Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia
Version 3.1(Dec09)
PREFACE
Male circumcision has been performed on boys and young men for many years, primarily for
religious and cultural reasons or as a rite of passage to mark the transition to adulthood.
Data from cross-sectional epidemiological studies conducted since the mid-1980s showed
that circumcised men have a lower prevalence of HIV infection than uncircumcised men.
This finding was supported by data from prospective studies that showed a lower incidence
of HIV infection in circumcised men than in uncircumcised men. Although the analysis
adjusted for cultural and social factors associated with male circumcision, it was not clear
from these studies whether promoting male circumcision among men who would not
otherwise be circumcised would result in a lower incidence of HIV infection. To address this
question, three randomized controlled trials were launched in Kenya, Uganda and South
Africa in 2004. The results from the South African study were published in late 2005, and
showed a 60% lower incidence of HIV infection among men randomly assigned to undergo
immediate circumcision compared with those assigned to delayed circumcision.
Confirmatory results from the two other trials were released in December 2006. These data
led WHO and UNAIDS to recommend in 2007 that male circumcision should be considered
an additional way of reducing risk of HIV infection in men and programmes for safe male
circumcision should be expanded rapidly in countries and settings with generalized HIV
epidemics and low prevalence of circumcision.
There is increased demand for male circumcision in several countries with a high incidence
of HIV, but there is little technical guidance on how services can be safely expanded given
the limited resources available. Reports of high complication rates following circumcisions
performed on young men by traditional circumcisers in southern and eastern Africa are
common, but the true incidence is not known. Technical guidance on the provision of safe
male circumcision services is therefore necessary. Although circumcisions are widely
performed by surgeons and general practitioners in an appropriate clinical environment,
resources are not currently adequate to meet the anticipated increased demand.
This technical manual on male circumcision is aimed at providers of male circumcision
services and programme managers. No attempt is made to describe all possible methods for
male circumcision. The methods covered have been selected on the basis of their safety and
practicality for use in resource-limited settings. The manual forms part of a comprehensive
package, which includes training guides and materials, as well as a male circumcision
quality improvement framework for use by providers, programme managers and national
medical authorities to ensure high-quality services. While providing detailed technical
information on the different surgical approaches, the manual also addresses broader issues
of sexual and reproductive health of men, and emphasizes that male circumcision must be
set within the context of other strategies for reducing risk of HIV infection. A full description
of best practices for surgery and anaesthesia in resource-limited settings can be found in the
WHO publication, Surgical care at the district hospital (Geneva, WHO, 2003).
The manual has been developed by the World Health Organization (WHO), in collaboration
with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and Jhpiego, as part of
work to support countries in providing safe male circumcision services, and ensuring that
circumcised men do not perceive themselves as fully protected against HIV and other
sexually transmitted infections and consequently forgo other HIV risk-reduction strategies.
The manual was developed from reproductive health and surgery training materials, as well
as on the basis of experience with service provision in Africa, the Eastern Mediterranean,
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