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SLOW PROGRESS IN CIRCUMCISING MEN TO FIGHT AIDS IN AFRICA

Monday, 26th of September 2011

 

• SLOW PROGRESS IN CIRCUMCISING MEN TO FIGHT AIDS IN AFRICA

New York Times, 26 September 2011

Circumcision, which cuts men’s risk of infection by 60 percent or more, has been urged by health authorities since 2007. Their goal is to circumcise more than 20 million men, 80 percent of 15-to-49-year-olds, in 14 African countries, by 2015.

But only about 600,000 men, less than 3 percent, have been circumcised so far, recent data shows. In South Africa, the epidemic’s epicenter, with 5.6 million H.I.V.-positive people, about 145,000 circumcisions have been performed; the goal is 4.3 million.

“Obviously, we’re nowhere near getting to where we need to be,” said Dr. Kim Dickson, a senior adviser on H.I.V. for the World Health Organization.

Dr. Stefano Bertozzi, director of H.I.V. and tuberculosis for the Bill and Melinda Gates Foundation, which finances circumcision programs, put it even more bluntly.

“That we have men that are willing to be circumcised and we haven’t been able to mobilize the resources to get them circumcised — it’s really inexcusable that it’s taking as long as it is,” he said. “This is the equivalent of a 60 percent effective vaccine for men. It’s my No. 1 priority in Africa. It’s clearly the most obvious, most cost-effective intervention we could use to dramatically change the course of H.I.V. in the near future.”

American officials say the 80 percent goal would cost about $2 billion, but would save $16.5 billion by preventing four million infections and their lifelong treatment costs. Some countries, notably Kenya and Tanzania, are making great strides, and experts see promising starts in Zimbabwe, Rwanda, South Africa and elsewhere. They are also hopeful that two plastic devices being tested in clinical trials, which allow simpler and faster circumcisions without doctors, will speed adoption on a continent where health workers are scarce.

But various obstacles have slowed mass circumcision campaigns in many countries: a dearth of political or logistical support from governments and traditional leaders; cultural misconceptions; and in some places requirements that doctors, not nurses or physician assistants, perform circumcisions.

“Even though people haven’t been saying it’s too hard to do — they don’t want to say that because it’s such an important intervention — it’s really, really difficult to bring this to scale,” said Dr. Jason Reed, an epidemiologist with the Centers for Disease Control and Prevention, who is a chairman for a working group on circumcision for the President’s Emergency Plan for AIDS Relief (Pepfar). Experts want to increase circumcision rates quickly because benefits from removing the foreskin, which is more susceptible to harboring the virus and transferring it to the bloodstream, are powerful and immediate. Circumcision also has advantages over medications, and possibly even potential vaccines.

“With drugs, you have to get people to take a pill,” which may cause side effects or require increasing doses, said Robert Bailey, an epidemiologist at the University of Illinois at Chicago, who helped design Kenya’s circumcision efforts. “Even if we had a vaccine, we’re probably going to need a booster. With circumcision, you don’t need a booster.”

Time is of the essence. Each five or six circumcisions prevents an infection, he said. “Every wasted day is costing us.”

Experts also say men being circumcised often agree to be tested for H.I.V. and counseled about safe sex, helping further protect sexual partners.

Kenya is furthest along, with about 330,000 circumcisions, a third of the government’s goal, which exceeds the international health agencies’ goal. “We’re hacking away at it every month,” Dr. Bailey said. “Those foreskins are flying.”

It took months to get support from leaders of the Luo tribe, which, unlike many other Kenyan groups, has no tradition of circumcision. But when Prime Minister Raila Odinga, a Luo, publicly encouraged circumcision, “that really opened the floodgates,” Dr. Bailey said. Kenya has other advantages: Local health organizations are deeply involved, and nurses and physician assistants, called clinical officers, can perform circumcisions there.

Kenya is also using high-volume strategies that do not require hospitals. During mass circumcision events, often held in vacation weeks, tens of thousands are performed. Mobile teams visit schools, social halls and soccer fields, and even sail boats to islands in Lake Victoria.

Tanzania has undertaken similar programs. As in Kenya, many Tanzanians are already circumcised, said Kelly Curran, an H.I.V. expert with JHPIEGO, an organization assisting Tanzania, “so you really just need to focus on certain geographic areas.” So far, out of a government goal of 2.4 million circumcisions, 110,000 circumcisions have been done, many in the Iringa region, where circumcision rates are low and, not incidentally, H.I.V. rates high.

South Africa, Zambia, Zimbabwe and other countries confront more daunting problems, experts say, including the expectation that doctors perform circumcisions.

In South Africa, women’s groups worry that circumcision will encourage men to stop using condoms, putting women at risk for H.I.V. and other sexually transmitted diseases, Dr. Dickson said, adding that so far circumcised men appear as likely to use condoms.

South Africa may turn the corner. At Orange Farm, site of a major circumcision study, many men are being circumcised, and their infection risk has declined by a remarkable 76 percent. Researchers there pioneered a quasi-assembly-line method, with nurses performing pre- and post-circumcision procedures and doctors sweeping in to quickly perform each operation.

Jacob Zuma, South Africa’s president, and Goodwill Zwielithini, king of the Zulus, the largest ethnic group, have become circumcision advocates. And the country has committed $33 million to the effort.

By contrast, President Yoweri Museveni of Uganda recently said circumcision is not scientifically proven to prevent H.I.V. and that only premarital abstinence and marital monogamy are sure to work. Only 9,000 of the 4.2 million circumcisions needed in Uganda have been performed.

“While you have support from the Ministry of Health, the ministry is not comfortable offending the president,” said Dr. Emmanuel Njeuhmeli, a senior biomedical prevention advisor for U.S.A.I.D.

In some countries, medical circumcision campaigns have encountered cultural barriers. Rumors have spread that circumcised men are promiscuous. And definitions of circumcision vary among ethnic groups practicing it. In Uganda, Dr. Bailey said, traditional circumcisions can be “extreme, cutting the skin far down the shaft,” causing healing problems and sometimes mutilation or death.

In Malawi, circumcision may involve symbolic nicks, “not really removing the foreskin, so there is an indication that a lot of men are circumcised when actually it’s not the case,” Dr. Njeuhmeli said.

In Zimbabwe, some groups practicing traditional circumcision are now allowing doctors to perform the procedure, avoiding infections and deformities. “We had to get their confidence,” said Dr. Karin Hatzold, an official with PSI, a nonprofit group working on circumcisions in Zimbabwe and other countries. It sends doctors to ritual circumcision camps in the bush where they perform the procedure in tents.

African men often want circumcision, not just because of H.I.V. prevention, but because some believe it makes sex better, researchers say.

Campaigns also advertise to attract men. Zimbabwe’s program goes door to door and into schools, Dr. Hatzold said. It also performs plays about circumcision, and recruited a popular reggae star, Winky D, to sing ditties with lines like, “The ‘in’ thing is to get circumcised.”

Some experts also hope the circumcision devices, the Shang Ring and PrePex, will win approval and hasten adoption of circumcision. The devices are plastic rings placed on the penis and worn at home for a week. “They squeeze so it cuts off the blood supply to the foreskin, and the wound heals without suturing,” Dr. Bertozzi said. PrePex would be simplest because no anesthesia is required.

Dr. Bailey said he worried that men would not return for removal of the plastic, or that the supply of devices would be inadequate.

But Dr. Caroline Ryan of the State Department’s Office of Global AIDS Coordinator, said “any device would be a game changer in circumcision.”

A version of this article appeared in print on September 27, 2011, on page D3 of the New York edition with the headline: Obstacles Slow an Easy Way to Prevent H.I.V. in Men.