Countries all over Africa are at various stages of developing and implementing policies to roll out mass male circumcision to prevent HIV, but until recently South Africa has done little more than talk about a strategy of its own.
Results from three randomized clinical trials released in 2005 and 2006 provided compelling evidence that circumcision could reduce a man's risk of HIV infection during heterosexual intercourse by as much as 65 percent.
One modelling study found that in the unlikely event of all adult men in sub-Saharan Africa being circumcised in the next 10 years, two million new infections could be averted. Acceptability studies confirmed there was a high demand for the procedure, and most men understood it would not protect them from HIV completely.
The scientific world needed no more convincing that male circumcision should be scaled up as soon as possible, particularly in a high-prevalence country like South Africa. Governments, civil society and traditional leaders have taken a more cautious approach.
South Africa's National AIDS Council (SANAC) raised the possibility of providing male circumcision services in 2007, but there was a lack of political support, according to Prof Helen Rees, head of SANAC's HIV Research Prevention Committee and executive director of the Reproductive Health and HIV Research Unit at the University of the Witwatersrand, in Johannesburg.
Rees told the Social Aspects of HIV/AIDS Research Alliance (SAHARA) Conference in Johannesburg on 2 December that SANAC had a much stronger civil society voice by 2008, when the issue of male circumcision was raised again.
This time, the women's sector wondered how male circumcision would benefit them, and traditional leaders were worried that medical circumcision would conflict with the traditional circumcision that is part of young men's initiation rites for several ethnic groups in South Africa.
After lengthy consultations, SANAC issued a number of recommendations including that rollout costs should not divert funds from female condom distribution and other programmes directly benefiting women; the procedure should be offered as part of a comprehensive sexual health package, including HIV counselling and testing; and communities should be informed that male circumcision was only partly effective in preventing HIV infection.
Rees said the health department had produced a draft set of guidelines and was conducting a feasibility and costing analysis. "We still don't know if we're just going to have guidelines, or a policy, or how we're going to pay for it," she told delegates. "But there is a sense of urgency at SANAC, and at every meeting updates of progress are given. I would hope that, starting in 2010, we would start to see it being phased in."
AIDS activists have expressed frustration at South Africa's slowness in turning an evidence-based prevention strategy into policy, but several social scientists at the SAHARA conference were concerned that campaigns promoting male circumcision in other countries were not framing messages carefully enough.
Prof Rebecca Upton, of the University of Botswana, told "a cautionary tale" based on research she conducted during a national campaign to promote male circumcision for HIV prevention. Many young men she interviewed said being circumcised was a free pass to having unprotected sex, while some young women believed that if their partner was circumcised he was likely to be HIV-negative.
"We have heard that if you get circumcised you will be safe, then you are protected - taking the blanket off is important if you want to be able to have sex. Most girls who want a baby, they also want you to be circumcised now," a 19-year-old male university student told her.
"I'm not arguing with science," Upton said. "But we need to keep listening to very important underlying cultural and social factors as we move forward with these male circumcision campaigns."
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Results from three randomized clinical trials released in 2005 and 2006 provided compelling evidence that circumcision could reduce a man's risk of HIV infection during heterosexual intercourse by as much as 65 percent.
One modelling study found that in the unlikely event of all adult men in sub-Saharan Africa being circumcised in the next 10 years, two million new infections could be averted. Acceptability studies confirmed there was a high demand for the procedure, and most men understood it would not protect them from HIV completely.
The scientific world needed no more convincing that male circumcision should be scaled up as soon as possible, particularly in a high-prevalence country like South Africa. Governments, civil society and traditional leaders have taken a more cautious approach.
South Africa's National AIDS Council (SANAC) raised the possibility of providing male circumcision services in 2007, but there was a lack of political support, according to Prof Helen Rees, head of SANAC's HIV Research Prevention Committee and executive director of the Reproductive Health and HIV Research Unit at the University of the Witwatersrand, in Johannesburg.
Rees told the Social Aspects of HIV/AIDS Research Alliance (SAHARA) Conference in Johannesburg on 2 December that SANAC had a much stronger civil society voice by 2008, when the issue of male circumcision was raised again.
This time, the women's sector wondered how male circumcision would benefit them, and traditional leaders were worried that medical circumcision would conflict with the traditional circumcision that is part of young men's initiation rites for several ethnic groups in South Africa.
After lengthy consultations, SANAC issued a number of recommendations including that rollout costs should not divert funds from female condom distribution and other programmes directly benefiting women; the procedure should be offered as part of a comprehensive sexual health package, including HIV counselling and testing; and communities should be informed that male circumcision was only partly effective in preventing HIV infection.
Rees said the health department had produced a draft set of guidelines and was conducting a feasibility and costing analysis. "We still don't know if we're just going to have guidelines, or a policy, or how we're going to pay for it," she told delegates. "But there is a sense of urgency at SANAC, and at every meeting updates of progress are given. I would hope that, starting in 2010, we would start to see it being phased in."
AIDS activists have expressed frustration at South Africa's slowness in turning an evidence-based prevention strategy into policy, but several social scientists at the SAHARA conference were concerned that campaigns promoting male circumcision in other countries were not framing messages carefully enough.
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"We have heard that if you get circumcised you will be safe, then you are protected - taking the blanket off is important if you want to be able to have sex. Most girls who want a baby, they also want you to be circumcised now," a 19-year-old male university student told her.
"I'm not arguing with science," Upton said. "But we need to keep listening to very important underlying cultural and social factors as we move forward with these male circumcision campaigns."
ks/he
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions
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