US Aids fund targets circumcised males

PETER NYANZI

KAMPALA

THOUSANDS of Ugandan men could benefit from circumcision as a means to prevent the spread of HIV/Aids, thanks to a US fund to fight the pandemic in Africa.
President George Bush set up the fund a few years ago.

The Washington Post, a US daily reported last week that the President's Emergency Plan for Aids Relief (Pepfar) - a $15 billion anti-Aids effort - would begin investing significantly in making circumcision available to African men seeking to protect themselves from HIV infection.

The paper quoted a delegation of US officials, led by the Health and Human Services Secretary, Mr Mike Leavitt, telling reporters in Johannesburg, South Africa that recent research showing that circumcision dramatically cuts the rate of HIV infection is 'highly convincing.'

Countries taking part in the Pepfar have been invited to seek money to expand access to the procedure, the paper said, adding that circumcision would become "an important part" of the programme in the coming months and years.

Uganda is one of the 15 countries that are beneficiaries of the programme. The country received $170 million (Shs290 billion) in 2006 alone, mainly for the provision of ARV treatment, prevention, care and support to infected individuals and orphans.
The Pepfar Emergency Plan Coordinator at the US Embassy in Kampala, Ms Premila Bartlett, declined to comment on how the programme would be implemented.

She referred Daily Monitor to the Public Affairs Officer, Ms Lisa Heilbron, who could not be reached by press time yesterday. Recent studies in Uganda, Kenya and South Africa indicate that the cells in the foreskin of a penis are especially vulnerable to HIV, and removing the foreskin makes a man about 60 per cent less likely to contract the virus.

Other studies have also shown that uncircumcised men are more likely to have genital ulcers, and the presence of ulcers can facilitate the transmission of HIV.
The Washington Post report said Kenya is among the nations preparing to expand circumcision services.

The US government had been reluctant to support circumcision until there was broad international consensus on the issue, but recent studies have said circumcision would be one of the major interventions in the 'international arsenal' against the disease.
However, some disagreements remain over how to introduce circumcision as a prevention activity, and its likely impact.

For example, a new study has shown that male circumcision does not reduce a woman's risk of catching HIV if her partner already has the virus.
The study published in the August 20th edition of the journal Aids, was conducted in Uganda and Zimbabwe.

However, it did show that women with high levels of sexual risk were slightly less likely to contract HIV if their partners were circumcised, and the investigators suggest that this finding should be explored in further studies.

http://www.monitor.co.ug/news/news082911.php

Uganda: Circumcision And Facts About HIV

The Monitor (Kampala)

OPINION
23 August 2007

Phill Wilson,
Executive Director,
Black Aids Institute.

President George Bush's administration revealed on Sunday that it will use part of its $15 billion-a-year global Aids programme to promote male circumcision in sub-Saharan Africa as an HIV prevention tool. The news is a welcome development that, for once, puts science at the forefront of the administration's response to this epidemic.

However, both abroad and here at home, educating people about circumcision as a way to slow HIV's spread is a necessarily sensitive endeavour. Everybody involved will have to abandon old bad habits if we are to have a sober dialogue about reducing HIV risk. Public health must respect communities' traditions and individuals' choices; communities and individuals must discard reflexive distrust of public health.

Study after study has found that HIV transmits far less easily through the skin of a circumcised penis than it does when the foreskin is still intact. Circumcision is a procedure in which the foreskin covering the tip of the penis is removed.

The most widely reported studies establishing the prevention benefits of circumcision come from Kenya, South Africa and Uganda, completed in 2005 and 2006. Researchers tracking groups of circumcised and uncircumcised men in those countries found the rate of HIV infection among men who had their foreskins removed to be anywhere from 51 percent to 76 percent lower. Those are big numbers, and they're just the latest studies to come up with such striking results.

Why does circumcision make such a difference? There are many theories. Laboratory studies have however established that the foreskin's inner lining has a high density of the cells that HIV targets.

Researchers also believe circumcised skin is both less porous and less likely to tear during intercourse, and thus provides fewer openings through which HIV, or other pathogens, can pass. More studies should pursue the question.

Meanwhile, public health must begin to make people aware of the dramatic difference circumcision appears to make in HIV risk. So as the Bush administration gears up its response to the compelling data on circumcision, it will be well advised to help local leaders do the leading, which is something its Aids programme has proven reluctant to do in the past.

That includes investing in raising the HIV-science literacy among local leaders and supporting culturally appropriate venues where communities can develop the tools needed to interpret the science.

No matter what the Bush administration does, and no matter what any local health department does here in the U.S., we must learn the facts about circumcision and HIV.

It is an entirely appropriate choice for any individual to opt against circumcision as a method of HIV prevention. But he must make that choice based on the facts, not as a self-defeating reaction to fears about government abuse.

http://allafrica.com/stories/200708230520.html

UK backs PNG circumcision program

The British High Commission in Papua New Guinea is backing a program to encourage men to be circumcised to reduce the spread of HIV/AIDS.

British surgeon Rosemary Taylor has been running an awareness program from Boram Hospital in the East Sepik provincial capital Wewak highlighting how men can help curb the spread of the disease.

The high commission said in a statement it would fund Taylor's continuing work through the Sexual and Reproductive Health Pilot Project in the province.

It said recent medical research indicated the rate of HIV/AIDS in adult males could be reduced by up to 60 per cent if they were circumcised.

The aim of the circumcision project is to educate and equip local people to safely perform circumcisions.

The commission said it would fund the purchase of a multi-media projector, a portable generator and a DVD player for the training program.

High Commissioner David Dunn said the commission was pleased to support the project to enhance local capacity in line with PNG's strategic plan for combating HIV/AIDS.IDS.

http://www.smh.com.au/news/World/UK-backs-PNG-circumcision-program/2007/08/23/1187462404988.html

Anti-AIDS Program To Fund Circumcision

By Craig Timberg
Washington Post Foreign Service

JOHANNESBURG, Aug. 19 -- President Bush's $15 billion anti-AIDS program will begin investing significant money in making circumcision available to African men seeking to protect themselves from HIV, top U.S. health officials said Sunday.

Recent research showing that circumcision dramatically cuts the rate of HIV infection is highly convincing, a delegation of U.S. officials, led by Health and Human Services Secretary Mike Leavitt, told reporters in Johannesburg.

Countries taking part in the President's Emergency Program For AIDS Relief have been invited to seek money to expand access to the procedure.

Circumcision funding would be small at first, with budgets in the hundreds of thousands of dollars for individual countries. But it is likely to grow to be "an important part" of the program in coming months and years, said Kent R. Hill, an assistant administrator for the U.S. Agency for International Development.

The cells in the foreskin of a penis are especially vulnerable to HIV, and removing the foreskin makes a man about 60 percent less likely to contract the virus, studies in South Africa, Kenya and Uganda have shown. The research reinforces studies showing that regions with high circumcision rates generally have lower rates of HIV.

In Kenya, men from the Luo tribe, which does not circumcise its boys, have an HIV rate of 24 percent compared to a national rate of 7 percent. Kenya is among the nations preparing to expand circumcision services, Hill said.

Some other African nations have reacted warily to the studies. Most tribes in Africa once routinely circumcised boys in manhood rituals but the practice has declined in southern Africa, in part because of the influence of European missionaries who discouraged the practice as primitive.

Last year, before the recent studies, the Bush administration cut funding for a small program that was offering circumcision to men in Swaziland, where an estimated one in three adults is infected with HIV, the highest rate in the world. Swazis do not generally circumcise their boys.

The Bush administration had been reluctant to support circumcision services until there was broad international consensus on the issue, Hill said. But the recent studies made clear that "this is going to be one of the major interventions in the international arsenal" against AIDS, he added.

http://www.washingtonpost.com/wp-dyn/content/article/2007/08/19/AR2007081900885.html

Circumcision may cut HIV risk among some groups of US men

Adam Legge, Monday, August 20, 2007

Circumcision could cut the risk of heterosexual HIV transmission in the United States- especially in some groups such as black and Hispanic men, according to a new evidence review.

But any man considering circumcision needs to discuss the possibility - and the risks associated with the procedure - carefully with their doctor.

Researchers at the US Centers for Disease Control and Prevention have analysed three randomised controlled trials of circumcision as a HIV prevention measure in Africa to find out if any recommendations for the US can be made on their basis.

In each trial - carried out in South Africa, Kenya and Uganda - men who had been randomly assigned to be circumcised were significantly less likely to become infected with HIV up to two years after, compared to a group of men who remained uncircumcised. The risk was cut by between 51 and 60%.

But the potential impact of adult male circumcision on HIV transmission rates in the US is hard to predict, say the researchers writing in PLoS Medicine.

This is because there are many differences between the underlying HIV epidemics in Africa and the US, plus differences in the prevalence of male circumcision in Africa and the US, and the considerable gaps in knowledge about the potential impact of circumcision on HIV transmission among men who have sex with men (MSM).

Adult male circumcision will likely have the largest impact in populations where circumcision has been rare, they say.

But circumcision is already very common in the US with hospital discharge data showing that around two thirds of all newborn boys were circumcised in the 1990s. However circumcision rates have traditionally been lower among Hispanic men in the United States, where only 42% of Mexican-American men participating in the Health and Nutrition Examination Surveys from 1999 to 2004 were circumcised, compared with 88% of non- Hispanic white men and 73% of non-Hispanic black men.

Circumcision rates have been declining in some parts of the United States, particularly the western states, in part because of the higher birth rate among the Mexican-American population. But they have been rising over the past few decades in African-American men, who are the highest risk group of heterosexual men in the United States for HIV infection.

However, based on the African data the authors conclude that "it is likely that circumcision will decrease the probability of a man acquiring HIV via penile–vaginal sex with an HIV-infected woman in the US."

They highlight findings from a study of men attending a Baltimore sexually transmitted infection clinic, which found that whilst circumcision was not associated with a protective effect throughout the whole clinic population, it was associated with a reduced risk of infection among men known to have had unprotected sexual intercourse with HIV-positive female partners. The risk reduction was approximately 55%, although the confidence intervals of this estimate were wide (0.22–0.97) (Warner 2007).

‘Some sexually active men may consider circumcision as an additional HIV prevention measure, but should do so only in consultation with their physician or health care provider, and with a clear understanding of the costs and risks of circumcision.’

The need to continue using other prevention measures such as condoms also needs to be emphasised. Men who choose to be circumcised should also be counselled about the importance of waiting until would healing is complete before having sexual intercourse.
Circumcision as a HIV prevention measure might be particularly effective in US Black and Hispanic men, given currently higher HIV infection rates in these populations- plus the fact that circumcision is currently less common in these groups, they add.

Reference
Sullivan PS et al. Male circumcision for prevention of HIV transmission: What the new data mean for HIV prevention in the United States. 2007 PLoS Med 4(7): e223.
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040223

Warner L et al. Male circumcision and risk of HIV infection among heterosexual men attending Baltimore STD clinics: An evaluation of clinic-based data [presentation]. Society for Epidemiologic Research Meeting; 21–24 June 2006 ; Seattle, Washington, United States of America. Available:http://cdc.confex.com/cdc/std2006/techprogram/P11223.HTM

http://www.aidsmap.com/en/news/EF947BEE-5467-46A1-B0F5-978DA9F2FF6C.asp

Govt asked to fund circumcision

New Zealand - The government has been urged to fund circumcision procedures to curb rising rates of STDs amongst Pacific Islanders.

Professor Sitaleki Finau from Massey University says there is a proven link between men being circumcised and lower rates of cervical cancer caused by infections.

He says if the government is serious about preventing diseases among Pacific people, then it should fund the $170 snip.

Sitaleki Finau says the government needs to maintain cultural values as traditionally Pacific Islanders have been circumcised and funding the procedure is one way to achieve that.

He says circumcision is the best measure to reduce infections, and cancer of the penis.

Finau says while it is mainly Pacific Islanders who request the procedure, funding should be available for anyone as it is in the government's best interests to fund circumcisions, to avoid costly operations for both men and woman, later in life.

http://tvnz.co.nz/view/page/411416/1291579

Male circumcision: a new strategy for HIV prevention?

Authors: ; WHO; UNAIDS
Publisher: World Health Organization , 2007

http://www.who.int/entity/hiv/mediacentre/MCrecommendations_en.pdf

This technical consultation paper from the World Health Organisation (WHO) and UNAIDS reports that male circumcision has been proven to effectively reduce the transmission of HIV from women to men. However, male circumcision does not provide complete protection against HIV, and it has not been proven to reduce the transmission of the virus from men to women. Circumcision for HIV positive men is not recommended. The paper emphasises that it is important to deliver accurate information about the implications of male circumcision in relation to HIV and that programmes promoting circumcision as a HIV prevention measure should be culturally aware, respectful of human rights and aware of gender issues.

The paper recommends that programmes promoting male circumcision should now be included in the range of HIV prevention strategies but that such programmes should not be seen as a replacement for these existing strategies. These programmes should deliver clear information, aimed at both men and women, emphasising that male circumcision only offers partial protection against HIV. It also recommends that such programmes be targeted to maximise their public health benefit, and in particular programmes should be directed at regions with very high HIV prevalence and low levels of male circumcision.

The World Health Organization recommeds male circumcision...

Recently the World health Organization and the United Nations body UNAIDS issued a joint statement containing their conclusions and recommendations with regard to the protective effect from male circumcision against HIV infection in female to male transmissions of 60%

New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications

Conclusion

1: The research evidence is compelling. The research evidence that male circumcision is efficacious in reducing sexual transmission of HIV from women to men is compelling. The partial protective effect of male circumcision is remarkably consistent across the observational studies (ecological, cross-sectional and cohort) and the three randomized controlled trials conducted in diverse settings.The three randomised controlled trials showed that male circumcision performed by well-trained medical professionals was safe and reduced the risk of acquiring HIV infection by approximately 60%.The efficacy of male circumcision in reducing female to male transmission of HIV has been proven beyond reasonable doubt. This is an important landmark in the history of HIV prevention."

"Recommendations :
1.1 Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
1.2 Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men."

Of course this will not silence the shrill and constant whine of the rabid anti-circumcision fringe and one can expect them in their desperation to crank up the decibels while science continues to marginalize them and their dubious cause.

Health benefits of male circumcision

Friday, 10 August 2007, 4:57 pm
Press Release: Massey University

Health benefits of male circumcision should be recognised by public health system

Massey’s Director Pasifika wants the Government to consider making circumcision available through the public health system in light of studies suggesting the procedure has health benefits for men and women as well as being considered important to Pacific people.

Professor Sitaleki Finau says studies show male circumcision helps prevent the spread of sexually transmitted diseases, including Aids, and there is a proven link between circumcised men and a decrease in cervical cancer caused by the human pampilloma virus.

He says New Zealand health authorities should take note of World Health Organisation backing for United States trials in Uganda, Kenya and South Africa confirming male circumcision can cut heterosexual HIV transmission by up to 60 per cent.

In a paper titled Circumcision of Pacific Boys: Tradition at the Cutting Edge, presented at a recent Public Health Association Conference in Auckland, Professor Finau provided insights into why most Pacific boys in New Zealand and in the islands continue to be circumcised.

This is despite a dramatic swerve away from the procedure that was almost standard for all army recruits and newborn boys born in New Zealand in the 1940s.

About 95 per cent of newborn boys were circumcised in that decade, but the numbers started to decline about 1950 to the point where circumcision rates in public hospitals last decade were about 0.35 per cent of total male births.

Currently, circumcision on social or religious grounds is unavailable in the New Zealand public health system and although virtually all of the 100,000 Samoan and Tongan males living in New Zealand are circumcised, the procedure must be paid for at private surgeries and health clinics.

Professor Finau thinks the Ministry of Health should review its policy – despite the climate of heightened emotion about human rights and the non-therapeutic removal of foreskin described by some men’s groups as genital mutilation.

Evidence that circumcision lowers a boy’s chance of suffering urinary tract infections, eliminates the risk of infections under the foreskin, decreases the risk of developing cancer of the penis (although a very rare condition) and reduces the risk for men of contracting sexually transmitted diseases are grounds for making male circumcision, he says.

“It’s in the national interest to circumcise men to protect men and women, and save on cervical cancer management. Women would be getting a good deal if more men were circumcised.”

Professor Finau says male circumcision among Pacificans is “a solemn ritual” and an important male rite of passage carried out between the ages of seven and 15 years. “Being circumcised is sign of manliness and sexual prowess. Not to be circumcised can bring shame on a man and his partner and family.”

He says there is evidence male circumcision was being done in the Pacific before the arrival of Europeans. The use of bone, bamboo and shell tools has been replaced by modern medical methods available in designated clinics such as the Langimalie Clinic, run by the Tongan Health Society in Onehunga, Auckland.

Before joining Massey last year, Professor Finau was Professor of Public Health at the Fiji School of Medicine in Suva and has previously held academic appointments at the Universities of Otago and Auckland.

He has a medical degree from the University of Queensland as well as Fellowships from the Australasian College of Tropical Medicine, and the Australasian Faculty of Public Health Medicine.

Remuera gynacologist John Thomson is also in favour of circumcision becoming available through the public health system as an effective method of preventing the spread of sexually transmitted diseases.

Dr Thomson has performed more than 6000 circumcisions in his private clinic in the past 30 years using a non-surgical device attached to the penis that causes the foreskin to come off in a few days.

The procedure costs from $170 for very small babies and more for older infants. He recommends babies be circumcised by six weeks of age. Most of the circumcisions he carries out are on Muslim boys.

http://www.scoop.co.nz/stories/GE0708/S00050.htm

Support for Circumcision Proposal

For some time now there has been a deliberate campaign by rabid anti-circumcision zealots to try sell the idea that circumcision is prohibited in Sweden. Here is a report which shows that in the end the truth always emerges.

-----------------------

Support for Circumcision Proposal

A controversial proposal by Sweden’s National Board of Health and Welfare regarding the circumcision of young boys is gaining support among political parties.

The plan, announced earlier this year, would oblige local councils to carry out a circumcision if the boy’s family wanted the procedure.

It’s aimed at halting the increasing number of circumcisions taking place outside of the health service, which leaves boys at a greater risk of infection.

The Minister for Health and Social Affairs, Göran Hägglund, is yet to take a stand on the issue, but fellow Christian Democrat Chatrine Pålsson Ahlgren, who sits on the parliamentary committee for social affairs, supports the proposal.

The committee’s chairperson, Kenneth Johansson of the Center Party, told Swedish Radio News that he wants to see greater availability of circumcisions within the health service, and more information published to challenge some parents’ belief that circumcision is prohibited in Sweden.

http://www.sr.se/cgi-bin/International/nyhetssidor/artikel.asp?ProgramID=2054&Nyheter=&artikel=1529741

Zambia forges ahead with circumcision plans

Lusaka, Zambia

There is standing room only in Room 3 of the urology clinic at the University Teaching Hospital (UTH) in Lusaka, Zambia's capital. About 30 young men and a handful of mothers with male children listen attentively as Sitali Mulope, clinical officer, briefs them on the benefits of surgically removing the foreskin of the penis.

Running through a list of advantages that includes hygiene and because "it looks nice and smart", Mulope mentions the reduced risk of contracting HIV and other sexually transmitted infections.

Although he downplays this particular benefit, he and his colleagues are well aware it is one of the main reasons why the room is so full.

Like other countries in the region, Zambia has a high HIV infection rate of about 17%, while male circumcision is only practiced by about 20% of the population, mostly as part of a traditional rite of passage for boys in the country's North Western Province.

When UTH became the first public health facility in Zambia with a dedicated male-circumcision clinic in August 2004, there was already evidence to suggest a connection between low rates of HIV infection and populations with high levels of male circumcision.

The following year a clinical study in South Africa appeared to confirm the link and a year later two studies in Uganda and Kenya supported the finding that circumcision could more than halve the chances of men contracting HIV.

By the time the World Health Organisation (WHO) formally endorsed male circumcision as an important strategy for HIV prevention in March 2007, 1 500 men had passed through the operating theatre at the UTH clinic and another clinic had opened at a public hospital in Livingstone, Zambia's second city.

The initial phases of both clinics were supported by JHPIEGO, an international health organisation affiliated with John Hopkins University in Baltimore, with funding from the United States Agency for International Development (USAid). Zambia's Health Department has since taken over the costs of the two clinics, where patients pay 10 000 kwacha (about $2,50), a fraction of the actual cost of the procedure.

Demand outstrips delivery
While other countries in the region have been slow to act on the WHO recommendations, Zambia is well on its way to formulating a policy for rolling out a national male-circumcision programme. The Ministry of Health has begun training small numbers of health workers and has held meetings with traditional and religious leaders, local and international NGOs, and donor agencies.

But financial and human resources to implement the programme lag behind demand fuelled by publicity surrounding the study findings.

"In 2004 we were doing about 20 cases a month," said Dr Kasonde Bowa, director of the UTH clinic. "The following year, in 2005, when the Orange Farm [South Africa] study started, we saw an increase to about 30 or 35. Now we're doing about 80 a month, but the demand is probably much more than that."

The waiting list at UTH is three to four weeks, but at hospitals without a specialised clinic, where circumcision is viewed as elective, low-priority surgery, the wait is closer to three months. For those unwilling to wait, private clinics charge up to 500 000 kwacha ($123).

At an estimated $69 per person, Bowa described circumcision as highly cost-effective, considering it is a one-time, permanent intervention unlike, for example, life-long antiretroviral treatment.

Dr James Simpungwe, director of clinical services in Zambia's Ministry of Health, told Irin/PlusNews that there was no official budget for a male-circumcision programme as yet, but donors were being asked to help bridge the current gap.

Counselling challenge
Until funding for more clinics can be found, the government is reluctant to launch an education campaign promoting male circumcision as a means of HIV prevention, while emphasising that it only provides partial protection against HIV and other sexually transmitted infections.

In the absence of such campaigns, Richard Hughes, country director for JHPIEGO in Zambia, worries that "people are taking information where they can find it".

Simpungwe confirmed that research by the Health Department found that some Zambians believed they could have unprotected sex after being circumcised. "It worries us a lot, because then we think we'll be reversing our achievements," he said. "When we start doing mass circumcision we will bombard them with the correct health education."

Mulope's session in Room 3 is part of the information UTH gives men before and after surgery. There is also a one-on-one session with the doctor or clinical officer who will perform the surgery and several follow-up appointments.

He appears to be struggling to provide information that is relevant and appropriate to the young men in the room as well as the mothers with small children. Asked how long the wound will take to heal, he advises adults to be "very reserved" for at least a month after the surgery. Only towards the end of the session, in response to a question, does he bring up the necessity of continued condom use after circumcision.

In the absence of detailed guidelines from the WHO, Bowa admitted "we struggle with what is the minimum counselling message, because the period we have to deal with these clients is very short and if the message is too long people get discouraged".

Staff shortages are another obstacle. "Normally, if we have enough manpower, we separate the guardians with kids from the adult men," said Chipo Musiwa, who doubles as clerk and counsellor at the UTH clinic. "We could do with at least two more counsellors."

Some of the pressure on the UTH clinic will be relieved when a stand-alone adult male circumcision unit opens at the nearby "New Start" HIV voluntary counselling and testing (VCT) centre, funded by the Society for Family Health, an affiliate of the non-profit social marketing organisation, Population Services International (PSI).

The advantage of offering the procedure at a VCT clinic, said Dr Manese Phiri, a medical adviser at the Society for Family Health, is the rare opportunity to reach male clients with a full range of reproductive health and HIV-prevention services.

"When a man comes for testing, we'll tell him about our other services, including male circumcision," said Phiri. "Equally, if a guy comes for male circumcision, we'll highly recommend they go through VCT."

Phiri worries that without guidelines, men circumcised at most private clinics and public health facilities are not receiving counselling or the offer of an HIV test.

"It's a challenge to inform clinicians that the WHO says, 'Now we recommend male circumcision as a prevention tool', but also emphasising the counselling part of it," he said. "We're going to be informing private practitioners of the importance of the counselling component but we have to do this carefully, so we don't create too much publicity and a demand that will swamp us."

According Bowa: "Health workers are already overstretched ... We really need to expand the staffing levels to roll out [a national circumcision programme]."

"Everything we do is a human resource constraint," pointed out Hughes. "Nobody would have dreamed of doing what we've done with antiretroviral therapy, with the kind of resources that were there. You have to make choices, and you have to choose the things that are going to make the most difference." -- Irin

http://www.mg.co.za/articlePage.aspx?articleid=315825&area=/insight/insight__africa/

At the Cutting edge - male circumcision and HIV

Treading softly where circumcision is not customary

Until recently, the Luvale people in Zambia's North-Western Province were widely denigrated by others for a practice many believed was barbaric: cutting off the foreskin of boys aged as young as 10 as part of their traditional initiation into manhood.

Today, the Luvale have been vindicated. Based on the results of three clinical trials showing that circumcised men are about 60 percent less prone to HIV infection than uncircumcised men, Zambia's Ministry of Health is launching a policy to promote male circumcision as a method of preventing the disease.

While they may not have been aware of the medical benefits of male circumcision, 50-year-old Emmanuel Kaleji said the Luvale had always believed that cutting off the foreskin improved cleanliness.

"We have known this all along, but I am happy that today government is beginning to appreciate it. When I was in boarding school, my mates used to laugh at me whenever we went to bath; they called me an amputee."

Kaleji said he was looking forward to inducting the younger two of his four sons into manhood in the "Mukanda" ritual, but he was afraid that the government could strip the procedure of its cultural significance in the name of science.

The chairman of the Luvale's cultural association, Marx Mbunji, shared his concern. "This policy should recognise and safeguard our culture. In areas where this is already practiced, our values dictate that a female doctor or a non-circumcised man should not practice male circumcision."

Circumcision is just one part of the traditional male initiation that lasts for two months and includes instruction in hygiene, family values, good parenting and interactions with women. Mbunji said the cultural aspect of Mukanda explained the perpetuation of the practice and its appeal even to non-Luvales, a number of whom have undergone the process.

Graduates of the ritual extol its virtues, saying that life-long relationships, which could not be formed in the impersonal atmosphere of clinical health facilities, were built between initiates and their instructors.

However, there are fears that conditions at the isolated bush camps where the ritual takes place may be unhygienic. Some Luvales are now taking their children to hospital to have the surgical procedure done by a medical practitioner before sending them to the camps.

Mbunji said these fears were unfounded. "Even previously, the complications were rare, but before HIV, the dangers were less. Now we are using one knife per child."

A key element in the government's policy of promoting male circumcision will be integrating an HIV counselling component and other essential information, such as the need to continue using condoms after being circumcised, and to abstain from sex while the wound heals.

Explicit instruction in how to prevent HIV does not form part of the two-month traditional initiation, although initiates are instilled with a sense of personal discipline and family values. "HIV is not our core business," Mbunji said.

Dr James Simpungwe, director of clinical services in the Ministry of Health, said it would be impossible for health facilities to meet some of the Luvale community's stipulations.

"For instance, the health establishment relies heavily on female nurses; also, not all male doctors who will be available to do the procedure will be circumcised. That said, we are ready to tap into the massive experience the Luvales have at their disposal," he said.

The Ministry of Health had been holding consultative meetings with the traditional leaders of circumcising and non-circumcising communities, as well as with religious and civil society leaders.

Chief Hamusonde, of the Ila ethnic group, in the Bweengwa Constituency in southern Zambia, warned that promoting a practice that was alien to his people would require treading carefully. "I will have to put it before the traditional council, so that circumcision can be considered as an HIV prevention strategy," he said.

Change would not come easily, and would require dispelling myths and stigmas about male circumcision, such as the belief held by Ila women that sex with circumcised men was painful.

"The Ministry of Health and the National AIDS Council will need to support us by giving us information, so that when we speak we know what we are talking about," Hamusonde said. Other traditional leaders have also expressed their willingness to break with tradition in the interests of public health.

In the House of Chiefs, in the capital, Lusaka, Chief Kashiba of the Chishinga people in Mwense, in the Luapula District of northern Zambia, recently called on his fellow traditional rulers to undergo the procedure.

"No-one need know," he said. "The operation may be painful, but it is very simple. By the time you return to your chiefdoms, you would have healed."

http://www.plusnews.org/InDepthMain.aspx?InDepthId=61&ReportId=73309

Circumcision: The kindest cut safety

Jan Ajwang

With several authorities including World Health Organisation recommending male circumcision as part of the package to fight HIV/ Aids, the practice is getting more popular by the day.

In March this year, WHO and Unaids, the joint United Nations Programme on Aids recommended the practice for heterosexual males and argued that it reduces the risk of infection by 60 percent. Thus circumcision would join Abstinence, Behavioural Change and Condom use as an additional option in the fight against the scourge.

Yet with the green light to circumcise, in Uganda, more than ever, more people are rushing for the option. Previously, circumcision was a practice for mainly the Muslim, Bagisu, and just a handful that did it for health reasons. Now that more people are opting for circumcision, the best hygiene practices are a must for everyone. The demand for circumcision has doubled at Kibuli Hospital where the majority of operations have been taking place.

As a Muslim missionary hospital, circumcision has always been a major operation even before it became popular. Many people including non-Muslims have, and are still getting circumcised. You, your spouse, friend or brother may be next for the operation and you just never know where you could go wrong.

A child was recently hospitalised at Kibuli Hospital after circumcision that was done by a local 'surgeon' in the community went bad. 'It damaged his urethra and he now has to be operated by a urologist, in an operation that is more costly compared to what would have been paid if they had done the circumcision under the best clinical conditions," said Mr Sinani Mbulambago, the Hospital Administrator.

Compared to the Shs40,000 that would have been paid at the hospital for a proper surgical procedure, the latter operation costs between Shs400,000- Shs450,000. To avoid such or worse cases, circumcision should be done under the best clinical atmosphere rather than use 'local surgeons' in the neighbourhood, at some mosques or cultural ceremonies.

"We cannot trust the way they do it; it is not clean and medically trusted. To avoid the risk of infection, circumcision should ideally be done by skilled health personnel," says Dr. Denis Otim of Kibuli Hospital.

The surgical operation involves careful dressing of the wound with stitches and prescriptions of drugs. Yet this may not be the case with circumcision done outside the hospital. For instance in cultural ceremonies, the proof of one's manhood could be illustrated in his ability not to stagger at the pain when substances as crude as local brew, salt or pepper are sprinkled on the freshly circumcised penis. In extremes, the same knife could be used for more than one person.

"In the process, one could be exposed to infections such as HIV/Aids," Dr. Otim says. Alternatively, the wound may not be taken care of well and could become septic, resulting in a delay in its healing and other infections.

Mr Mbulambago explains that after the operation, one is advised to protect the wound from water, and is given antibiotics to keep germs at bay and painkillers to reduce pain. The patient is advised to return for examination after two days until he heals. If you work, it is advisable to get the operation done on Friday and take the weekend off to rest so that by Monday, you can not only go for the check up, but turn up for work. If one cannot return to the hospital, he can at least visit a nearby trusted clinic or health centre where they can get similar attention.

"If the patient mismanages it, the wound gets septic or they could also be affected if they don't return for check- up when they are expected," Mbulambago explains. He also advises that one must not wear overly tight clothing after circumcision because it can affect the wound.

It takes at least 7-10 days for the wound to recover, but it could vary depending on the sensitivity of one's skin. It's also advised that if one is sexually active, intercourse should be resumed at least after one month of the operation.

"If you have sex within a week or so after circumcision, you will get hurt given that the underneath tissue takes a longer time to heal," says Dr. Otim. An operation costs Shs40,000 for children and Shs60,000 for adults but could vary in case of other complications. The price is even higher at private clinics and hospitals.


http://www.monitor.co.ug/health/health08025.php

Namibia: Circumcision Arouses Interest in Country

New Era (Windhoek)
30 July 2007

Petronella Sibeene
Windhoek

Recent research reports claiming that male circumcision reduced the risk of HIV/Aids infection by up to 60 percent, have started receiving serious attention from the health sector in Namibia.

Namibian HIV Clinicians Society President, Dr Bernard Haufiku, said in light of research findings in some countries suggesting that male circumcision is one of the most effective methods of reducing infection, relevant stakeholders in Namibia have started networking so as to find a way to address this issue.

"It is a big issue with high cost implications, but we (Clinician society) feel circumcision should be recommended once resources are available. It should be recommended and should be done under hygienic conditions," he said.

Despite reports that male circumcision reduces the HIV transmission rate, Haufiku called on Namibians to continue applying the traditional ABC HIV prevention principle.

He said although there is scientific evidence that circumcized men have 60 percent less chance of contracting the HIV virus as compared to uncircumcized males, studies have not yet shown the direct benefit for women.

"The behavioural change messages of prevention packed in the traditional ABC (Abstain, Be faithful, Condomize) are still very valid, and circumcision is just an "add on" intervention. Our ABC message can actually include another C to become ABCC," he said.

"Circumcision" Haufiku added "is not a magic bullet, nor is it a licence to unprotected sex or any risky behaviour."

While national strategies to scale routine offer for male circumcision for all Namibians are yet to be decided, Haufiku said health care workers and Medical Aid Funds should not deny individuals the right to have access to circumcision where it is available and safe.

Last week Wednesday, medical experts met in the capital to discuss the new development in the search for a reduction to the spreading of HIV virus.

A surgeon from Zambia ,Dr Kasonda Bowa, said countries such as Kenya, Uganda and South Africa have pilot-tested the new development, and it was found that male circumcision is one method that can be used in reducing HIV along with condoms.

Although male circumcision does not prevent one from becoming 100 percent infected, there is a 61 percent reduction, he said.

Male circumcision in Namibia is not practised by all tribes. It is mostly done in the Kunene and Omaheke Regions where the Ovaherero people originate.

The same regions have recorded low HIV infections, which shows that male circumcision is one of the methods to be used in reducing the infection rate, said Ministry of Health and Social Services official, Sandra Gowases.

Statistics show that 15 000 Namibians die of HIV/Aids every year, and with an infection rate of 19,7 percent, it is one of the hardest-hit countries in sub-Saharan Africa.

The 2006 National Sentinel Survey Report also shows that overall, HIV prevalence from the 2006 survey was 19.9 percent, representing an increase of 0.02 percent compared to 2004 which recorded a prevalence rate of 19.7 percent.



http://allafrica.com/stories/200707300941.html