Huge circumcision programme gets under way in Southern Africa

HARARE - An unprecedented circumcision campaign covering 13 countries in East and Southern Africa is being unfolded in a bid to break the epidemic of AIDS that is wreaking havoc with the people and economies in the region.

From Kenya to South Africa, hospitals and tented clinics in the bush offering free circumcision are almost in danger of being overwhelmed by men, bringing with them boys and infants.

Kenya has performed 120,000 circumcisions. In Zimbabwe, the pilot phase of the campaign projected 2,000 volunteers, but got 2,800. In a small tent in the Makonde area north of Harare recently, three doctors circumcised 70 volunteers in three days.

According to details announced at the International AIDS Conference in Vienna this week, the campaign aims to circumcise 38 million males - 80 percent of all males under 49 years at a cost of $2.5 billion.

The rationale is simple? removal of the foreskin reduces the risk of HIV infection by 60 percent. Over the envisaged 15-year campaign period, it is envisaged that AIDS and the HIV virus that causes it will be brought down to manageable levels.

Not long after AIDS emerged in the 1980s as a deadly global threat, public health experts noticed a curious set of contrasts in Africa.

In countries where circumcision was an inherent practice, like in North and West Africa where it is dictated largely by Islam, AIDS was not engulfing whole populations as it was in parts of the continent where the practice was rare.

The first large-scale tests to confirm the occurrence were done from 2004 in South Africa, Kenya and Uganda. They proved conclusively that half the 10,000 subjects who had volunteered to be circumcised recorded 60 percent less infections than the group that didn’t undergo the procedure.

The inside of the foreskin, says urologist Christopher Samkange, chief trainer for the Zimbabwean campaign, is almost the only skin surface of the human body without the barrier of cells with the protein keratin that makes the outer skin layer hard and impervious.

“That is the entry point for the virus,” he said. “It has no defence. Whatever goes under the foreskin will get into your body and survive.”

The block of 13 adjoining countries - from Kenya in the north, South Africa in the south, Namibia in the west and Mozambique in the east - make up the highest HIV-infected part of the world, where the cause is almost entirely unsafe sexual practice.

“We have an epidemic,” said Samkange. In 1997, Zimbabwe had an HIV infection prevalence of 29 percent, but the figure has dropped to 13.7 percent this year. It still means 1,029 people are dying each week, outstripping sevenfold the death rate from the severe cholera epidemic here in 2008.

But within five years, after the first phase of the campaign aiming at males between 13 and 29 years, “we will have an immediate fall in prevalence,” he said.

Across the 13 countries, over the full 15 year period of the campaign, it is expected to prevent four million new infections, and save $20 billion in medical costs, forecasts the Washington-based Population Services International, one of the major drivers of the programme.

“The real value of male circumcision means that the person circumcised has protection for life, it happens only once and it cannot be taken away,” said Samkange.

But he adds that it is imperative that circumcision is complemented by the use of condoms and change in behaviour to safe sex, the message that drummed into volunteers during their several counselling sessions.

They especially have to be warned against men regarding circumcision as a licence for accelerated risky behaviour, says Samkange.

The alternative to prevention by circumcision, he says, is to flood the affected countries with anti-retroviral therapy (ART) medication, like Botswana, “so HIV-AIDS becomes like hypertension, that can be kept under control throughout people’s lives”.

But the cost is staggering. In Zimbabwe, he said, “it will cost $400 million to prevent, but $4 billion to treat,” he adds.

Besides, says Elizabeth Matuka, the UN special envoy for Aids in Africa, despite the improvements in access to ART in the continent, “for every two people who are put on ART today, an additional five are newly infected by HIV.”