Six boys sit on green plastic classroom chairs in gowns with their clothes neatly folded on a side table. Cloth booties cover their feet and lower leg. They smile nervously.
They are waiting to be called for a medical circumcision.
Eduardo says he is 16 years old, as is his friend sitting next to him. Why are they getting a circumcision? “For hygiene, and for HIV,” they tell us. And their classmates are getting one too.
This is the Military Hospital in Maputo, Mozambique. It serves civilians as well as soldiers and their families. Mozambique, which borders South Africa, Swaziland, Botswana and the other countries in the Southern Africa, is at the epicenter of the HIV/AIDS epidemic: Estimates suggest 2.4 million people, or 12.5 percent of its population, is living with HIV/AIDS. But the country’s epidemic is not uniform: It has hit the southern region more than the north.
Three separate randomized trials have shownthat male circumcision is among the most effective interventions against HIV/AIDS, reducing transmission by about 60 percent. This is a huge impact. As one AIDS researcher has said to me, if we had a vaccine that effective, we would be sparing no effort to distribute and administer it.
But widespread deployment of male circumcision has not yet occurred. In South Africa the rate of male circumcision is 35 percent. In Botswana, Zambia, and Swaziland, the rate is around 15 percent. While Angola and Madagascar have rates over 80 percent. These are largely unchanged since the research definitively proved circumcision’s potential preventive power.
The explanations for inaction are many. There is a shortage of trained manpower to conduct all the circumcisions. There are not enough facilities to perform all the necessary operations. The costs are too great. There are cultural barriers. Muslims in the north and west of Africa get circumcised at age 13. That’s probably one of the reasons the epidemic has not made significant inroads into places like Ethiopia, Senegal and Mali. In southern Africa, which is more Christian, men do not get circumcised and will not accept it the argument goes.
But the waiting room in Maputo Military Hospital gives the lie to all these excuses.
It is true that many countries in Africa have few physicians. In Mozambique there are just 1000 to 1200 total physicians for a population of 21 million people. But you don’t need a surgeon or general practitioner to perform male circumcisions. It is really a very simple procedure. In just two weeks—one of classroom study and one of supervised practice under a mentor-- a nurse or health officer is trained to perform male circumcision in Mozambique. And it may not even take anyone previously trained in a health field to do the simple procedure. The current complication rates (bleeding and infection) are below 1 percent at the Military Hospital.
In Mozambique, it is estimated that 800,000 to 1 million circumcisions of males from 15 to 44 are needed to alter the course of the epidemic. In Maputo, each trained nurse performs between 12 and 14 circumcisions per 8 hour day. Simple math shows that doing 10 per day, 4 days a week, requires just 400 trained personnel to conduct 800,000 circumcisions in 1 year. This is far from impossible.
Facilities? It would require just 400 surgical beds and they wouldn’t have to be in fully equipped surgical suites. As has been shown in Kenya and Swaziland, male circumcision can be done sterilely in mobile units or field tents.
Cost? At the Maputo Military Hospital, with renovation of the surgical suite, the total cost, including surgical beds, lights, sterilization facilities, surgical instruments, needles, syringes, sterile gowns and gloves, bandages, and salaries, is $75 per case. For all 800,000 circumcisions this amounts to $60 million. Today, in Mozambique, the United States government is contributing over $200 million per year to fight HIV/AIDS, and the Global Fund contributes tens of million more dollare. Just $60 million one time down payment with a few million more dolalrs each year is not prohibitive.
Cultural barriers? That men have not gotten circumcision does not mean they are against getting circumcision. Eduardo and his friend suggest cultural barriers are more imaginary than real. As part of a large health survey in Mozambique in 2003, well before circumcision was proven to prevent HIV, 60 percent of men reported they would get a circumcision. The Maputo Military Hospital has a waiting list of 300 people for the procedure, and recently expanded to Saturday surgeries to respond to demand. And this is without one bit of advertising or mass mobilization. It’s just word of mouth.
Four years delay in rolling out the most effective prevention strategy available is long enough. All of us working in HIV/AIDS must embrace circumcision with the same vigor as putting people on life-saving anti-retroviral treatment. Both interventions save lives.
This must be what the tuberculosis sanitariums of 19th
This model seems neither scalable nor sustainable. The WHO estimates
Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.