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GNP+ participated in the WHO/UNAIDS meeting on circumcision in Montreux from 6 to 8 March. The meeting presented the current evidence on the role of male circumcision in HIV prevention; identified potential models for the impact and cost effectiveness of male circumcision as HIV prevention option; and fostered in-depth discussion on policy and programme implementation issues.
The summary and recommendations will be available in 10 to 14 days, at which time GNP+ will distribute them widely and provide editorial comments based on the discussions during the meeting. There's no point now in speculating what will get into the report. In this message we will outline some of the evidence for male circumcision as a prevention intervention and discuss what the modelling shows us.
Evidence for circumcision
There is substantial evidence that circumcision performed in a clinical trial setting under sterile conditions with intensive counselling and access to condoms can reduce HIV transmission to HIV-negative men by up to 60%. This is significant and will likely result in significant HIV transmission reduction in non-clinical trial settings. However, this is a PARTIAL reduction in transmission and communication messages should be clear that condoms must still be used.There is no evidence for substantial benefit or risk to men living with HIV. There is no evidence that circumcision can prevent the transmission of HIV from HIV-positive men to HIV-negative women. In fact, one trial was stopped early due to worries that circumcision of HIV-positive men can increase transmission to HIV-negative women because the men did not wait until their wounds were healed before recommencing sexual activity with their partners.There is little evidence to suggest that risk compensation happens after circumcision; however, the uptake of condom use in circumcised men is still very low and this must still be monitored to evaluate the effect on women.
Modelling
Male circumcision can reduce prevalence by up to 40% in communities over a 10 to 20 year period Male circumcision - even when condoms are not used optimally - still provides a protective effect. Risk compensation (the phenomenon of decreased condom use after circumcision) must be massive to overcome the effects of circumcision. Male circumcision will have the most impact in areas where circumcision is currently NOT being practised; where the prevalence of HIV is high; and where there is a large population. Cost-effectiveness models show that cost is not a barrier to implementing male circumcision
Discussions
There were basically two camps: researchers and policy makers invested in male circumcision on the one hand and "generalists" on the other. The former include social researchers, sexual and reproductive health people, human rights experts, etc. In general, the issues of most concern to women and people living with HIV were taken up and the discussions were productive and respectful. We were reminded that the WHO and UNAIDS can make recommendations but that countries decide how to implement them. Therefore, many of the non-researchers were pushing for strong language in the guidelines, especially around gender and resource allocation.
Donors were clear that they were willing to fund male circumcision but not at the cost of other programmes, although the Global Fund did indicate that they could be willing to consider reallocation from other prevention services (not treatment) once consensus on male circumcision was obtained and guidelines were issued.
GNP+ proposes to wait until the publication of the recommendations before commenting further on the meeting in order to avoid speculation. Our initial feeling is that the recommendations will be comprehensive and acceptable. The difficulty will be to monitor how they are implemented in countries.
Once the recommendations are released, GNP+ will provide an editorial to the guidelines to reflect the issues that were important to people at the meeting and make suggestions on advocacy and programme monitoring.
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