Circumcision is Africa’s best weapon against AIDS
By Ezekiel Emanuel
The opinions expressed are his own.
They are sitting on pews. One side of the pews is open to the air and the other side is a non-descript, white closed door. Sitting close to the door is a boy dressed in black sports warm-ups. He has a somewhat anxious look on his face. As I begin to ask him a question, a woman walks toward the pews wearing a bright yellow T-shirt with blue lettering that says: “Want to get smart? Get circumcised.”
I am at the epicenter of the HIV/AIDS epidemic: southern Africa. To be specific this is Gaborone, the capital of Botswana. The HIV/AIDS prevalence is about 25% among young women.
The boy in the track warm-ups tells me he is 17 years old and in high school. At his school, people had presented on male circumcision. His parents approved. Today, a school holiday, he came to wait for his turn to go behind the door. There is only thing he is scared of: the pain.
The door opens, his tall friend comes out not looking any worse or in pain from the procedure. Indeed, he looks as if the only thing that happened was a discussion. As he opens the door, he jokes about his friend being next to get cut.
Several other boys from the same high school class are waiting and give a similar story. While this location is not overflowing, all the seats in the pews are filled with men waiting to go through the door. And if what these high schoolers say is true, all their friends are, if not excited, still planning to come to the center in the next few weeks. Centers like this will take boys as young as 10 years old. Interestingly, there seems not to be a push to circumcise babies yet.
In Botswana, circumcisions are performed by physicians with nursing assistance. When they have three tables going at once, a physician can perform up to 30 circumcisions a day because they do the anesthetizing, the procedure, and the first few “anchor” sutures, leaving the nurses to finish the suturing and apply the dressing. The estimate is that Botswana needs to circumcise about 500,000 men, almost a quarter of the population. While this might sound like a huge number, one doctor working 5 days a week for 50 weeks a year can do 7,500 circumcisions.
The story is much the same in South Africa. The health minister of Kwa Zulu Natal province talks about circumcision: “They are lining up. Every time we have a camp for circumcision, we have openings for 50 and 100 show up to get it done.” According to the minister, endorsement from the Zulu king has had an enormous impact in getting the population to accept circumcision.
Unfortunately, ramping up to implement circumcision has been slow. Secretary of State Hillary Clinton recently announced that 1 million circumcisions have been performed over the last 4 years, three-quarters funded by the U.S. government. This is just 4% of the number of circumcisions needed in sub-Saharan Africa. This seems disappointing. It has been four years since randomized controlled trials definitively showed that circumcision can reduce HIV transmission by 60%. And at $75 or so per procedure, circumcision is one of the great bargains in the fight against HIV/AIDS. As many cynics have observed, if there were an HIV/AIDS vaccine as effective as circumcision, we would have been celebrating wildly and intensely pushing its production and distribution. Why has circumcision been treated differently? Why has it taken so long to ramp up circumcision?
Myriad reasons are given. The most common is cultural acceptance. While Muslim men in northern Africa are circumcised, the argument goes, men in southern Africa aren’t. That’s true, but not practicing circumcision in southern Africa is not the same thing as circumcision not being culturally acceptable. The pews in Botswana and the reports by the Kwa Zulu Natal health minister suggest demand is not the problem.
The problem now seems to be a lack of supply of trained circumcision personnel and sites, and a lack of will to push forward with the same fervor seen for rolling out anti-retroviral drugs. For years, success of the United States government HIV/AIDS global program has been measured by two numbers: the size of the President’s emergency AIDS relief budget and the number of people on ARVs in developing countries. And funding for prevention has been half that devoted to care and anti-retroviral treatment. The number of men circumcised has to be given the same level of prominence and attention as the number of anti-retroviral drugs. We need to demand faster action on circumcision.
Circumcision is a fast, one-time and cheap procedure that is tremendously effective in the fight to prevent HIV/AIDS. What have we been waiting for? We cannot and should not wait 4 more years or we will squander a tremendous opportunity to turn the fight against AIDS around.
PHOTO: A Zimbabwean woman walks past a billboard promoting male circumcision to combat Aids in the capital, Harare, February 9, 2011. REUTERS/Philimon Bulawayo