Circumcision Recommended in Global HIV Fight

By Craig Timberg
Washington Post Foreign Service
Thursday, March 29, 2007

JOHANNESBURG, March 28 -- Global health officials said Wednesday that countries with rampant AIDS epidemics should begin offering free or subsidized circumcisions in hopes of preventing millions of new infections and deaths.

The new recommendations, from the World Health Organization and the U.N. AIDS agency, came in response to growing evidence that removing a man's foreskin lowers his risk of contracting HIV by 60 percent. Circumcision campaigns could prevent 5.7 million new infections in Africa over the next 20 years, the agencies said.

"The evidence is really now quite conclusive that male circumcision is effective at preventing HIV among men," said Kevin De Cock, the top HIV-AIDS official for the World Health Organization, speaking in a conference call from Paris.

The announcement capped a gradual reversal in attitudes about circumcision. A small group of researchers has been hailing its value for more than a decade, producing dozens of studies showing that regions with high HIV rates generally have low rates of circumcision. Three experiments, including two whose results were reported in December, have largely settled the debate in the scientific community.

Attention since has focused on implementation, especially in sub-Saharan Africa, where HIV rates are highest and public health systems generally rudimentary. National health officials on the continent have generally said they were waiting for guidance from WHO before attempting to expand access to circumcision.

"Everybody's been holding back, holding back, waiting to see what these people are going to say," said Derek von Wissell, head of Swaziland's national anti-AIDS program, speaking from Malkerns, Swaziland. "This is the breakthrough we've been waiting for."

Other countries reacted more warily. Nomonde Xundu, a top AIDS official in South Africa, said the country is weighing whether to offer circumcision services as it finalizes a new long-term AIDS plan.

"We're all looking for effective interventions to reduce HIV. This seems to be one of them," Xundu said. "We have to be careful how we move forward. . . . It's a lot of work that needs to be done."

In Wednesday's announcement, global health officials said circumcision should be part of prevention programs that also include counseling, HIV testing and the provision of condoms. They urged nations to make circumcision a priority for adult men most at risk of contracting HIV, rather than for infants.

Officials also warned that circumcision performed in unhygienic conditions can be dangerous and that men who resume sex before completely healing -- which generally takes several weeks -- may increase the chances of infecting themselves and their partners. There is no clear evidence that women are less likely to contract HIV from circumcised men, officials said.

"This is an exciting development, but it is partial protection for men," said Catherine Hankins, an official with UNAIDS, speaking in the conference call from Paris.

Expanding circumcision programs would be logistically daunting but possible and affordable, because they would reduce the need for expensive treatments later, advocates say. A circumcision costs $50 to $100 in training, personnel, facilities costs and supplies. A year of antiretroviral treatment here costs about $150.

"Here we have an opportunity to prevent infections before they even occur," said Robert C. Bailey, an epidemiologist at the University of Illinois at Chicago who oversaw one of the three experimental trials showing the effectiveness of circumcision. "It's a cost-effective intervention."

Yet in countries where AIDS has strained health-care systems, offering circumcision would require major new funding, probably from outside donors, global health officials said.

In October, President Bush's $15 billion anti-AIDS program abruptly cut funding to an agency in Swaziland that provided circumcision, saying it violated U.S. government policy. But on Wednesday, the head of the Bush program, Mark Dybul, said in a statement, "The U.S. President's Emergency Plan for AIDS Relief will support safe male circumcision services when host country governments include this new HIV prevention recommendation as part of an expanded approach to reduce HIV infections."

"Any prevention program that does not have circumcision as one of its key components is inadequate," said Francois Venter, a Johannesburg AIDS physician and president of the Southern African AIDS Clinicians Society.

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