A big effort is under way to circumcise 80% of young men in Zimbabwe after a study four years ago found that the operation reduced the chance of contracting HIV by 60%.
Yet the procedure is still not widely available across sub-Saharan Africa, where HIV prevalence is high, the International Aids Conference in Vienna was told today.
In Zimbabwe, Population Services International (PSI) is working with the government to try to get mass circumcision underway, using a "conveyor belt" strategy that allows doctors and nurses to move rapidly from one patient to another, operating on 10 instead of three patients an hour. The goal is to circumcise at least 80% of all young men between 15 and 29 – a total of 1.2 million.
HIV rates are high in Zimbabwe – at 13.7% of men under 49 – but only 10% of men are circumcised.
"Zimbabwe is the country where male circumcision would have the highest impact," said Dr Karin Hatzold, senior director of HIV services for PSI in Zimbabwe. "The number of male circumcisions needed to avert one new infection is only seven. It could avert 40% of all HIV infections."
There were no real cultural, traditional or religious barriers to circumcision in Zimbabwe, she said. But there was a shortage of clinics, and qualified doctors.
PSI told the conference that it had devised a rapid circumcision strategy which it calls Move (Models of Optimising Volumes and Efficiency), using pre-sterilised, pre-assembled kits. Instead of stitches, the wound is cauterised. A team of doctors and nurses operate on four patients at a time, each in a private, curtained but adjoining cubicle. One doctor gives the local anaesthetic to all four patients. By the time he reaches the fourth patient, the first is ready for the operation, using a fast, forceps-guided method.
"In the past, they were doing one to two patients per hour, which is eight per doctor per day," said Hatzold. "Now they can each do eight to 10 per hour, which is 40 per day."
News that circumcision can prevent HIV infection has created high demand, with a waiting list of 700 in the capital, Harare, according to Hatzold.
PSI received financial help from the Bill and Melinda Gates Foundation for the study demonstrating the efficiency of Move. But to reach 80% of young men, they will need to embark on an education and information campaign, she said.
"We are very likely to receive funds from USAid – the US government is becoming very supportive. That will help us to start a mass media campaign. If you talk about this in TV interviews, you see huge impact."
There are concerns that some men will think they are safe from HIV infection once they are circumcised, which is far from the case – they have reduced their risk by 60% but not completely. Scientists will hope that risky sexual behaviour does not increase.
Men who undergo circumcision will be warned that they are still at risk and advised to use condoms. And although circumcision protects men, there is no evidence it makes an HIV positive man less likely to infect a woman.
Dr Krishma Jafa, PSI's HIV, TB and reproductive health global director, said she hoped the rapid circumcision model would prove useful in many other countries – there are 13 countries in southern and eastern Africa where under 10% of men are circumcised and HIV rates are high.
"We are in discussions in Zambia, demonstrating to them that it is a viable route to take," she said.
"It doesn't compromise dignity, it is respectful of the client, who is behind curtains, and it is useful where there are restricted funds and limited numbers of clinicians."
So far, a total of about 150,000 men have been circumcised with a view to protection from HIV in sub-Saharan Africa, mostly in Kenya, Swaziland, Zambia and Zimbabwe.