Three clinical trials concluded in recent years confirm that adult male circumcision performed by trained health care workers in medical settings may significantly reduce the risk of HIV acquisition among men through heterosexual intercourse.

On December 12, 2006, the National Institutes of Health announced findings from two studies demonstrating the efficacy of adult male circumcision in reducing risk of HIV acquisition among men. Conducted in Kisumu, Kenya and Rakai, Uganda, the trials showed 53 percent and 48 percent reductions, respectively, in HIV acquisition in circumcised men compared with uncircumcised men. These findings parallel those of a 2005 study conducted in Orange Farm, South Africa, which showed a 60 percent reduction in risk for circumcised men.

On March 28, 2007, the World Health Organization and UNAIDS released guidelines recommending that "circumcision now be recognized as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men."

The San Francisco AIDS Foundation believes that this is an important development in HIV prevention, and that adult male circumcision may provide an additional strategy in a comprehensive HIV prevention package. At the same time, male circumcision must be considered with the following points in mind:

• Being circumcised is not HIV protection. Circumcision may reduce, but does not eliminate risk of HIV infection. Sexually active men, whether or not they are circumcised, should use condoms to protect against acquiring and transmitting HIV and other sexually transmitted infections.

• There is a potential for men who have been circumcised to believe they are fully protected and to lapse in condom use and other modes of risk reduction, which could have the effect of increasing HIV transmission rather than decreasing it.

• The studies in sub-Saharan Africa took place in highly controlled medical settings and were conducted by medical experts on previously uncircumcised men who have vaginal sex with women. These men were given counseling about sexual risk and were provided with condoms. Their health was regularly monitored for any adverse outcomes from the circumcision, which were treated upon detection.

• There is no comparable evidence about the effect of male circumcision for gay and other men who have sex with men.

• There is no comparable evidence about the effect of male circumcision for anal intercourse.

• There is insufficient evidence about whether circumcision in HIV-positive men protects their male or female sexual partners.

• There is no evidence about the effect of male circumcision on reducing acquisition of HIV among women. Another study in Rakai, Uganda is currently looking at this, but it is not yet completed.

• The evidence from the trials in sub-Saharan Africa applies to adult men. It cannot tell us specifically about the potential HIV risk reduction benefits of circumcision conducted on newborns or children.

• Male circumcision has cultural and religious significance in many settings, which may affect its acceptability among different communities.

With these facts in mind, the Foundation believes the following:

• Circumcision is an invasive medical procedure that must be conducted by trained individuals under sterile conditions with appropriate monitoring and an adequate healing period to eliminate the risk of bacterial infection. Community and health care provider education will be essential for the implementation of male circumcision as an HIV prevention strategy.

• Payment for the procedure should not be an obstacle to any man who chooses to undergo it; public and private health care programs and insurers should cover male circumcision as part of preventive medicine.

• Adult male circumcision should always be voluntary, with appropriate informed consent.

• The public health community should understand and respect religious and cultural meanings of male circumcision in formulating implementation strategies.

• Circumcision is a personal decision that should be made in consultation with providers, pediatricians and others. The Foundation does not make recommendations about individual health choices.

Additional information about circumcision is available at:

• http://www.aidsvaccineclearinghouse.org/MC/index.html

• http://www3.niaid.nih.gov/news/newsreleases/2006/AMC12_06press.htm

• http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html

• http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm