As a medical procedure, circumcision is simple and becoming simpler. New research shows that nurses can perform it safely after three days of training, and it can be done in assembly-line fashion using devices that don’t require scalpels and stitches.
Although circumcision’s effect on protection against HIV is clear — three studies have shown a 60 percent reduction in risk to men — as a public health strategy, it is fraught with caveats.
Many ethnic groups have strong cultural traditions against the procedure. In adult men , circumcision requires six weeks of sexual abstinence while healing. And, its protection isn’t complete enough to allow men or women to forego other forms of protection, such as condoms. A woman having intercourse with an infected man is less likely to become infected if the man is circumcised, but the degree of protection remains uncertain. Also, there is no evidence that circumcision protects gay men practicing anal intercourse in any way.
Nevertheless, many AIDS researchers and advocates view it as a strategy that needs far more promotion since it provides some protection to men having sex with infected women.
“It’s not a perfect solution, but it’s a critical piece of the fight against HIV/AIDS,” said Mitchell Warren, executive director of AVAC, an advocacy organization.
Fourteen African countries are targeted for increased circumcision efforts. Non-medical circumcision is a ritual of attaining manhood for some ethnic and tribal groups. It also is widely practiced in Islamic populations.
International health agencies have set a goal of having 80 percent of males between ages 15 and 49 circumcised by 2015. That would require 20 million circumcisions. Only 1.5 million have been done in the five years since the World Health Organization recommended it in countries with a high rate of HIV infection.
But, the obstacles are numerous. The procedure costs $65 to $95, with an additional cost of about $60 for health system overhead. In some countries it must be performed by physicians, making “task shifting” — the assignment of certain duties to less expensive practitioners — impossible. In Uganda, for example, it will require an act of parliament to allow nurses to perform circumcisions, said Angelo Kaggwa, a Ugandan working with AVAC.
Studies show that many African men are willing to become circumcised, and in some areas many have recently gotten the procedure.
In Nyanza Province in Kenya, 50 percent of men originally randomly assigned to not be circumcised in one of the clinical trials have chosen to have the procedure in the five years since the study ended. Follow-up shows that circumcision has reduced their chances of becoming infected by 65 percent — essentially the same amount as found during the study.