Male circumcision slowly taking off

The World Health Organization endorsed male circumcision (MC) as an HIV-prevention measure two years ago, but implementation of large-scale male circumcision programmes has been relatively slow.

Several countries in sub-Saharan Africa, where the need is greatest, have only started drafting policies and strategies to roll out programmes in the past year.

UNAIDS calculated that one HIV infection is averted for every five to 15 male circumcisions, and designed a tool to help countries plan large-scale male circumcision programmes. Catherine Hankins of UNAIDS explained it to delegates at the 5th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa.

After punching in surveillance data on HIV prevalence and sexual behaviours, and expenditure on performing male circumcisions, including the cost of facilities, drugs, surgical supplies and staff salaries, countries can calculate the cost of a national male circumcision programme, and how many men they would need to reach to achieve the desired results within a chosen time-frame.

In terms of the model, Namibia calculated that a national roll-out costing 823 million Namibian dollars (about US$107.5 million) would result in cost savings of 5 billion Namibian dollars (about US$653 million), based on the number of infections averted.

Much of the work on male circumcision is still taking place at the three sites where the clinical trials took place: South Africa, Kenya and Uganda. The Rakai Health Sciences Programme in Kalisizo, Rakai District, Uganda, is carrying out post-trial research on the long-term effects of male circumcision on HIV incidence and behaviour.

Around 3,000 men per year are being circumcised there, with funding from the US President's Emergency Plan for AIDS Relief (PEPFAR), and Dr Godfrey Kigozi of the Rakai programme reported that "demand is still overwhelming".

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Slow progress

The Bophelo Pele Male Circumcision Project at Orange Farm, outside Johannesburg, the site of the South African trial, is still the only facility in the country that offers free male circumcision for HIV prevention.

Dirk Taljaard, the project manager, told delegates that the programme aimed to circumcise 50 percent of young men in the township over a five-year period.

He noted that one surgeon assisted by five nurses can perform between six and 10 circumcisions every hour at a cost of about R350 (U$45) per procedure, and training nurses to carry out the surgery would mean more men could be circumcised, but South Africa does not allow nurses to perform the operation.

Outreach activities to educate households in Orange Farm about male circumcision include door-to-door campaigns, talks at schools and churches, radio spots, and referrals from clinics that treat patients for sexually transmitted infections.

Men can proceed with the surgery if they give their informed consent after group and individual counselling sessions that include the offer of HIV testing and information on safe sex, and if they test HIV positive and have a CD4 count above 200, which means their immune systems have sufficient strength.

A significant additional benefit of the programme has been the large numbers of young men it has reached with voluntary HIV counselling and testing. "It gives us an excellent opportunity to engage them about safe sex and HIV, which is very important even if they decide not to be circumcised," said Taljaard.

The programme also revealed widespread confusion among men about the difference between traditional initiation rites and medical circumcision: 45 percent believed they were circumcised when they in fact had intact foreskins; 19 percent of these men tested HIV-positive, compared to 9.5 percent who actually were circumcised.

The finding emphasizes the need for culturally sensitive information delivery about the procedure, followed by individual pre- and post-surgery counselling. "Without political backing and will, male circumcision will have very limited impact," said Taljaard.

The South African and Ugandan governments are both drafting policies on male circumcision, while other countries, including Kenya, Namibia, Botswana, Zambia and Swaziland, are at various stages of implementation.

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