UN calls for mass circumcision of men to tackle Aids epidemics

· Trials find procedure reduces infection by 60%
· Programmes expected to focus on African nations


The United Nations yesterday urged all countries with devastating Aids epidemics to launch mass male circumcision programmes following evidence that the surgical procedure can protect against HIV infection.

The World Health Organisation and UNAids, the joint UN programme on HIV/Aids, made the official recommendations after a meeting of experts in Montreux, Switzerland, to consider the evidence from three trials in Africa, which were stopped early when it became clear that men who had been circumcised were up to 60% less likely to get HIV than those who had not.

Experts accept circumcision is a sensitive issue, tied in to social and religious traditions. During sectarian fighting in India, Muslims and Hindus at one time would tell friend from foe by pulling down their trousers - all Muslims were circumcised.

But research suggests men and women in Africa would accept male circumcision if it lowered the risk of Aids, and WHO experts yesterday held out the prospect of cultural change over a decade or more. Catherine Hankins, associate director of the WHO, said that within about a decade in the 1980s and 1990s, South Korea went from no circumcision of boys to circumcising 90%, influenced by the example of the US.

WHO and UNAids recommend that all heterosexual men should be offered circumcision in countries with severe Aids epidemics. "We are talking largely or most importantly about countries of sub-Saharan Africa and to a lesser extent eastern Africa," said Kevin de Cock, director of the Aids department at the WHO. But he said it was for countries to decide whether and how to implement the guidance. He expected discussions would now take place on the implications in countries in Europe and the US. However, there is no evidence yet that circumcision offers any protection to men who have sex with men.

Circumcision could bring many benefits in the long term - it is estimated that universal male circumcision in sub-Saharan Africa, where HIV/Aids is most prevalent, could prevent 5.7 million new infections and 3 million deaths over 20 years.

But the WHO's experts yesterday tempered enthusiasm with considerable caution. Circumcision, they say, must not be seen as a magic bullet. It is only partially protective, and they fear some men may assume they can sleep around with impunity and no longer need to practise safe sex techniques, such as wearing a condom.

"We haven't had news like this in an extremely long time," said Dr Hankins. "It is an exciting development, but it is partial protection for men. Circumcised men can still become infected and can still transmit the virus to their partners."

The logistics of rolling out circumcision are formidable for impoverished countries burdened with Aids and already struggling to test, counsel and treat all who arrive at their clinics. The WHO is recommending they first focus on adult males, even though the procedure is easier in babies, because it is most urgent to reduce infections in the sexually active age group.

It emphasises the importance of sensitivity, counselling and a lack of coercion when offering circumcision and that those who perform it are trained and perform the procedure in a hygienic setting. The WHO also wants donor governments to help fund programmes.

Dr de Cock said the meeting of experts that decided on the guidance disagreed on little, although "there are people who are very concerned that male circumcision has such heavy social and cultural connotations that they would want more data from the world of social science before making any recommendations".

Some spoke in terms of "symbolism and assault on the body's integrity", he said. But set against that was the weight of the disaster that Aids represented in Africa. "The thing to me that comes closest to the Aids epidemic for its assault on African culture is slavery," said Dr de Cock.

At a glance: Circumcision

Circumcision is almost as old as mankind. The first evidence of the ritual removal of all or part of the foreskin as a rite of puberty comes from aboriginal tribes around or before 10,000 BC, followed by communities in north-eastern Africa and the Arab peninsula some 4,000 years later.

The Jewish tradition of male circumcision dates back to the book of Genesis, part of the Torah, which told of God's command to Abraham that he should circumcise himself and his sons. Circumcision was considered a sign of the Covenant.

Jesus was circumcised, but St Paul ruled that converts to Christianity did not need to undergo the operation. In 570, Muhammad was born "already circumcised" which is said to have given rise to universal circumcision among Muslim men.

As the centuries moved on, arguments raged over circumcision. The foreskin was identified as the most sensitive part of the penis by the Italian anatomist Jacopo Berengario da Carpi in the 15th century. In the 1800s removal of the foreskin became widespread in Britain and the US to prevent boys masturbating. About a quarter to a third of the world's males are circumcised, most of them Muslim or American.

Sarah Boseley, health editor
Thursday March 29, 2007
The Guardian