By Craig Timberg
Washington Post Foreign Service
Sunday, July 16, 2006; A12

JOHANNESBURG -- In the year since a major South African study indicated that circumcision reduced the rate of HIV infection among men, several African countries hit hard by the disease have moved toward embracing the procedure in the battle against AIDS.

But not South Africa.

Swaziland and Zambia have begun offering discounted circumcisions in pilot programs to men who want them or to boys whose parents request them, and Botswana, Uganda, Lesotho and Tanzania are contemplating the idea.

Yet in South Africa, where more people are infected with HIV than in any other African country, the results of the research have rarely been reported, much less publicly discussed. If anything, AIDS activists here say, circumcisions will soon become less common because of a law signed by President Thabo Mbeki last month.

"They might have made it more difficult to implement what may be our most important HIV-prevention strategy ever," said Francois Venter, president of the Southern African HIV Clinicians Society.

The law, which has not yet taken effect, bans the circumcision of boys younger than 16. It was aimed at curbing circumcisions performed as a tribal rite, a practice that leads to dozens of deaths and injuries each year. The measure includes exceptions for religious reasons, meaning it will have no effect on the country's small Jewish and Muslim communities, and on medical grounds, though they were not defined.

In the debate on the measure, the research into the procedure's effect on the transmission of HIV was not discussed, participants said.

"That was not the issue at all," said Tseliso Thipanyane, chief executive of the South African Human Rights Commission, a leading supporter of the law, which addresses several issues regarding the rights of children. "The concern in our country has been the number of kids who have been dying, the number of kids who have lost their manhood."

Circumcision removes a penis's foreskin, which is made up of cells particularly susceptible to infection with and also possibly effective at transmitting HIV, the virus that causes AIDS. In addition, researchers believe that the foreskin traps fluid, allowing the virus to live longer on an uncircumcised penis after intercourse and increasing the likelihood of infection.

Jews and Muslims worldwide have practiced circumcision for centuries, and it is common among most ethnic and religious groups in the United States.

In Africa, most tribes historically included circumcision as part of coming-of-age rituals, but the tradition has faded as countries have become more urbanized. Researchers have noted for several years that African countries with the highest HIV rates generally have low rates of circumcision.

The South African study, conducted at the impoverished, densely populated Orange Farm township south of Johannesburg, was the first to measure experimentally the effects of circumcision on the spread of HIV.

Researchers recruited 3,274 young men there and performed the surgery on half of them. After 18 months, 49 of the uncircumcised group had become infected with HIV, but only 20 who had been circumcised were infected. The researchers suggested that circumcised men were 60 percent less likely to contract HIV than were uncircumcised men.

Articles on the study and on similar ones underway in Uganda and Kenya have appeared in dozens of journals and newspapers throughout Africa and the world. But in South Africa, where discussions of AIDS frequently are tense and highly politicized, a search of online databases found only two references to the research in a publication here.

The polarized nature of the AIDS debate in South Africa dates to 2000, when Mbeki questioned whether HIV was the sole cause of the disease and whether antiretroviral treatment was safe and effective. Activists here have long argued that Mbeki's doubts undermined the South African response to AIDS.

At a meeting on circumcision last month at Chris Hani Baragwanath Hospital in Soweto, the first gathering of its kind in South Africa, Martin G. Veller, a University of the Witwatersrand medical school professor, argued that South Africa could reduce its HIV rate by two-thirds through circumcising males between ages 15 and 24.

Veller estimated a one-time cost of $32 million to set up new surgical facilities and annual operating costs of $32 million the first several years. Over time, Veller said, the intervention would prevent 150,000 infections a year and save nearly $1 billion in annual medical costs in treating HIV patients. An estimated 5 million now have the virus in a country with a population of 44 million.

But Veller said there was no sign of government interest in any approach involving government-supported circumcisions.

"There's a kind of quietness about it," he said. "It really needs to be discussed."

South African officials say they will continue to monitor the research on circumcision and change policy and law if the evidence becomes sufficiently compelling.

"The research is ongoing," said Joel Netshitenzhe, a senior policy adviser to Mbeki, speaking from Pretoria. "Once they've finalized it, there would have to be policy work based on the outcomes."

Yet activists say the government's record on AIDS gives them little confidence that it will act quickly or prudently, no matter what the research shows.

"The thing that remains unpredictable is how this is received and processed, and whether it's acted on at all," said Mark Heywood, an official with the Treatment Action Campaign and the head of the AIDS Law Project at University of the Witwatersrand in Johannesburg. "The whole HIV policy and thinking is in disarray."