Male Circumcision

Tuesday, December 23, 2008

Risk Of HIV Infection In Heterosexual U.S. Men Reduced By Circumcision

A new U.S. study has found that being circumcised significantly reduced the risk of HIV infection in heterosexual African American men known to have been exposed to the virus. The findings complement those of recently reported clinical trials in Africa, where interventional use of adult male circumcision similarly reduced the risk of HIV infection in heterosexual men. The findings of the new study, along with similar results from other studies, suggest that circumcision may protect other heterosexual males in the U.S. The promising new findings are reported in the January 1 issue of The Journal of Infectious Diseases, now available online.

Lee Warner, PhD, MPH, and colleagues at the Centers for Disease Control and Prevention (CDC) and the Johns Hopkins University School of Medicine studied the records of more than 26,000 African American men who had had HIV testing during visits to two Baltimore, Maryland, STD clinics from 1993 to 2000. The subjects selected for the study said that they did not inject drugs and had sex only with women. Their visits to the clinics were classified as involving known HIV exposure if there had been a recent notification of such exposure by a sex partner or by a clinic's disease intervention specialists; clinic visits for other reasons were classified as involving unknown HIV exposure. By these criteria, the investigators found 394 visits with known exposure and 40,177 visits with unknown exposure.

In visits by men with known HIV exposure, being circumcised was associated with a 51 percent reduction in HIV prevalence (10.2 percent of circumcised men vs. 22.0 percent of uncircumcised men). In contrast, HIV prevalence did not significantly differ in circumcised compared to uncircumcised men with unknown HIV exposure (2.5 percent vs 3.3 percent).

The investigators noted that three other U.S.-based studies had previously suggested that circumcision may be associated with reduced HIV risk, but the findings were limited by small sample size or extremely low HIV prevalence and did not achieve statistical significance. Indeed, HIV prevalence in the United States is very low (about 0.4 percent), and the proportion of circumcised adult males is high (about 80 percent), which could make it hard for conventional observational studies (i.e., studies that are not clinical trials) to discern whether circumcision actually has a protective effect. By focusing on patients who had documented exposure to an HIV-infected female partner, the current study was able to reveal that there was indeed a protective effect. This approach, the investigators said, "represents a significant methodological advancement over most previous observational studies."

In a separate editorial on the topic, Ronald H. Gray, MBBS, MSc, of Johns Hopkins University, pointed out that circumcision may be especially important for minority U.S. populations, including Hispanic as well as African American men - subgroups most at risk for HIV infection. He also noted that the American Academy of Pediatrics has thus far not recommended routine neonatal circumcision, and that Medicaid does not cover the procedure. "It is to be hoped," he said, "that the paper by Warner et al., in conjunction with the weight of evidence from international studies, will persuade the Academy to recognize the public health importance of this surgery for prevention of HIV in minority U.S. populations."

Fast Facts:

Recently reported clinical trials in Africa have shown that interventional use of adult male circumcision reduced the risk of HIV infection in heterosexual men.

The current U.S. study was able to show that circumcision significantly protected heterosexual African American men. It did so by focusing on subjects who had documented exposure to an HIV-infected female partner.

Monday, December 22, 2008

Uganda: Circumcision for All in 200

Uganda: Circumcision for All in 2009

Hilary Bainemigisha
19 December 2008

Kampala — All boys and men in Uganda will be mobilised for free circumcision beginning next year, the assistant commissioner for national disease control, Dr. Alex Opio, has said.

Opio said Government plans to introduce free mass circumcision before the end of 2009 as one of the ways to reduce HIV spread.

He said the free circumcision would in the long run be available in Government hospitals and health centres.

But every male will be expected to make an informed consent.

"A national policy on circumcision is coming out soon and a national task force has been appointed to speed up the process, effect mass communication and train more personnel in medical male circumcision," he said.

Whereas various researches have demonstrated that circumcision reduced a man's risk of getting HIV, 75% Ugandan men are not circumcised, according to the 2006 National Sero-Survey.

Health experts hope that new approaches like circumcision would further reduce Uganda's HIV prevalence, which has stagnated at 6.5%.

Having a circumcision policy will enable Uganda to receive funding from development partners for circumcision programmes.

"PEPFAR, the Global Fund, the World Bank and many others have all indicated willingness to fund," says Sereen Thaddeus, a USAID senior reproductive health adviser, who represented development partners at a circumcision stakeholders' meeting at Imperial Royale hotel last Wednesday.

Depending on the funding, circumcision may also be accessed from subsidised private centres at the lowest possible cost. It will be performed only by medically trained personnel in order to reduce the risk of complications.

Results from three randomised trials in South Africa, Kenya and Uganda proved that medical male circumcision (MMC) reduces sexual transmission of HIV from women to men by at least 50%.

According to Dr Angela Akol of Family Health International, this means whereas 100 uncircumcised men may all get HIV from sex with infected partners, 50 of them may escape it if all the 100 men were circumcised.

Dr. David Serwadda, Director of the Makerere University School of Public Health, who led the four-year study in Uganda, says all the studies produced similar results yet they were conducted in different countries, on different populations using different techniques.

Serwadda explains that the foreskin is vulnerable to tears and ulcers that provide an entry point for HIV. The inner skin is very soft and allows HIV to easily penetrate.

When this is cut off, the tip of the penis hardens making it difficult for HIV to penetrate.

Recent evidence from the Rakai study suggests that men with multiple partners
may get
the greatest benefit from circumcision, partly because it reduced the risk of sexually transmitted infections.

The protective effect grows over time, possibly due to the hardening of the skin on the head and shaft of the penis after circumcision.

Using computer modelling, the World health organisation (WHO) estimated that implementation of mass circumcision could avert up to 5.7 million HIV infections and three million AIDS deaths worldwide by 2026.

Based on that, WHO and UNAIDS, a UN body charged with HIV matters, issued a set of recommendations last year for the use of medical male circumcision in HIV prevention efforts.

Based on WHO recommendations, some African countries like Rwanda and Kenya have developed a national circumcision policy and are implementing mass circumcision programmes.

Opio told the circumcision stakeholders' meeting that even before free circumcision becomes available, Government is encouraging Ugandans to get the cut at hospitals and health centres that have the facilities.

However, he emphasised that circumcision does not guarantee full protection from HIV and should only be considered as one part of a comprehensive package to prevent HIV.

"People must be told that even if they are circumcised, they can still contract HIV and transmit it to their partners. Therefore, circumcised men should continue to practice abstinence, have fewer sex partners and use condoms," he said.

Opio said the national task force for male circumcision has been finalised and will include officials at the national level, those from the Ministry of Health, Uganda AIDS Commission and development partners.

Others on the task force are representatives from NGOs, districts and hospitals. "We are soon giving them appointment letters. They will be answerable to the Director General for Health Services," Opio said.

On why it has taken Uganda this long to come up with a policy, Opio explained that Government opted for a cautious approach to avoid a situation where the policy is announced and the system is not ready to absorb the demand. "We have to first build capacity, consensus, acceptability, a right communication strategy and a national task force," he said.

"The task force will now develop the policy, an implementation plan and programme as well as tools for monitoring and regular evaluation," Opio says.

However, there are still many issues to consider. Currently, doctor:patient ratio is 1:22,000 and many of these are busy with the various diseases that afflict Ugandans. The task force needs to train personnel especially midwives and nurses to back up the qualified surgeons.

Stakeholders expressed concern that political support is necessary for the programme to succeed. In Kenya where circumcision has tribal ego implications, it took the Prime Minister Raila Odinga, three ministers and six MPs to announce at a rally in Kisumu that they had undergone the operation.

President Yoweri Museveni has in the past questioned the usefulness of circumcision in HIV prevention.

But Opio said the President only raised concerns about the implication of poor communication on circumcision. "We have looked at these concerns and we are going to meet him to address them."

The presidential advisor on HIV/AIDS, Dr Jesse Kagimu, said the president has always insisted on well researched and proven scientific information on preventive HIV methods. He will support any intervention that can help roll back the scourge, he said.

Dr. Freddie Ssengooba of Makerere University School of Public Health added that a good communication strategy is needed to avoid inappropriate uptake, quarks and unsafe practices.

In his presentation on MMC communication strategy, Ssengooba said priority will be on explaining its role in HIV prevention and directing people where to go for it.

Wednesday, December 17, 2008

Male circumcision lowers cervical cancer risk: study

WASHINGTON (Reuters) – Three studies published on Wednesday add to evidence that circumcision can protect men from the deadly AIDS virus and the sexually transmitted virus that causes cervical cancer.

The reports in the Journal of Infectious Diseases are likely to add to the debate over whether men -- and newborn boys -- should be circumcised to protect their health and perhaps the health of their future sexual partners.

Dr. Bertran Auvert of the University of Versailles in France and colleagues in South Africa tested more than 1,200 men visiting a clinic in South Africa,

They found under 15 percent of the circumcised men and 22 percent of the uncircumcised men were infected with the human papilloma virus, or HPV, which is the main cause of cervical cancer and genital warts.

"This finding explains why women with circumcised partners are at a lower risk of cervical cancer than other women," they wrote in their report.

A second paper looking at U.S. men had less clear-cut results, but Carrie Nielson of Oregon Health & Science University and colleagues said they found some indication that circumcision might protect men.

The circumcised men were about half as likely to have HPV as uncircumcised men, after adjustment for other differences between the two groups.


In the third report, Lee Warner of the U.S. Centers for Disease Control and Prevention and colleagues tested African-American men in Baltimore and found 10 percent of those at high risk of infection with HIV who were circumcised had the virus, compared to 22 percent of those who were not.

"Circumcision was associated with substantially reduced HIV risk in patients with known HIV exposure, suggesting that results of other studies demonstrating reduced HIV risk for circumcision among heterosexual men likely can be generalized to the U.S. context," they wrote.

Studies supporting circumcision to reduce HIV transmission had all been done in Africa and U.S. studies were less clear.
Dr. Ronald Gray of Johns Hopkins University in Baltimore and colleagues said they found the reports encouraging.

"In the United States, circumcision is less common among African American and Hispanic men, who are also the subgroups most at risk of HIV," they wrote in a commentary.

"Thus, circumcision may afford an additional means of protection from HIV in these at-risk minorities."

But they noted that the American Academy of Pediatrics does not recommend routine circumcision for newborns.

"As a consequence of this AAP decision, Medicaid does not cover circumcision costs, and this is particularly disadvantageous for poorer African American and Hispanic boys who, as adults, may face high HIV exposure risk," Gray and colleagues wrote.
"It is also noteworthy that circumcision rates have been declining in the U.S., possibly because of lack of Medicaid coverage."
Medicaid is the state-federal health insurance program for the poor and disabled.

Thirty-three million people globally are infected with AIDS, which has no cure and no vaccine. HPV is the most common sexually transmitted infection in the world, with 20 million people in the United States infected. It causes cervical cancer, which kills 300,000 women globally every year.

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.

Saturday, December 6, 2008

The kindest cut: How circumcision is the secret weapon in the battle against HIV/Aids

In Zambia, an experiment in the battle with HIV/Aids is producing staggering results. If this were a vaccine trial, the medical world would be hailing it as a miracle. But instead of a wonder drug, the secret weapon is circumcision. Jeremy Laurance reports

Monday, 1 December 2008

After weeks of waiting, Michael Phiri decided to take matters into his own hands. The 16-year-old from George Compound, a township outside Lusaka, was so anxious to be rid of his foreskin, and so frustrated after being turned away from the circumcision clinic at local hospital for the third time, that he took a bread knife and did the job himself. The resulting bloody mess had one positive outcome; it sent him straight to the top of the queue for surgery, and he got his operation performed, as an emergency, by the urology specialist Kasonde Bowa.

"He had made a good start, with a dorsal cut as far as the rim of the glans, but things had got difficult from there," a smiling Dr Bowa says, with admirable understatement.


As Zambia's leading expert on circumcision, Bowa tells this story (the patient's name has been changed) to illustrate the soaring demand for the procedure that is sweeping Lusaka and other towns across sub-Saharan Africa, as word spreads of its remarkable preventive power. After 25 years of research and the expenditure of billions of pounds, it turns out that the oldest surgical operation in the world, performed since antiquity, is the best defence we have against HIV/Aids.

In crisp shirt and tie, despite the sweltering heat, Bowa tells me of the benefits of circumcision. We're standing outside his cluttered office at the University Hospital, where the exotic flamboyant trees that pepper this sprawling city shed their vermilion blooms on to the patients waiting in the shade below.

Bowa started Zambia's first pilot project offering circumcision as a defence against HIV in 2004. It was soon overwhelmed. "We were operating three afternoons a week but had such high demand that we were unable to cope. We needed more space and more staff."

The simple act of removing a man's foreskin reduces his risk of contracting HIV by about 60 per cent. The reason is that the moist underside of the foreskin is thickly supplied with Langerhans cells, a key route for entry of the virus into the body. Langerhans cells are also present in the glans (head) of the penis, but after circumcision the skin of the glans becomes drier and thicker, denying the virus an easy point of entry.

The medical evidence, from a series of studies, of the protective effect of circumcision has been growing for two decades, but it is only since publication of three randomised trials in Kenya, Rwanda and South Africa in late 2006 that the global health community started to act. The trials were stopped early and all 10,000 men involved offered circumcision when initial findings showed that the protective effect was so great that it would have been unethical to continue.

In March 2007, the World Health Organisation and UNAids gave their official backing to circumcision and called on countries to offer it to all heterosexual men. Kevin de Cock, head of the WHO's Aids department, described it as "an extraordinary development", adding: "Circumcision is the most potent intervention in HIV prevention that has been described."

In the story of Aids, it is rare to come across a development as positive as this. Tragedy has been piled upon tragedy, and the world has tired of the unremitting gloom. Flooding Africa with condoms and trying to change sexual behaviour has had little demonstrable impact. Research on an Aids vaccine has foundered and an effective microbicide is still not in sight.

The toll from the disease is staggering – an estimated 33 million people infected with HIV, and 25 million dead. Even more alarming, however, is that new infections are growing by 2.7 million a year, outnumbering the annual two million deaths. For every two people put on drug treatment, five more become infected.

Against this litany of despair there is now, for once, a message of hope – a chance of curbing, and even reversing, the epidemic. Circumcision, if rolled out across the continent, offers the first real prospect of saving lives by preventing infection on a significant scale. Estimates suggest that if universal circumcision were introduced across sub-Saharan Africa, it could prevent 300,000 deaths in the next 10 years and three million deaths over the next 20 years. It is sometimes described as a "surgical vaccine" – with good reason.

Zambia has been among the first to offer the operation and pilot new services, and other countries are following its lead. Yet, globally, only 1 per cent of total Aids funding is earmarked for male circumcision. Progress towards delivering the single most effective preventive measure yet discovered against the pandemic is agonisingly slow.

Across the road from Bowa's office, what is believed to be the world's first dedicated circumcision clinic outside a hospital or research programme is doing brisk business. Launched last year by the international charity the Society for Family Health, following Bowa's lead, the New Start centre is sited in an anonymous, dusty building behind the YWCA. Its appearance gives no hint of the pioneering work carried out within. This is deliberate; the charity fears that the service would be besieged if it were more widely advertised.

As I watch, John Banda, a shopkeeper, aged 29, climbs on to the table in one of the three operating rooms, clutching his green surgical gown and grimacing at the ceiling as Aggie Mahule, one of half a dozen nurses and clinical officers given two weeks' training to carry out the procedure, injects local anaesthetic into the base of his penis. "Relax and feel at home," says Aggie kindly as she swabs the surgical area with disinfecting iodine. John, fearful of the pain and, possibly, for his manhood, makes no response.

Next door in the "recovery" room, Richard Chimuka, 31, a computer trainee wearing a black designer shirt and low-slung jeans, sits with his legs apart, looking relaxed and pleased that, for him, the operation is over. The surgery was over in 12 minutes – and no, it wasn't painful, he says. Does it bother him that the operation was performed by two women? "Actually, I felt excited about it – like putting my painting in a gallery," came the smooth reply.


It's not difficult to persuade Zambians of the virtues of circumcision. It is already practised traditionally by the Luvale and certain other tribes in the North-Western Province, where the HIV rate is half that in the rest of the country (6.9 per cent of the population in the region is infected, compared with 14.3 per cent for the country as a whole). In Lusaka, one in five of the adult population is infected (20.8 per cent), one of the highest rates in the world. Surveys have shown wide acceptance of the procedure and increasing interest among parents wanting the operation for their children.

More than 1,500 men have had the operation since the New Start clinic opened in August 2007, and more have been circumcised by mobile surgical teams that visit hospitals in Kafue and Kabulonga, an hour's drive from the city. This is good for them, but in the context of the country's epidemic – 100,000 new infections a year – it is like using a water pistol against a forest fire.

In a week spent in Lusaka, I searched for any agency, charity or expert opposed to rolling out circumcision – and I could not find one. Among the dozen organisations I visit, all voice their support – only the level of enthusiasm varied.

"It is the most important defence against the disease that we have," says Mannasseh Phiri, a GP and Zambia's best-known Aids activist. "The trials have shown that it really does work, it is relatively easy to do and it is a lot cheaper than putting people on drug treatment."

Jeffrey Stringer, director of the Centre for Infectious Diseases Research in Lusaka, which is piloting a neo-natal circumcision service, tells me: "If we had a vaccine as effective as this, we would be jumping up and down in the streets. A 60 per cent protective effect is fantastic. It is one of the most effective preventive strategies we have." Yet, as Steve Gesuale, head of the circumcision project at the Society for Family Health, points out, there is "very little funding from donors, very little government support and very little going on".

Why? Official backing from WHO and UNAids has not been enough to persuade governments and donors to put their money and resources behind circumcision – yet. Richard Harrison, the director of the Society of Family Health, says the reason is fear. "There is always a sense of jeopardy around big decisions, especially when they involve sex. You only have to remember the row over condoms 20 years ago. By endorsing circumcision publicly, the Zambian government would be exposing itself to criticism, especially from religious groups who are incredibly powerful. The government is not going to shout its support from the podium – it prefers to give it tacitly."

There is also the difficulty that an HIV/Aids prevention strategy is all about the future, because it takes at least a decade for the benefits to be felt, while treatment is about the here and now. "It is very difficult to get people to concentrate on something that is 10 years away," he says.

Neighbouring governments, members of the Southern African Development Community, have been unable to agree a common approach. President Yoweri Museveni of Uganda dismissed the proposal as the West's latest "golden calf" which Africa was expected to worship and warned that it could suck resources from other preventive strategies (a concern shared by some of the charities I spoke to).

In Malawi, a former minister of health is reported to have said that she would not back any measure that benefited men and not women. (Women would, of course, benefit indirectly if fewer men were infected – and estimates suggest that male circumcision would save more female lives than any other preventive method.) The Malawian ex-minister's response may have been a cover for the real reason – a fear that the proposal was an attempt to Islamise the country.

While Kenya and Rwanda have announced policies favouring circumcision, they have yet to find the resources to put them into practice. Only Botswana, smaller and wealthier than Zambia and with one-tenth of its population, has forged ahead, offering the operation in all government hospitals after President Festus Mogae enthusiastically declared: "We have nothing to lose but our foreskins."

In Zambia, despite the lack of public support, the message about the benefits of the operation is reaching all levels of society. In Garden Compound, the densely crowded township close to the centre of Lusaka, the tiny Viro Clinic – "We prolong and save" reads the legend above the door – displays a poster in the window advertising male circumcision. Outside, the faded red and blue plasterwork is crumbling. Inside, the three cramped rooms contain a pot plant reaching almost to the roof, an examination couch doubling as the operating table, and a small fridge. Beside it, on a table, a teddy bear is propped against a broken clock, along with red plastic roses.

Violet, the smiling receptionist, says demand for circumcisions has increased. "There are more in the winter [June and July] and in the evenings and early mornings when it is cooler. The wound heals better," she says.

Interest in circumcision has spread beyond the capital, to the country's vast hinterland, according to Karen Sichinga, chief executive of the powerful Churches Health Association of Zambia, which runs one-third of all Zambia's hospitals, mainly in rural areas. "The demand is increasing in our mission health facilities," she says.

For Sichinga, the operation does not carry the moral dilemmas involved in handing out condoms or preaching abstinence, an important factor for a faith-based charity. But she, like some others, is cautious of treating it as the silver bullet, the "answer" to Aids that has been so desperately sought for so long.

"Science has proved that the benefits outweigh the disadvantages," she said. "But you have to work hard to persuade people. Over 90 per cent of Zambia is Christian, not Islamic."


From township clinics to mission hospitals in the furthest reaches of the country – all such facilities will need to be recruited if the target of 500,000 circumcisions in five years, notionally set by the Society for Family Health, is to be achieved. Even that represents only half the number required to curb Zambia's HIV infection rate, calculated on the basis that four operations are needed to prevent one infection.

Supporters of the programme are pinning their hopes on a substantial chunk of the $307m (£200m) allocated to Zambia by the Global Fund last month being used for a major scale-up of circumcision. The Gates Foundation is also considering a proposal which, if approved, would provide millions of dollars for the strategy.

Some experts, including Bowa, warn that even if the money is available, the vast increase in staff and facilities needed will take time to deliver. Others are more optimistic. Hospitals are already being used at weekends, with existing staff paid extra, and discussions are under way to hold circumcision clinics in the evenings. High-risk groups could be targeted first – the military, the police. It is not as simple as rolling out a vaccination programme, but there is already experience with cataract surgery, which is provided to hundreds of thousands of people across the world by staff with basic training, and circumcision providers from several countries in Africa have travelled to India to learn from the cataract experience.

Catherine Sozi, country co-ordinator for UNAids, dismisses suggestions that extending circumcision right across Zambia would prove too great a challenge. "That was what they said about anti-retroviral drugs – that they could not be provided in poor areas that lacked medical support. It will never happen, they said – and look how well we have done. We will scale up circumcision. The studies show it is working. It will become a human rights issue if we don't."

Science and society: Why circumcision works 

Circumcision is an essential weapon in the fight against HIV/Aids in sub-Saharan Africa because, uniquely in the world, the disease there is widespread in the heterosexual community. 

Although it offers less protection (60 per cent) against the virus than a correctly used condom (100 per cent), condoms are only effective where the key risk-groups are sex workers and their clients, and men who have sex with men. 

In sub-Saharan Africa, the main driver of the epidemic is multiple concurrent relationships – the practice of taking several lovers at the same time. Condoms are not the answer in this context because these are long-term relationships, including marriage, in which condom use is low. Surveys in Zambia show that only 30 per cent of men use condoms, mostly in casual sexual encounters. Circumcision confers protection, though limited, in all situations, for life. 

Critics fear that circumcision will encourage men to think they are immune and to ignore safe-sex advice, so increasing risks. Evidence from the trials in Kenya, Rwanda and South Africa showed no change in sexual behaviour following circumcision – and at the Society for Family Health's New Start clinic in Lusaka, men are repeatedly warned each time they return for a check-up that they are not completely protected and need to continue practising safe sex. 

There are also fears that men will not wait for the wound to heal – six weeks is the recommended period of total abstinence, from intercourse and masturbation. Sex during this period could be dangerous as the wound is an the ideal pathway for HIV transmission. Men are warned of the dangers and there is no sign they are returning to sex too early.

A third objection is that the operation benefits men but not women. This has angered groups concerned about equal rights. But a reduction of HIV prevalence among men will indirectly benefit women. Estimates suggest that male circumcision has the potential to save more women's lives than any other preventive measure. 

At the Society for Family Health's clinic, men are offered an HIV test before the operation, and more than 80 per cent accept the offer. Calls for the test to be made mandatory have been rejected because of concern that it could deter people from seeking the surgery. 

Some experts warn that circumcision must only be offered with counselling and HIV testing. Others say quantity is what counts and services should be established on a factory model. At Orange Farm in South Africa, one of the three research sites whose work led to the WHO announcement, a conveyor belt service is offered, with a target to circumcise 80 per cent of the men among the town's 200,000 population. A study of the cost-effectiveness of the operation suggested that, if scaled up to 25,000 procedures a month at $47 (£31) each, it could save more than $60m in treatment costs over eight years. 

Rolling out the surgery may be less easy in some countries. In Zambia, efforts to scale up circumcision have the support of traditional circumcisers and there are no cultural objections to the practice. In Kenya, however, circumcision is a mark of tribal identity; non-circumcising tribes such as the Luo are resistant to adopting a practice associated with their rivals. Top politicians from the Luo community, including three government ministers, have recently admitted to being circumcised in an attempt to promote the culturally taboo practice.

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