| Male Circumcision (August 2008) PDF version
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President George W. Bush's
Emergency Plan for AIDS
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Male Circumcision
In accordance with WHO/UNAIDS normative guidance, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) supports safe medical male circumcision (MC) for HIV/AIDS prevention based on requests from host governments and in keeping with their national policies, guidelines and cultural norms.
PEPFAR recognizes that medical male circumcision can be an important part of HIV prevention programs. At the same time, it is important that male circumcision be safely provided and that it be integrated into, and not substituted for, a comprehensive HIV/AIDS prevention program. Given the possible misperception that circumcision eliminates HIV transmission risk, MC efforts must reinforce the “ABC” approach – Abstain, Be faithful and correct and consistent use of Condoms – and must be linked to voluntary HIV counseling and testing, as well as screening and treatment of sexually transmitted infections (STI).
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The Power of Partnerships:
- In fiscal year 2007, PEPFAR allocated approximately $16 million to support male circumcision activities with that figure increased to nearly $26 million in fiscal year 2008. These funds support activities in Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, and Zambia.
- Male circumcision programs provide linkages to other PEPFAR-supported programs addressing HIV counseling and testing, gender norms, medical injection safety, prevention of sexual transmission, and HIV care and treatment.
- PEPFAR maintains a collaborative relationship with other global agencies, such as WHO/UNAIDS and The Bill and Melinda Gates Foundation, to ensure that medical male circumcision services are provided as safely, effectively, and quickly as possible in order to provide the most positive impact in the prevention of HIV/AIDS.
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PEPFAR-supported MC activities include a comprehensive approach to HIV prevention:
- MC is an elective surgical procedure using local anesthesia following education and consent of the client. MC is delivered within the context of comprehensive HIV prevention messages and services including HIV counseling and testing, STI assessment and treatment, HIV prevention counseling following the ABC approach, post-operative wound care, and provision of male and female condoms.
- Under the leadership of host country governments, and consistent with local policies and norms, PEPFAR supports the implementation of safe medical male circumcision services performed in clinical settings by trained personnel.
- Country activities pertaining to male circumcision include: facility and community assessments; clinical trainings; development of communication and counseling approaches; working with host country governments to establish quality assurance and medical ethical standards; service provision; and supporting integration of male circumcision components into surveillance and supply chain management systems.
- It is critical to ensure appropriate tracking, follow-up and treatment of any complications, while continuing to emphasize the importance of comprehensive prevention approaches.
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Male Circumcision Trial Findings:
- Three randomized controlled clinical trials in sub-Saharan Africa demonstrated a 50-60% reduction in risk of female-to-male HIV transmission among men randomized to receive circumcision compared to uncircumcised controls. This evidence is supported by long-standing ecologic and observational data.1
- Elective surgical male circumcision confers a partially protective effect against HIV acquisition for HIV-negative men at risk of acquiring HIV from HIV-infected female sexual partners, and may be particularly effective in populations where HIV prevalence is high and male circumcision prevalence is low.
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PEPFAR at Work
The following examples illustrate how PEPFAR is working in partnership with host nations to support the scale-up of comprehensive male circumcision services:
- In Zambia, PEPFAR continues to support a broad approach to prevention which includes male circumcision. Safe and effective medical male circumcision services are now provided at various sites to reduce new HIV infections and other sexually transmitted diseases. Working with the Ministry of Health, male circumcision is offered at the University Teaching Hospital in Lusaka and the General Hospital in Livingstone, as well as through satellite facilities. PEPFAR is also supporting training, public health evaluation on neonatal circumcision, and the development of comprehensive prevention messages to accompany medical male circumcision services.
- In Botswana, after former President Festus Mogae called for adding male circumcision to Botswana’s HIV/AIDS prevention approach in November 2007, the Ministry of Health developed a five-year strategy aimed at reaching 80% coverage. Currently less than 20% of males in Botswana have access to male circumcision services. PEPFAR supports Ministry of Health efforts to complete an assessment of what is needed to scale-up male circumcision. PEPFAR also supports the development and implementation of a male circumcision communications strategy and program, and is exploring possible opportunities to engage the private sector to provide male circumcision services. PEPFAR has allocated funding for male circumcision training and services and is working with the national Male Circumcision Reference Group and the Male Circumcision Technical Working Group to plan implementation.
- In Swaziland, the National Male Circumcision Task Force provides leadership in directing a national approach for scale-up of male circumcision services. PEPFAR has worked in collaboration with the Swaziland Ministry of Health and the World Health Organization to assist in the development of a National Male Circumcision Policy and Implementation Plan. PEPFAR is supporting the Ministry of Health to roll out medical male circumcision services in public hospital facilities and through local non-government organizations.
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1 Citations:
RH Gray, G Kigozi, D Serwadda, et al. Male circumcision for HIV prevention in young men in Rakai, Uganda: a randomized control trial. AIDS. Lancet. 2007 Feb; 369: 657-66.
RC Bailey, S Moses, CB Parker, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized control trial. Lancet. 2007 Feb; 369: 643-56.
B Auvert, D Taljaard, E Lagarde, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298. Epub 2005 Oct 25.
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