Circumcision: A quick cut to reduce the risk of AIDS

prevention is better than cure Young men in two separate compartments at a clinic in South Africa waiting to undergo circumcision. NYT

Young men have flocked by the thousands to this clinic for circumcisions, the only one of its kind in South Africa. Each of them lies down in one of seven closely spaced surgical tables, his privacy shielded only by a green curtain.

“I’ve done 53 in a seven-hour day — me, myself, personally,” said Dr Dino Rech, who helped design the highly efficient surgical assembly line at this French-financed clinic for cutting off foreskins.

Circumcision has been proven to reduce a man’s risk of contracting HIV by more than half. Yet two years after the World Health Organisation recommended the surgery, the government here still does not provide it to help fight the disease or educate the public about its benefits.

Some other African nations are championing the procedure and bringing it to thousands. But in South Africa, the powerhouse country at the heart of the epidemic, the government has been notably silent on the issue, despite the withering international criticism the country has endured for its previous foot-dragging in fighting and treating AIDS.

“Countries around us with fewer resources, both human and financial, are able to achieve more,” said Dr Quarraisha Abdool Karim, the first director of South Africa’s national AIDS programme in the mid-1990s under President Nelson Mandela. “I wish I understood why South Africa, which has an enviable amount of resources, is not able to respond to the epidemic the way Botswana and Kenya have.”

Even without government involvement, demand for the surgery, performed free under local anesthetic, has surged over the last year here at the Orange Farm clinic. The men are counselled to continue using condoms, since circumcision provides partial, though substantial, protection.

Additional benefit
Men waited nervously one recent chilly morning for their turn. Most were hoping the procedure would help them stay healthy here in the nation with more HIV-positive people than any other. But some said they were also drawn by a surprising, if powerful, motivation: They had heard from recently circumcised friends that it makes for better sex. You last longer, they said. Your lovers think you’re cleaner and more exciting in bed.
“My girlfriend was nagging me about this,” said Shane Koapeng, 24. “So I was like, ‘OK, let me do it.’”

As new HIV infections have continued to outpace efforts to treat the sick in Africa, there is growing concern about the ballooning costs of treatment for an ever-expanding number of patients who need medicines for the rest of their lives. Almost 2 million people were newly infected in 2007 in sub-Saharan Africa, bringing the total of those living with HIV in the region to 22 million, according to UN estimates.

The major international donors to AIDS programmes, including the US and the Global Fund to Fight Tuberculosis and Malaria, are ready to pour money into male circumcision, but the countries have to be ready to accept the help.

“You can’t impose it from the outside, particularly such a sensitive intervention,” said the Global Fund’s executive director, Dr Michel Kazatchkine.
Public health doctors agree that circumcising millions of men will be no simple task. Africa has a severe shortage of doctors and nurses, and circumcision is potentially a political and cultural minefield in countries where some ethnic groups practice it but others do not.

Still, some countries are showing it can be done. In Botswana, circumcision was largely stopped in the late 19th and early 20th centuries by British colonial-era administrators and Christian missionaries. But Festus Mogae, who was president from 1998 to 2008, provided a critical endorsement of male circumcision just before he stepped down.
Over the past year, the government has trained medical teams to do circumcisions in all its public hospitals and aims by 2016 to have circumcised 4,70,000 males from infancy to age 49, which is 80 per cent of the total number in that group. Public awareness is being raised through advertisements on radio and television. Billboards have sprouted across the country featuring a star of the national youth soccer team.

“Men have started to flock to the hospitals,” said Dr Khumo Seipone, director of HIV/AIDS prevention and care in Botswana’s Ministry of Health.

In Kenya, where the Luo do not generally practice circumcision, Prime Minister Raila Odinga, himself a Luo, encouraged the procedure and lobbied elders. The HIV infection rate among Luo men is more than triple that of Kenyan men generally —17.5 versus 5.6 per cent.

Done everywhere
So far, more than 20,000 men in Kenya have been circumcised in hospitals, dispensaries, village schools, social halls and tents. Teams of doctors, nurses and counsellors have even taken boats to islands in Lake Victoria to circumcise Luo fishermen.

In sharp contrast, male circumcision has no political champion in South Africa, where the largest ethnic group, the Zulus, have generally not practiced it since the early 19th century, when it was abandoned due to protracted warfare, according to Daniel Halperin, an epidemiologist and medical anthropologist at Harvard University.

Thabo Masebe, a spokesman for President Jacob Zuma, said the health ministry must first set a policy on circumcision before Zuma, who took office in April, can take a position. Zuma is Zulu. The province of KwaZulu-Natal, the Zulu heartland, has the highest adult HIV prevalence rate in the country, 39 per cent, according to UNAIDS.

“The president gets involved when decisions are made,” Masebe said. “If the president spoke now, and when the time comes to make a policy, a different decision is taken, it wouldn’t sound good.”

South Africa has made strides in recent years, and now provides antiretroviral therapy to more people with AIDS than any other developing country. But this is not the first time its policies have lagged behind. The country delayed for years providing antiretroviral medicines to treat AIDS under its former president, Thabo Mbeki, who denied the scientific consensus about the viral cause of the disease. Harvard researchers estimated that the government would have prevented the premature deaths of 3,30,000 South Africans earlier in the decade if it had provided the drugs.

“South Africa has no shortage of scientists,” said Olive Shisana, chief executive officer of South Africa’s government-financed Human Sciences Research Council. “We have a shortage of people willing to take the evidence that exists and use it for public health.”

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