Science News - January 3, 2009

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Demand for circumcision exceeds

availability in sub-Saharan Africa

Procedure catches on among men as a way to prevent HIV

ing agencies to endorse the surgery as a public health measure against HIV.

Laboratory studies have also tendered an explanation for the protection offered by circumcision. Uncircumcised men retain soft foreskin around the head of the penis, which provides an ideal region for HIV to infect.

But despite increasing demand and new sources of funding, African governments have been slow to promote circumcision as a public health measure and to mobilize resources. Without subsidization from governments or outside agencies, the costs of the operation have limited it mainly to middle- and upper-class men.

Halperin says Swaziland, which has opened clinics on weekends for male circumcision, and Botswana, with a govern-ment-funded promotional program, are leading the way among countries that have high HIV burdens and low circumcision rates. South Africa has yet to develop a policy regarding male circumcision. But in Orange Farm, just outside of Johannes-

By Nathan Seppa

Clinics offering discounted or free circumcision for men in sub-Saharan Africa are experiencing long lines and keen interest as word spreads that the operation provides partial protection against HIV and may offer other benefits, researchers report.

But governments in the region have been slow to embrace the measure. As a result, demand in many countries is far surpassing availability.

“Right now, it’s a school holiday here, and the clinics are absolutely packed with people,” Robert Bailey of the University of Illinois at Chicago said in early December. Bailey is working on a male circumcision project in Kisumu, Kenya. Similar scenes occur sporadically across southern and East Africa, areas where large numbers of men haven’t been circumcised and HIV has hit the continent hardest.

Despite the lack of male circumcision in these parts of Africa, there’s long been an undercurrent in favor of the procedure, says Daniel Halperin of the Harvard School of Public Health in Boston. In the 1990s, focus groups and surveys indicated plenty of acceptance for the

100%

operation, he says. And around that time, researchers first documented that areas of Africa where male circumcision was widespread had fewer cases of HIV.

Now men in southern and East Africa are actively seeking out the operation. “They’re more energized,” says Ronald Gray, a physician and epidemiologist at Johns Hopkins University in Baltimore who has worked extensively in Uganda.

This cultural shift follows the release of three clinical trials in 2005 and 2007 showing that circumcision reduces a man’s risk of acquiring HIV by at least half. Those trials led international fund-

burg, researchers with ANRS, the French national AIDS research agency, are circumcising and then monitoring young men in an effort to document the long-term effects on HIV rates. Dino Rech, who works at Orange Farm, says doctors are circumcising 20 to 100 men per day there, the largest program in the country.

The results of this study and the effect of mass male circumcision in Africa won’t be known for years, says Lawrence Gostin, an attorney at Georgetown University in Washington, D.C. Meanwhile, Gostin is working with UNAIDS to develop a checklist of issues that countries can use as they put male circumcision to work as a public health tool. The outline appears in the Dec. 3 Journal of the American Medical Association.

Safety will be a crucial issue. Since high complication rates from surgery could derail a campaign promoting circumcision, countries will have to make sure clinics have sterile facilities, proper instruments, trained personnel and close follow-up of patients, says Ingrid Katz, an infectious disease physician at Harvard Medical School. Katz and Alexi Wright of the Dana-Farber Cancer Institute in Boston discuss the topic in the Dec. 4 New England Journal of Medicine.