A need for caution, counselling, and testing
The March 2007 WHO/UNAIDS document, New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications, does not recommend circumcision for HIV-positive men. It also states that HIV-positive men and men who do not know their HIV status should not be denied male circumcision. This latter position reflects the possibility that denying male circumcision on the basis of HIV status could 1) increase stigma among HIV-positive men who are not circumcised and 2) increase the chances that HIV-positive men will seek surgery from unsafe or poorly-trained providers if they are turned away from medical points of service.
To date, there have been three randomised controlled trials of male circumcision for HIV prevention. These studies enroled HIV-negative men. A separate trial in Uganda's Rakai District enroled HIV-positive men and men who did not wish to know their status. Much of what is known today about the safety and efficacy of male circumcision in HIV-positive men comes from this trial. These findings, which are summarised below, raise additional questions that must be carefully explored as programmes expand.
The primary findings are based on a trial of HIV-positive men with CD4 cell counts above 350. This trial also enrolled the female partners of these men. It took place at the same site as a study of male circumcision in HIV-negative men, so it was possible to compare rates of wound healing, adverse events, and sexually transmitted infections (other than HIV) between the two groups.
Research findings to date
In the Rakai district study, male circumcision was safe for HIV-positive male volunteers. There was some evidence that HIV-positive men took longer to heal post-surgery compared to their HIV-negative counterparts. However, overall rates of post-operative complications and adverse events were comparable between the groups of HIV-positive and HIV-negative volunteers. Circumcision appeared to reduce HIV-positive men's risk of genital ulcer disease.
The female partners of HIV-positive men who resumed sex before complete wound healing appeared to have a greater risk of becoming infected six months after their partners' circumcision than did the female partners of HIV-positive men who did not resume sex before complete wound healing.
The WHO/UNAIDS document leaves a range of options for programme implementation. Some critical issues include: safety, rates of wound healing and adverse events in HIV-positive men who have CD4 cell counts below 350 and/or are immunocompromised, and optimal strategies for involving couples in counselling and testing prior to surgery.
The issues surrounding male circumcision for HIV-positive men are of great concern and interest to a range of civil society groups working in HIV prevention treatment and care, including groups of women, HIV-positive women, and sexual and reproductive health advocates.