GNP+ welcomes the convincing evidence of circumcision as an HIV prevention strategy, as presented at last March's WHO/UNAIDS Montreux Consultation on Circumcision in which GNP+ participated. The discovery of prevention strategies with such high effectiveness is rare.

The guidance issued by WHO/UNAIDS is not based on a consensus reached at the Montreux consultation; rather, it reflects "a fair summary of the diverse discussions held", according to WHO. While most of the guidance is rational and based on the best advice and science available today, GNP+ is concerned about how some of the points might be interpreted in national plans and community programmes.

• Any circumcision programme must be implemented in the context of a comprehensive prevention programme that includes the promotion of condoms, counselling, informed consent and continued messaging around safer sex strategies, which reflects the conditions under which the clinical trials were conducted. This reflects the situation in which the clinical trials took place. Without these complementary strategies, the prevention rates of circumcision will not approach the 60% level achieved in the trials. In fact, circumcising large numbers of men without this prevention programme may result in a public health threat.


• Circumcision programmes must be seen as an add on to current programming, instead of stand alone progammes. The WHO/UNAIDS Guidance suggests that vertical programmes could be implemented as a short-term measure in order to fast-track circumcision implementation. There was no consensus on this at the Montreux consultation and a number of participants and donors disagreed with a vertical approach to circumcision programme implementation. The experience with other vertical programmes (VCT, PMTCT, among others) has demonstrated that this is not the most effective approach to programme implementation with HIV/AIDS. Furthermore, the added value of counselling and complementary services (including sexual and reproductive health services, sexuality counselling, access to treatment and care, etc.) will ensure the maximum effectiveness of circumcision programmes.


• Related to this, it is imperative that circumcision programmes be added to - and not substitute - existing HIV/AIDS programmes within a country's plan to scale up to universal access to treatment, care and prevention. Targets must be set within the national universal access plans and additional funding must be found to support the addition of circumcision programmes. Under no circumstances should resources be diverted from other prevention, treatment or care programmes.


• Circumcision programmes must be set up in a manner that enables the evaluation of the impact on women. Women must be involved in monitoring the outcomes of circumcision programmes, including possible changes in men's sexual behaviour as a result of their circumcisions. Already, women are more at risk of HIV infection than men and are much more likely to be victims of gender-based violence. If men perceive that they are impervious to HIV infection after they are circumcised, the chance exists that their behaviour could become more reckless and/or violent. Women must be engaged in monitoring eventual changes in men's behaviour.


• Currently the WHO/UNAIDS Guidance does not recommend to circumcise HIV-positive men. It must be stressed that the guidance does not mean that HIV-positive men should not be circumcised. This is an important point. What the Guidance states is that - at this time - there is not enough evidence to demonstrate a protective effect of circumcision for HIV-positive men or their partners to warrant a recommendation to circumcise. GNP+ is concerned that this recommendation could be misinterpreted to prohibit HIV-positive men from receiving circumcision services. This could have an amplifying effect on the existing stigma and discrimination experiences by HIV-positive men if their participation or inclusion in activities in society is determined by their circumcision status. Circumcision should not be a pre-requisite for inclusion in any activities in society, including sexual activities. However, if this recommendation is misinterpreted when implementing circumcision programmes, men living with HIV are open to discrimination as their foreskins would set them apart as living with HIV. Circumcision services should be offered to all men who want them and, as stated in the WHO/UNAIDS Guidelines, not conditional on an HIV-negative test. Circumcision should be offered to men on a voluntary basis - under no circumstances should circumcision be forced, coerced or mandatory for men living with or without HIV.


• Groups of people living with HIV are already involved in implementing prevention, treatment and care programmes. GNP+ urges countries to include PLHIV groups in their plans to implement circumcision programmes in order to capitalise on the knowledge, experience and expertise.


• Many have called on the involvement of civil society in monitoring the implementation of circumcision programmes in countries. GNP+ recognizes the importance of such a call but notes that this call provides no recognition of the lack of resources within civil society groups to do so.

GNP+ encourages PLHIV networks and groups to consult especially AVAC's advice A New Way to Protect Against HIV?.? Please also refer to the joint position of the three Pan-African community networks, NAP+, SWAA & AFRICASO.