By Craig Timberg
Washington Post Foreign Service
Monday, December 26, 2005
MBABANE, Swaziland -- For 150 years, Swazi men such as Howard Mlondolozi Dlamini honored the wishes of a long-dead king who, fearing for the readiness of his young troops, banned the time-consuming rituals of circumcision that mark the arrival of adulthood throughout much of Africa.
Today, the biggest threat to Swaziland is not invasion but AIDS, and a study in neighboring South Africa has revealed that male circumcision decreases the likelihood of contracting the disease. As news spreads, the surgery has made a sudden comeback in a country that has among the world's lowest rates of circumcision and the highest rates of HIV infection.
In recent months, hundreds of Swazi men have been circumcised. Dlamini, 42, a traditionalist who often wears a red patterned Swazi cloth knotted at the shoulder rather than Western clothes, underwent a 30-minute procedure in September.
"I have seen people dying left and right, and leaving children," said the hospital administrator and father of two, who has lost three close relatives to AIDS. Speaking in the nearby city of Manzini, he recalled thinking, "To take good care of my children, let me undergo the procedure."
Even now, with lifesaving retroviral drugs increasingly available, the AIDS rate in Swaziland remains extremely high. The United Nations estimates that two of every five working-age adults are infected with HIV. An estimated 20,000 people here last year died of complications caused by AIDS, and in the past decade the disease has lowered life expectancy from 57 years to 33. There is worry that AIDS could severely depopulate Swaziland, a tiny nation of 1.2 million people on the border between South Africa and Mozambique. "I worry that this younger generation will be wiped away," Dlamini said.
As hospital wards overflow, avoiding HIV has become a consuming concern for Swazis. Since the South African report appeared saying that circumcised men are 60 percent less likely to contract HIV, the shift in Swazi attitudes toward circumcision -- once widely viewed as unmanly -- has been dramatic and swift.
Hospitals that once rarely performed circumcisions have recently been doing 10 to 15 a week, with two-month waiting lists. A physician with a radio show has called on his listeners to have the surgery, which removes the foreskin and along with it the cells most vulnerable to HIV. A lawmaker has advocated the procedure in a speech to parliament and demanded that the government increase capacity and subsidies for it.
Although some international donors have warned that the study is not definitive, and some critics in the United States and elsewhere regard male circumcision as a form of mutilation, many Swazi men, and in some cases women, are taking action.
After learning of the research, Lungile Maziya, 35, a pharmacy technician, scheduled circumcisions for all four of her sons, ages 6 to 15. She also scheduled the surgery for her husband, a practical precaution in a nation where polygamy is still practiced and wives in monogamous marriages rarely count on faithfulness from their spouses.
Only her 15-year-old balked. She said she told him, "My boy, when you're 18, you'll really thank me for this."
Ritual circumcision once was routinely practiced across sub-Saharan Africa as boys reached puberty. But it has become far less common, especially in southern Africa, as traditional values have slipped away and young Africans have moved to densely packed urban areas.
The South African study was the first to experimentally test the effectiveness of circumcision in preventing HIV, but dozens of studies have shown that infection rates are far higher in regions with low circumcision rates.
In Kenya, the national infection rate is 7 percent, but among the Luo tribe, which does not traditionally circumcise boys, it is 24 percent. Overall, no country that circumcises a majority of its boys has an HIV rate among working-aged adults higher than 7 percent.
The South African experiment recruited 3,274 young men in Orange Farm township and performed the surgery on half. After 18 months, 49 of the uncircumcised group had become infected with HIV, but only 20 who had been circumcised were infected. The team of French and South African researchers calculated that the circumcised men were 60 percent less likely to get HIV.
The study has been attacked by opponents of circumcision in the United States and Europe, who regard it as akin to female genital mutilation, still common in some traditional societies but widely condemned elsewhere.
There are other drawbacks. In the first several weeks after the surgery, men are actually more vulnerable to HIV because the virus can easily enter the wound. Even some advocates of circumcision worry that newly circumcised men may wrongly believe they are totally protected and engage in more high-risk sexual behavior.
The South African study, in fact, found an increase in the number of sexual partners among the circumcised men, though even with their riskier behavior, they still contracted HIV far less frequently than those who were not circumcised.
The largest international supporters of AIDS prevention have treated the results cautiously, saying they must wait for results from similar experiments in Uganda and Kenya before deciding whether to offer circumcision far more widely in countries with high rates of HIV.
"They are waiting for a vaccine," Bertrand Auvert, the lead researcher, said from Paris. "They are not waiting for a cut from some scissors."
But two prominent Americans based in the capital have aggressively pushed news of the circumcision research into the public consciousness here. Daniel Halperin, a researcher and AIDS technical adviser for the U.S. Agency for International Development, has convened meetings among Swazi doctors to discuss the research.
Alan Brody, the top official in Swaziland for UNICEF, began incorporating messages about the protective effects of circumcision in public education campaigns in 2002. With the results from South Africa, Brody has become increasingly vocal. Now, official discussions are focusing not on whether to make circumcision more widely available, but how.
Swaziland's health system is already overwhelmed with cases of late-stage AIDS and a rapidly expanding program of antiretroviral drugs. The country has just eight surgeons and about 50 practicing doctors. Nurses also are in short supply, and newly trained medical personnel frequently leave for better pay and conditions abroad.
But those who remain fear that if the medical system doesn't keep up with the demand for circumcision, the surgery increasingly will be done in unhygienic, ritual settings or hastily established operating rooms. Brody has suggested using the military to set up mobile hospitals that would move from village to village, offering free circumcisions to any male between 10 and 24. Under that scenario, nurses or paramedics would be trained to perform the surgery, which is relatively uncomplicated. Yet even he acknowledges that such an approach would require some 150,000 circumcisions and could take two years.
"This is a crisis," Brody said. "The science is in place to say, 'Let's move forward,' at least in Swaziland and also in most of southern Africa. Let's not delay."
Marwick T. Khumalo, a legislator who credits circumcision with protecting him from HIV, has put his advocacy in explicitly Swazi terms, telling parents that their paternal bloodline depends on protecting their sons from the virus.
"It's important that people preserve their family legacy, their family name," Khumalo said in the nearby town of Ezulwini.
In Mbabane, Themba Ntiwane, a physician with a weekly call-in radio show, first spoke of circumcision in September. The board soon lit up, and the calls have not stopped.
"Everyone wants to have it done," Ntiwane said. "Not one person has called to say it's 'un-Swazi.' "