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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
“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
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.
Circumcision and HIV infection in sub-Saharan Africa
In general, areas of Africa where male circumcision is widespread have fewer cases of HIV.
Percent of men circumcised Percent of people with HIV (2003 data)
40% 0% 0%