About Medical Male Circumcision

What is medical male circumcision?
Medical male circumcision is the removal of all or part of the foreskin of the penis by a trained health professional. The term medical male circumcision differentiates circumcision that is performed by a trained health professional from traditional circumcision, which is performed as part of a religious ritual or cultural rite of passage.

How did we learn that male circumcision works to help prevent HIV?
Male circumcision for HIV prevention was evaluated in three large-scale randomized controlled clinical trials that enrolled in total about 10,000 men in Kenya, Uganda, and South Africa. Each of these trials used surgical techniques that had proven safe and effective over years of use in other contexts. Each participant received a standard prevention package including treatment for sexually transmitted infections, condoms, and behavior change counseling. Some of the participants were randomly assigned to the experimental group, in which they received circumcision during the trial. Other participants were assigned to the control group and were asked to remain uncircumcised throughout the study. All participants were counseled at every study visit that they couldn't assume they would be protected. Over the course of the trial period, some participants got infected even though they were being counseled and receiving prevention services. This is consistent with what we know about the AIDS epidemic: even with information and services, not everyone can protect himself or herself all the time.

In the trials, participants who received circumcision plus the prevention package were estimated to have 60 percent fewer infections than those in the control group (who received the prevention package alone). Rates of condom use and risk behaviors were similar between the circumcised and uncircumcised groups. This led researchers to conclude that circumcision provided risk reduction beyond that provided by standard prevention (i.e., STI treatment, condoms and counseling).

Why does male circumcision work as an HIV prevention method?
There is no definite answer to why medical male circumcision reduces men's risk of HIV infection during vaginal sex, but there are several possible explanations. The foreskin of the penis has many cells of a type that are vulnerable to HIV infection. Removing the foreskin removes these "target cells" and makes the penile skin more durable, which might also reduce risk. Medical male circumcision also reduces the rate of genital ulcer disease. Genital ulcers can increase the risk of HIV infection.

When did male circumcision research take place?
Clinical studies to determine male circumcision's safety and efficacy in reducing risk of HIV transmission were undertaken between 2005 and 2007. A trial conducted in Orange Farm, South Africa found a 50 percent reduction in men's risk of HIV infection and released these data in 2005. Ugandan and Kenyan trials released similar findings in late 2006. Based on this evidence, WHO and UNAIDS issued a 2007 guidance document recognizing male circumcision as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. The WHO/UNAIDS guidance document on male circumcision for HIV prevention states that the service should be offered along with HIV testing and counseling services, treatment for sexually transmitted infections, the promotion of safer-sex practices, and the provision of male and female condoms.

Where did male circumcision trials take place and where is it currently being rolled out?
Three trials in HIV-negative men in Kenya, South Africa, and Uganda were completed, and these trial sites are also expanding male circumcision services to the broader community.

Now that the trials are completed and there is guidance from the WHO, many countries are considering introducing male circumcision as part of their prevention programs. The pace and the stage of effort vary among these countries. The WHO is tracking the progress in male circumcision scale-up. Visit http://www.malecircumcision.org/ to download the latest country implementation update. 
 
Who will benefit from male circumcision research?
Medical male circumcision reduces heterosexual men's risk of getting HIV from female partners. There may eventually be benefits to women if male circumcision coverage increases to where it reduces the number of HIV-positive men. Some researchers have predicted that if male circumcision were to become widespread in sub-Saharan Africa, almost 6 million infections would be prevented over 20 years, as would 3 million deaths among both men and women.

Much more information is needed about male circumcision and its impact on women and their ability to negotiate condom use and shared sexual decision-making. For more information on the implications for women, please visit the Male Circumcision and Women page at the Clearinghouse on Male Circumcision. 

It remains unclear whether medical male circumcision could have an impact on HIV transmission among gay men and other men who have sex with men. A meta-analysis of available data found insufficient evidence of circumcision's protective effect in MSM.  However, recent findings show that circumcision might help reduce transmission in MSM who report a preference for the insertive sexual role.

AVAC is currently supporting women's community-based efforts to monitor, evaluate, and develop or expand advocacy around new and emerging HIV prevention strategies via the Women's HIV Prevention Tracking Project (WHiPT). There are currently WHiPT teams receiving support for pilot projects tracking the implications for women of the introduction of male circumcision for HIV prevention. Visit the WHiPT page for more information.

For more information on medical male circumcision, go to the Male Circumcision Clearinghouse and read AVAC's report, A New Way to Protect Against HIV? Understanding the Results of Male Circumcision Studies for HIV Prevention.

Visit the HIV prevention research timeline and trials map for details on other ongoing biomedical HIV prevention research trials. 

Click here for more information on medical male circumcision trials.