Male Circumcision and HIV Prevention: Directions for Future Research

Male circumcision is increasingly being considered as a preventive medical procedure to reduce the acquisition of sexually transmitted HIV infection. This report presents the findings of a two-day meeting of international researchers, which the Horizons Project convened in February 2000 to explore the programmatic and research implications of the association between male circumcision and HIV prevention. Meeting participants addressed the following questions:

• Is there sufficient evidence to propose male circumcision as a feasible public health intervention to slow the spread of HIV?
• What are the operations research issues relevant to male circumcision and HIV prevention?
• What are the next steps to be taken in the area of male circumcision and HIV research?

This report presents the findings of the meeting in three parts. It begins with a discussion of the current state of research and an identification of major gaps in knowledge and understanding. (Among the unknowns are "the mechanisms and the role of the foreskin in the acquisition of HIV infection by men; the existence of, as yet, unexplored confounders in the attribution of causality; and the expected effect of male circumcision on HIV infection in different populations.") This is followed by a discussion of operations research issues, which include:

• Traditional and clinical circumcision practices - are they safe?
• Acceptability of male circumcision as a public health intervention
• Age at circumcision
• Gender and ethical issues
• Is male circumcision a feasible public health intervention?
• Behavioural implications of male circumcision
• The effect of male circumcision on male-to-female transmission of HIV
• Cost-effectiveness of male circumcision in HIV prevention.

The report concludes by listing recommendations for future research. Among the general recommendations are that randomised controlled trials (RCTs) be conducted among potentially high-risk males, though such trials "are nevertheless fraught with methodological and ethical difficulties". In contrast, "studies on attitudes toward and understanding of the benefits of male circumcision are relatively easy to conduct, as is an assessment of current circumcision practices." Recommendations specific to Horizons are also offered; they include "integration of assessment of attitudes toward and acceptability of male circumcision in ongoing studies, development and field test of a rapid assessment tool, collaboration in modeling the cost and impact of male circumcision interventions, and development of proposals for longer-term studies on cost, safety, and outcomes of male circumcision in the context of HIV prevention."

In short, in light of the fact that "this procedure has profound cultural implications and carries the risk of complications, and its benefits are realized only many years later", participants concluded that it would be premature to recommend male circumcision in currently non-circumcising communities, pending further research on its safety, feasibility and effectiveness at preventing HIV.