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.
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