Sunday, December 14, 2008


Male circumcision catches on in sub-Saharan Africa as a way to prevent HIV infection; but demand for the operation exceeds availability

By Nathan Seppa

Clinics offering discounted or free circumcision for men in sub-Saharan Africa are experiencing long lines and keen interest as word spreads that the operation provides partial protection against HIV and may offer other benefits, researchers report.

But governments in the region have been slow to embrace the measure. As a result, demand in many countries is far surpassing availability.

“Right now, it’s a school holiday here and the clinics are absolutely packed with people,” says Robert Bailey, an epidemiologist at the University of Illinois at Chicago who is working on a male circumcision project in Kisumu, Kenya. The clinics where Bailey is doing research offer circumcision to boys age 10 and up, although most clients are men ages 20 to 25.

The experience in Kisumu is being replicated sporadically across southern and East Africa, areas where large swaths of men haven’t been circumcised and where HIV has hit the continent hardest.

Despite the lack of male circumcision in these parts of Africa, there’s long been an undercurrent in favor of the procedure in these areas, says Daniel Halperin, a global health expert at the Harvard School of Public Health in Boston. In the 1990s, focus groups and surveys indicated plenty of acceptance for the operation, he says.

Around that time, researchers first documented that areas of Africa where male circumcision was widespread had fewer cases of HIV.

Now men in southern and East Africa are actively seeking out the operation. “They’re more energized,” says Ronald Gray, a physician and epidemiologist at Johns Hopkins University in Baltimore who has worked extensively in Uganda.

This cultural shift follows the release of three clinical trials in 2005 and 2007 showing that circumcision reduces a man’s risk of acquiring HIV by at least half.

Those trials led to endorsement of the surgery by the World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the U.S. President’s Emergency Plan for AIDS Relief — key funding sources — as a public health measure against HIV.

African media have seized upon male circumcision as a hot story in the past few years, leading many men to openly pursue circumcision where it’s not the norm. In Uganda — where Gray is doing field work and where only one-fourth of males are circumcised — a musical group called the “Circ Squad” got circumcised and made a music video about the issue.

But the newfound circumcision chic comes with a problem: Although men and adolescent boys are queuing up in droves, many medical facilities in sub-Saharan Africa aren’t up to the task. In Uganda, Gray says, most men get put on a waiting list.

In neighboring Kenya, Bailey is seeing the same thing. “There’s much more demand than we can meet,” he says.

Despite increasing demand and even new sources of funding, including the Bill & Melinda Gates Foundation, African governments have been slow to promote circumcision as a public health measure and to mobilize resources.

Without subsidization from governments or outside agencies, the costs of the operation have limited it mainly to middle- and upper-class men. Even recently, Halperin notes, a public clinic in Swaziland that gets support from outside sources was charging about $40 for a circumcision, “not an insignificant amount for many African men,” he says.

The slow response — despite strong public demand — is the result of indifference shown in past years by international funding agencies and African governments toward the benefits of male circumcision, Halperin says. “If we had an AIDS vaccine that was half as effective as circumcision, the donors would have been all over it,” he says.

“Although evidence from the trials and biological work are very clear, it’s difficult for policy makers to get their minds around the idea that we ought to use surgery to prevent a disease,” Gray says.

Laboratory studies have tendered an explanation for the protection offered by circumcision. Uncircumcised men retain soft foreskin around the head of the penis, providing an ideal region for HIV to infect. Circumcision removes this tissue, leaving only skin that’s toughened with keratin, a protein that resists viral invasion, Bailey says.

Make no mistake, circumcision is only partially protective. And some people have worried that men, once circumcised, would become careless and have more unprotected sex. But early studies of the issue show little evidence of that happening.

For men who are ambivalent about being circumcised, the new wave in Africa offers an opportunity to have a hygienic version of the operation in a clinic. For those who come from groups with traditions of circumcising boys, the clinical availability is safer than a traditional ceremony that carries risks of complications, says Neil Martinson, a public health physician at the University of the Witwatersrand in Johannesburg, South Africa.

Recent studies suggest that circumcised men are less likely to get other sexually transmitted diseases, particularly herpes and human papillomavirus, says Gray.

Halperin notes that men and women often cite sexual pleasure, perceived to be greater if the man is circumcised, as a reason for the operation.

Indeed, women seem to have plenty of say in the decision making, Bailey says. “Many women prefer men who are circumcised because of the hygiene issue,” he says. “And our clinics are packed with mothers bringing their sons in to get circumcised. “

Circumcising young male children raises a question of how to best allocate health resources, Martinson says. While it may seem to make sense in the long run to circumcise all boys, “that might divert resources to [infant] kids when there are 16- and 18-year-olds who should be getting circumcised and who have a clear, direct risk of contracting HIV,” he says.

Halperin says Swaziland, which has opened clinics on weekends just for male circumcision, and Botswana, with a government-funded promotional program, are leading the way among countries that currently have high HIV burdens and low circumcision rates. Rwanda is planning a large-scale male circumcision campaign focused on the country’s military and possibly university students. Zambia has received substantial outside funding to gear up a male circumcision program, but still has long waiting lists.

South Africa has yet to develop a policy regarding male circumcision. But in Orange Farm, just outside of Johannesburg, researchers with the French National AIDS Research Agency are circumcising and then monitoring young men in an effort to document the long-term effects on community HIV rates. Surgeon Dino Rech, who works at Orange Farm, says doctors are circumcising 20 to 100 men per day, by far the largest program in South Africa.

The results of this study and the effect of mass male circumcision in Africa won’t be known for years, says Lawrence Gostin, an attorney at Georgetown University in Washington, D.C. Meanwhile, Gostin is working with UNAIDS to develop a checklist of issues that countries can use as they put male circumcision to work as a public health measure. These issues include safety evaluations for clinics, sensitivity to privacy issues and ensuring access to poor people and those in remote areas. The outline appears in the Dec. 3 Journal of the American Medical Association.

Still up in the air is the knotty question of whether to screen men for HIV before circumcision, he says. Excluding HIV-positive men and boys could constitute discrimination, breach confidentiality and cause stigmatization, Gostin and UNAIDS’ Catherine Hankins note in the JAMA article.

Safety will be a crucial issue. Since high complication rates from surgery could derail a campaign promoting it, countries will have to make sure clinics have sterile facilities, proper instruments, trained personnel and close follow-up of patients, says Ingrid Katz, an infectious disease physician at Harvard Medical School in Boston. Katz and Alexi Wright of the Dana-Farber Cancer Institute in Boston discuss the issue in the Dec. 4 New England Journal of Medicine.