Medical Male Circumcision: thinking through the impact for a feminised epidemic

Issue Backgrounder: Male Circumcision for HIV Prevention: Implications for Women

Overview
In March 2007, WHO/UNAIDS released recommendations confirming that adult male circumcision, although only partly protective, now be recognised as an additional important intervention to reduce the risk of heterosexually acquired HIV infection in men. The recommendations concluded that there is strong evidence fmm three randomised control trials and other data that male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%.

Given that women and girls remain most affected by HIV worldwide, it is absolutely critical to ask: What do these findings mean for women?

The answers to this question are still emerging. At present, information contillues to be gathered from long-term follow-up in communities whem trials took place, and as programmes begin to scale up in various settings. As these activities continue, it is critical to consider the potential benefits and concerns surrounding male circumcision for HIV prevention and its implications for women.

Some potential benefits:
In the randomised clinical trials men's risk of HIV infection dropped by 60%. This is the individual benefit of the intervention, if male circumcision for HIV prevention is scaled up in high HIV prevalence areas, where there are low rates of male circumcision, fewer men would acquire HIV infection thus reducing the risk of exposure to their female partners. This process is 36 Nursing Update August 2008 termed secondary protection and it translates into a potential population-level benefit for the intervention over the long term. Male circumcision also reduces rates of genital ulcer disease and STIs in men here, too, there could be a secondary benefit for women because these infections are co-factors for HIV transmission.

Long-term observational studies in Rakai, Uganda that looked at male-to-female HIV transmission suggested that women's risk of acquiring HIV from their HIV-positive partners dropped by roughly 60% if those partners were circumcised. This data was from a study that predated the randomised control trial. In this case, the HIV-positive men had been circumcised at birth. However, other observational data from studies in different settings do not confirm these findings. In addition, as is discussed below, the findings from the randomised control trials of male circumcision in HIV-positive men are not as clear.

Male circumcision is an intervention that brings men into contact with the health services. Historically, it has been difficult to reach men with information and services related to HIV, STIs and sexual and reproductive health. Well-designed male circumcision programmes could use the intervention as an entry point for a range of other selvices, including couples counselling, domestic violence interventions and condom promotion.

One trial in Rakai, Uganda found that women with circumcised male partners had lower rates of genital ulceration, bacterial vaginosis and trichomonas infections, which benefits the woman.

Alongside these benefits, there are aJso concerns:
The data available from the one randomised clinical trial of male circumcision in HIV-positive men to date suggest that circumcision did not protect female partners from HIV. Among couples who resumed sex before the man's circumcision wound was completely healed, transmission of HIV to their female partners was higher than with men who delayed resumption of sex and higher than uncircumcised, HIV-positive men, While there are some limited data from clinical trials about how male circumcision affects condom use, alcohol use and number of sexual partners among circumcised men, these are limited as they come from clinical trials in which men received regUlar counselling and condom access. Additional information is needed on the risk behaviours that have already been measured and on other factor such as coercive sex and domestic violence.

How will male circumcision a surgicai intervention that requires clean equipment and specific training for practitioners, be integrated into other HIV prevention offerings? What will the impact be on counsellors, health professionals, community educators and advocates, including HIV-positive women, who are working in other areas of HIV treatment, prevention and care? There is also a clear need to increase communication around what is known and unknown, and to ensure the engagement of a wide variety of women's and community groups with research findings and ongoing work.