Manual for Male Circumcision under Local Anaesthesia

Male circumcision under local anaesthesia Version 2.5C (Jan08)
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. A further
trial, which is assessing the impact of male circumcision on the incidence of HIV infection in
female partners, is underway, but is not expected to provide results before end 2008.
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,
and developed countries. The manual and materials were reviewed by actual and potential
providers of male circumcision services representing a range of health care and cultural
settings where demand for male circumcision services is high.
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Male circumcision under local anaesthesia Version 2.5C (Jan08)
ACKNOWLEDGEMENTS
This manual is based on the work of a large group of clinical and public health experts who
participated in technical consultations and reviews. Particular thanks are due to the
following:
- Tim Hargreave and Emmanuel Otolorin who wrote and edited the draft manual;
- the Orange Farm, Kisumu and Rakai study teams, who generously shared slides, videos
and training materials;
- Robert Bailey, Palesa Mohaleroe, Emmanuel Otolorin and Stephen Watya for
photographic illustrations;
- Oheneba Owusu-Danso and Kwabena Danso for photographs and a description of the
Gomco clamp method, from which the illustrations were made;
- Bill Mansen and John Orr for review of Chapter 7;
- Micheline Diepart, Gerald Dziekan and Selma Khamassi for review of Chapter 8;
- Gillian Kidd, Department of Medical Illustration, University of Edinburgh, Scotland who
prepared the illustrations of the surgical methods;
- Melanie Bacon, Robert Bailey, AS Chawla, Han-Sun Chiang, Kelly Curran, Adam
Groeneveld, John Krieger, Jasper Nduasinde, Redouane Rabii, and Stephen Watya
who provided detailed written comments on the manual;
- Joanne Ashton, Joint Commission International;
- Bertran Auvert, Melanie Bacon, Kasonde Bowa, Dy Bun Chhem, Kelly Curran, Adam
Groeneveld, Tim Hargreave, Chris Heyns, Martin Kaluwaji, Sifuni Koshuma, Chiapo
Lesetedi, Palesa Mohaleroe, Samuel Mutamba, Jasper Nduasinde, John Opeya Oloo,
George Shawi Shilaluke, Ajit Sinha, B.S. Toma, Stephen Watya and Charles Wiysonge
who participated in a technical review of the draft manual in Montreux, Switzerland, in
April 2006; and
- Khalil Abu-Dalu, Adam Abzak, Yona Amitai, Zahavi Cohen, Cyril Fine, Esther Galili,
Benjamin Gesundheit, Debby Gedal-Beer, Eitan Gross, Mordechai Halperin, Pinhas
Livne, Yoram Mor, Neil Perlman, Hanni Rosenberg, Inon Schenker, Francis Serour, Eli
Simhi and Moshe Westreich, for detailed review and comments during a technical
meeting in Jerusalem, Israel, in December 2006, facilitated by the Jerusalem AIDS
Project.
The technical content of the manual has been reviewed by representatives of the Pan-
African Urological Surgeon’s Association (PAUSA), the Korean Andrology Society, the
Taiwan Andrology Society, and the Israeli Association of Paediatric Surgery.
The development of the manual was coordinated by Tim Farley and Manjula Lusti-
Narasimhan (WHO Department of Reproductive Health and Research), Isabelle de Zoysa
(WHO Family and Community Health Cluster), Kim Dickson and George Schmid (WHO
Department of HIV and AIDS) Meena Cherian (WHO Department of Essential Health
Technologies), and Cate Hankins (UNAIDS). Final technical editing and layout were
undertaken by Pat Butler and …, respectively.
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