV infection in men based on a 66 percent reduced risk of HIV infection among circumcised men compared to uncircumcised men after 4.5 years of follow-up in Kenya (Bailey, et al,. 2010). However, a recent study suggests that MC may not have a protective effect for men who have sex with men (Sanchez, et al, 2010).  MC has been found to reduce the risk for transmission of high-risk human papillomavirus (HR-HPV) in HIV negative and positive men (Gray et al., 2010; Serwadda et al., 2011). A meta-analysis of 26 studies concluded that there was a significant lower risk for syphilis and chancroid among circumcised men (Weiss et al., 2006).

In terms of male-to-female HIV transmission, a prospective study in seven African countries found that MC may decrease the risk of male–to-female transmission, although the results were not conclusive and may depend on viral load (Beaton et al., 2010). Women do benefit from MC because it reduces HIV infection in men, thus limiting women’s exposure, and because having a circumcised partner reduces a woman’s risk of other STIs and cervical cancer. Having a male partner who is circumcised can reduce a woman’s chances of infection with HR-HPV by about 25 percent (Warwer et al. 2011). For further background and updates on basic and programmatic MC research and activities, see the ‘Clearinghouse on Male Circumcision for HIV Prevention’, www.malecircumcision.org.

MC is considered a minor surgical procedure that can be provided in aseptic conditions by well-trained health professionals using proper equipment and supplies. WHO advises that the surgery should be part of a minimum package of services.

Five-part minimum package recommended by WHO (2010):
(1) HIV testing and counseling;
(2) Active exclusion of symptomatic STIs and syndromic treatment where needed;
(3) Provision and promotion of male and female condoms;
(4) Counseling on risk reduction and safer sex; and
(5) Male circumcision surgical procedures performed as described in the approved manual (WHI/UNAIDS/JHPIEGO, 2008).

More comprehensive packages can be offered depending on the facility and the prevailing issues and needs of the surrounding community.  For example, MC services targeting young boys could offer counseling on drug abuse or on improving gender norms and roles. As part of the WHO initiative for implementing ‘models for optimizing the volume and efficiency of male circumcision services for HIV prevention’ (MOVE), WHO has delineated a set of ten recommended MC service standards (WHO 2008).  In addition to adult MC services, policy and program planners need to address policies, standards, and services for neonatal circumcision and approaches for working with and improving safety of procedures by traditional MC practitioners.

Indicator Selection

With the current scaling-up of programs and expected increases in demand for circumcision services, systems need to be in place for monitoring and evaluating (M&E) levels and trends of MC, quality of services, and the impact on various measures of the HIV epidemic.  WHO and partners have developed a MC Action Framework with 19 indicators, 7 of which cover purpose and key program objectives and 12 are component objective indicators that can be adapted for country-specific activities (WHO 2010b). The six PEPFAR MC indicators are a subset of the 19 WHO framework indicators as are the 11 indicators selected for this database. MC rates, which also can be estimated through DHS, in addition to indicators for knowledge, intentions, and the use of MC services can be disaggregated by region, by clients’ ethnic and age groupings, and where available, by clients’ risk behaviors and relevant demographic and socioeconomic factors. Several of the database indicators can be adapted for M&E use with neonatal MC, which many experts believe is the future direction for programs, since circumcision of neonates is easier and less expensive than that of adults. Although men are the primary focus of MC services, women and girls may also be involved in decision-making and indicators can be added that examine the involvement of women and girls, their access to knowledge, and their understanding and acceptance of MC in their male partners (WHO/UNAIDS, 2010b). Further studies are also needed to assess change in sexual behavior as a result of MC, to assess acceptability and safety of MC, and to investigate links with traditional practices. Operational research can be used to enhance MC program quality, effectiveness, and efficiency.

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References:

Bailey RC, Moses S, Parker CB, et al., The protective effect of adult male circumcision against HIV acquisition is sustained for at least 54 months: Results from the Kisumu, Kenya trial, Presentation, XVIII^th International AIDS Conference,  Vienna, Austria, July, 2010.

Baeten JM, Deam D, Kapiga SH, et al., Male circumcision and risk of male-to-female HIV-1 transmission: a multinational prospective study in African HIV-1-serodiscordant couples, AIDS: 2010 Mar 13;24(5):737–44.

CDC, 2008, Male circumcision and risk for HIV transmission and other health conditions: Implications for the United States, Atlanta, GA: CDC.  http://www.circlist.com/rites/ritesimages/CDC%20Male%20Circumcision%20in%20the%20US%20and%20HIV.pdf

Gray RH, Serwadda D, Kong X, et al. Male circumcision decreases acquisition and increases clearance of high-risk human papillomavirus in HIV-negative men: a randomized trial in Rakai, Uganda. J Infect Disease. 2010 May 15;201(10):1455-62.

PEPFAR, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, D.C.: PEPFAR. http://pdf.usaid.gov/pdf_docs/Pcaac330.pdf

Sánchez J, y Rosas S, Hughes VG, et al.  Male circumcision and risk of HIV acquisition among MSM, AIDS: 2011, Feb 20;25(4):519–23.

Serwadda D, Wawer MJ, Makumbi F, et al. Circumcision of HIV-infected men: effects on high-risk human papillomavirus infections in a randomized trial in Rakai, Uganda. J Infect Disease. 2010 May 15;201(10):1463-9.

Uthman OA, Popoola TA, Uthman MMB, Aremu O (2010) Economic Evaluations of Adult Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men in Sub-Saharan Africa: A Systematic Review. PLoS ONE 5(3): e9628. doi:10.1371/journal.pone.0009628.

Warwer MD, Toban AR, Kigozi G, et al., Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda, The Lancet. 2011, Jan 15;377(9761):209-18.

Weiss HA, Thomas SL, Munabi SK, Hayes RJ, Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta-analysis, Sexual Transmission and Infections. 2006 Apr;82(2):101-9.

WHO/UNAIDS, 2010a, Scaling-up male circumcision programmes in the Eastern and Southern Africa Region, A sub-regional consultation, Tanzania, June 2010, Geneva: WHO. http://www.who.int/hiv/pub/malecircumcision/meetingreport_mc_jun10/en/index.htm

WHO/UNAIDS, 2010b, A guide to indicators for male circumcision programmes in the formal health care, Geneva: WHO. http://www.who.int/hiv/pub/malecircumcision/hiv_mc_me.pdf

WHO, 2008, Male Circumcision Quality Assurance: A guide to enhancing the safety and quality of services, Geneva: WHO.  http://www.who.int/hiv/pub/malecircumcision/who_hiv_mc_q_assurance.pdf

WHO/UNAIDS/JPIEGO, 2008, Male circumcision under local anaesthesia Version 2.5C, Geneva: WHO http://www.who.int/hiv/pub/malecircumcision/who_mc_local_anaesthesia.pdf