Countries that have been quick to incorporate medical male circumcision into their HIV prevention programmes are already seeing good results compared with those that have been slower to embrace the procedure, say experts.
Following three African trials that proved the efficacy of male circumcision in preventing vaginal HIV transmission to heterosexual men, the UN World Health Organization in 2007 developed guidelines for the scale-up of voluntary medical male circumcision. Some 14 African countries have incorporated these into their national HIV programmes.
“In countries where there has been political leadership and community buy-in, we are already seeing results from male circumcision scale-up, while in countries like Uganda – where one of the randomized controlled trials took place – we see that HIV incidence is on the rise in comparison to neighbouring countries where male circumcision programmes are in place and incidence is falling,” said Catherine Hankins, UNAIDS chief scientific adviser, at the 6th International AIDS Conference on HIV Pathogenesis, Treatment and Prevention in Rome.
Uganda’s President Yoweri Museveni has been accused of undermining efforts to increase male circumcision by his scepticism about its ability to prevent HIV. Most recently, Museveni visited western Uganda, where media reports quoted him as saying organizations that promoted the procedure were misguiding and could put the lives of many people in danger “since it had not been proven to be scientifically true”.
Although the country launched a national male circumcision policy in 2010, progress in scaling it up has been slow.
Lesotho, Malawi, Rwanda and Uganda have so far failed to achieve any momentum in achieving 80 percent coverage of male circumcision recommended in order for the procedure to have the maximum benefit, according to the US President’s Emergency Plan for AIDS Relief. Ethiopia and Swaziland have achieved 12 and 14 percent respectively, while Botswana and Zambia have achieved 4 percent and South Africa and Tanzania have reached 3 percent. Mozambique, Namibia and Zimbabwe have each achieved 1 percent coverage.
Leading the pack is Kenya, which has set the standard for male circumcision scale-up in Africa, circumcising an estimated 290,000 adult and adolescent men since the programme started in November 2008. The programme has primarily focused on western Kenya’s Luo community, which has the country’s lowest circumcision rates and highest HIV prevalence levels.
“We have had tremendous leadership from Prime Minister Raila Odinga, who comes from the Luo community and has strongly endorsed male circumcision, as well as from the cultural leaders of the Luo people,” said Peter Cherutich, head of HIV prevention at Kenya’s National AIDS and Sexually transmitted infections Control Programme. “Key to the success is the quick translation from research to policy and implementation, as well as task-shifting and the formation of effective partnerships for scale-up.”
Apart from scaling up male circumcision at health facilities, Kenya holds an annual “rapid results initiative” to boost numbers over a four- to six-week period; in 2010, the campaign provided male circumcision to 36,000 men and boys over 30 days.
According to US government and UNAIDS estimates, Kenya is on its way to averting 47,000 adult HIV infections between 2009 and 2025, saving US$247 million in the process.
Elsewhere on the continent
In Swaziland, the recent endorsement of male circumcision by King Mswati III is likely to boost the country’s efforts to scale up the practice.
In Tanzania, where the government announced plans to circumcise at least 2.8 million men and boys between the ages of 10 and 34 over a five-year period, a rapid results campaign in early 2011 saw more than 10,000 boys and men circumcised over six weeks. According to JHPIEGO, an international health NGO and affiliate of Johns Hopkins University, which is working with the Tanzanian government to scale up male circumcision, the initiative could have averted 2,000 new HIV infections.
Zimbabwe has set a goal of circumcising 1.2 million men by 2015, and has reached close to 30,000 men already, despite scepticism about the country’s capacity to scale up the programme.
UNAIDS estimated that one HIV infection is averted for every five to 15 male circumcisions performed.
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