Editor's note: Africa has the world's largest number of HIV infections and AIDS cases. Across the continent the disease is being battled with public education and antiretroviral drugs. A new additional strategy is male circumcision. Several tests show that circumcised men have substantially reduced risks of contracting HIV. In response, several campaigns have been launched to circumcise men.
GlobalPost has investigated this public health effort in eastern and southern Africa. The series starts in Kenya in the fishing villages by Lake Victoria and includes a video of a circumcision. Also, a Kenyan doctor describes his work running a circumcision clinic, health writer Mercedes Sayagues gives her controversial opinion on the issue and a South African doctor describes the circumcision campaign in several southern African countries.
JOHANNESBURG, South Africa — Male circumcision programs aimed at preventing HIV transmission are expanding and gaining greater acceptance across southern and eastern Africa.
In a Q&A with GlobalPost, Dr. Dino Rech, regional clinical consultant for Population Service International/Society for Family Health, discusses his experiences in scaling up male circumcision programs across southern Africa, including in Zambia, Swaziland, South Africa and Zimbabwe.
Dr. Rech was previously the medical manager of South Africa's Orange Farm site — the location of an early male circumcision research trial — where he managed the clinical side of a scale-up program that expanded male circumcision services in the township.
GlobalPost: Can you give a sense of the different views towards male circumcision that you have encountered in southern Africa?
Rech: From my perspective the public views change from place to place and depending on the amount of advocacy and exposure people have had to the research. Normally when you go into countries or programs that are new and you're talking to new politicians and new ministries of health, there's a lot of skepticism. People think to themselves, 'Well, how can this work? How does removing some skin make any difference to a person's chance of getting HIV?' But when you show them the observational data from Africa, when you show them the data from the randomized control trials, when you explain the biological and mechanical mechanisms — the removal of the receptor cells, and the keratinization of the skin, which makes it less likely to be susceptible to bruises when you have intercourse and hence infection — then people start to come around slowly.
Obviously you've got feminist groups that are worried that men will get circumcised and then pressurize women to have sex without a condom. But you try to convince them that this [male circumcision] happens as part of a complete package. People get counseled twice, three times, four times even before they can undergo the procedure. They get counseled at two follow-up visits. People get a huge amount of information telling them that this is not full protection, it's just partial protection as part of an HIV program.
A lot of countries, like Botswana and Zambia, have the football analogy. The goalkeeper is male circumcision, so he's the last line of defense, but in front of him you've got your defenders: monogamous relationships, condomizing, knowing your status ... You've got a defensive wall — the normal preventative measures — and then circumcision is your goalkeeper if something goes wrong.
Generally people are cautious at first, but with more information and education most countries are coming around. Even the lobby groups against male circumcision are slowly starting to understand that we're not just chopping off thousands of foreskins. You need large counseling teams, large support teams, large follow-up teams, emergency services teams, that all support this initiative.
GlobalPost: Have you noticed any areas of southern Africa where the take-up of male circumcision has been comparatively fast from the get-go?
Rech: No. In every country you do surveys and there seems to be this huge demand, but when you start services, it kind of trickles in. People are apprehensive — people don't want to be the first one to have it done. Slowly, with word of mouth and as a good resource system is put in place, more people start coming. We haven't launched on a huge scale anywhere with mass media campaigns. The President of Zambia yesterday [Nov. 3] for the first time kind of endorsed male circumcision. Slowly things like that will start to see greater demand happening. But it's a slow process, you know. It's not men queuing around the block for male circumcision. It takes a lot of work to get them there.
GlobalPost: What kind of impact do you expect from the comments by Zambian President Rupiah Banda, who [on Nov. 3] in a speech encouraged men to be circumcised?
Rech: I think when people see political leaders and ministries of health backing programs like this, it takes away any skepticism that they would have. But at the same time, those people still have got to convince themselves it is necessary. It's not like having a cataract operation where you can't see properly and you remove the cataract. With MC [male circumcision], you're fine and you make a decision to go have an operation that is going to cause you pain and discomfort, it's going to keep you sexually inactive for six weeks. It takes a bit of convincing to get people to actually agree to that. So even with those president's comments — I don't think the queues will start going around the block. I think it will help, but it still takes a lot of education.
GlobalPost: What is on the horizon for bringing male circumcision to other areas in Southern Africa?
Rech: All these countries that I've mentioned [Zambia, Zimbabwe and Swaziland] are expanding. In countries like Botswana, the ministries of health are looking at integrating our services into their hospitals. South Africa recently has been really positive about taking steps forward. More and more ministries of health are starting to think about male circumcision. They want to use the funding around male circumcision to strengthen their health services in general. So they'll refurbish theaters [operating rooms], add staff that can do male circumcision and other procedures, and take advantage of MC to do general health-care system strengthening.
GlobalPost: On what scale does male circumcision need to be performed in a country in order to be really effective?
Rech: The modeling studies have all shown that for every 4 to 10 circumcisions, depending on countries and the HIV prevalence rate, you prevent one HIV infection. So in a country like Swaziland, I know that for every four circumcisions the program's doing, we're saving one of those four men from infection.
On a bigger scale, it's better. The quicker you get to a threshold level of 70 or 80 percent of men circumcised, the more impact it has. Even on a smaller scale it has an impact. I think even if it was one in 50 men that we were circumcising, if it was an HIV infection prevented, if you look at the economics of it and the long-term effects on the health care system — not having to support that person with ARVs, not having to treat them when they're ill — it will save health care systems lots of money, it will save lots of lives, and I think it's an important part, with a lot of education and a lot of counseling, of a comprehensive HIV package.
At the moment some people have described male circumcision as the next brightest thing in fighting HIV after a possible vaccine. Recently there was a vaccine trial where they were looking at it being 30 percent effective, and there was a lot of excitement about that. We've got a surgical method which is offering men up to 60 percent less chance of contracting the virus when compared to men who are not circumcised. That's pretty huge.
GlobalPost: What challenges do you face in scaling up male circumcision programs?
Rech: Unfortunately it's not as simple as giving an injection. It requires a huge amount of resources. Many African countries have what they call clinical officers or nurses. In Zambia and in Kenya they allow this middle cadre, between a doctor and a nurse, to do it [male circumcision]. Even nurses perform the procedure — they train them and let them do it. In southern Africa we've got more doctors and the feeling is we'll hopefully have enough doctors, but that's what I'm worried about. Will we have enough doctors, will we have enough people to assist the doctors, will we have space at our medical facilities to allocate to areas where we can do the counseling, the recovery and the procedure, the cost of the instruments, the extra kits ... It's an expensive program to roll out. The economics show that you will probably recover that money in the long term, but it's still complicated to run.
Disseminating the correct messaging so that men understand it would probably be right up there with the problem of resources. But that's one that with good social marketing we can deal with in a relative way. And we've seen big numbers turn out, we've seen Kenya at 45,000 male circumcisions since they started their program a year ago. Orange Farm were at 18,000 recently, so now close to 20,000. The Zambian program is scaling up quickly and will soon be at close to 10,000 — so, men are coming. It's not like we're sitting all day with empty clinics and waiting for people. But we need to be sure that if we do generate this demand, that we can then actually offer the services and we don't one day end up with cases where we're having to turn people away.