Rolling out circumcision

The news from the circumcision trials caused huge debate in Africa, with reactions varying from enthusiasm to suspicion. In Swaziland, where a third of the entire population has HIV, there was soaring demand for the operation after the Orange Farm results were announced,¹ and a 2007 report said that 60% of men were getting turned away from clinics performing circumcision because of the demand.²

But in Uganda, President Yoweri Museveni said that he was worried that the news about circumcision would dilute the message that the only way to protect yourself from HIV was to “avoid all risky sexual behaviour”.³

The Third South African AIDS Conference in June 2007⁴ heard calls for a mass circumcision drive to become an integral part of public health policy in the Republic as soon as possible, but also strong disagreement about the best way for circumcision to be introduced in South Africa as a component of national prevention campaigns.

Professor Alan Whiteside of the University of KwaZulu Natal said: “There’s no question that we need a male circumcision programme, but a mass programme is more debatable. Operationalising it is going to be complicated.” He advocated routine opt-out male circumcision at birth (as in the Rwandan study above).⁵ However Professor Timothy Quinlan of the University of KwaZulu Natal was sceptical about the need for a mass programme, arguing that the evidence does not justify it. “A mass circumcision programme is an experiment in disguise,” he said. “It’s not focusing on the real problem.”

Instead, he said, prevention needs to focus on the two factors known to have the biggest effect on HIV-transmission rates: concurrent partnerships and high viral load during primary infection.

Women’s health advocate Marge Berer told the 2008 International AIDS Conference⁶ that men were confused about the degree of protection that circumcision affords, and suggested that circumcision should be publicly described as like a cheap condom that breaks 40% of the time.

Berer suggested that there needs to be couple counselling before circumcision, so that both partners fully understand the implications. Moreover, she criticised the rolling out of circumcision as a top-down solution with minimal involvement or advocacy from those affected, especially women.

By the end of 2008,⁷ many countries in southern Africa had implemented national policies, but constraints in local health systems were slowing down implementation, with not enough trained staff to do the procedure. Kim Dickson, a medical officer in the HIV-prevention unit at the World Health Organization, told the 2008 International Conference on AIDS and STIs in Africa (ICASA) Conference⁸ that countries in East and Southern Africa were moving forward with plans to scale up male circumcision. Botswana and Swaziland had completed the preparation of policies, while Kenya had set up centres to train healthcare workers in the procedure.

A survey in Lesotho found that over 80% of Basotho were aware of the benefits of circumcision in preventing HIV, and many men were willing to be circumcised.  However, the small country has about five doctors per 100,000 patients, so health services are largely run by female nurses and most men regard it as "shameful to go to a woman and ask to be circumcised", according to Dr Mpolai Moteetee of the Ministry of Health and Social Welfare. Cost was another major barrier, she added.

Namibia was developing a strategy for a roll out and identifying pilot sites, but Dr Ndwapi Hamunime, a Ministry of Health official, said the estimated cost of about US$200 per adult was "a bit expensive - we are not going to be able to scale up male circumcision on our own ... we will have to seek funding for this."

Swaziland was still waiting for parliamentarians to approve a policy. Kim Dickson said there were concerns about "foreign volunteer doctors flying in to circumcise African men", and that the WHO was drawing up guidelines on the matter.

Kim Dickson presented an update on the circumcision roll out to CROI 2010.⁹ Kenya has taken a lead in expanding medical circumcision, she said, but even though 90,000 men were circumcised in Kenya in 2009, this is still only 60% of the number the country needs to reach, according to mathematical models, in order to reduce HIV prevalence by 45 to 50% by 2025.

Dickson cited the 2009 review⁵ of mathematical models in PLoS Medicine, which suggests that if male circumcision in a country where 35% of the men are already circumcised were to rise to 80%, it will reduce HIV prevalence in the whole population by 25% and in women by about 20%. By 2015, this proportion of men circumcised would prevent over four million HIV infections in the 15 focus countries targeted by the United States President’s Emergency Plan For AIDS Relief (PEPFAR), which contain 16 million people with HIV, about half the world’s HIV-positive population. This would save $20.2 billion at a cost of $4 billion.

This would require performing the huge figure of 12 million circumcisions in the peak year (2012 for the model’s purposes). Botswana alone, for instance, would have to spend $9 million in this year, but the savings would be immediate, amounting to $13 million in the same year and rising to $23 million after four years. Botswana’s cumulative cost would be $30 million, but its cumulative saving $300 million.

Dickson surveyed progress towards mass programmes in the 13 countries recommended to adopt them by WHO/UNAIDS in their March 2007 consultation paper.

Kenya has made the most progress, with the figures cited above, but no other country has performed nearly as well. The next largest number of circumcisions performed was in Zambia, with 16,800 circumcisions in 2009 and 6200 in the last two months of the year, when Kenya performed 36,000. Only four countries (Kenya, Zambia, Botswana and Rwanda) are delivering nationally run services (Rwanda only in the military). Tanzania, Malawi and Mozambique are piloting schemes, and South Africa has one pilot site in Orange Farm as a continuation of its randomised controlled trial there. But other countries are still at the stage of training staff or finishing off implementation and monitoring strategies.

Even getting this far has required a lot of dialogue and communication between different groups. In 2008, a meeting of African Ministers of Health endorsed the WHO strategy, but there have had to be multi-level stakeholder meetings with groups ranging from traditional leaders in Kenya and Lesotho to women’s groups in Zimbabwe.

As in many other areas, the presence of strong leadership and a champion for the approach has been crucial; for instance, in Botswana former president Festus Mogae is leading the circumcision drive, while in Kenya it took a personal meeting between the Prime Minister, Raila Odinga, and the Luo Council of Elders to overcome previous opposition to the concept in this traditionally uncircumcised people.

In Kenya, a programme called the Rapid Results Initiative using volunteers managed to perform 36,000 circumcisions in the two months of November and December 2009: a measure of the kind of commitment needed if high-prevalence countries with heterosexually driven epidemics are to successfully use male circumcision as an HIV-prevention strategy.

This programme achieved 1200 circumcisions a day in 30 working days in eleven districts in Nyanza Province (home of the Luo), in which 95 teams of volunteer workers undertook the programme, averaging 9.6 circumcisions per team and a maximum of 22.8, at a cost of $30 each, far less than the WHO estimate of $50.

An important aspect of the Kenyan RRI was that the country has already conducted other RRIs, for instance in HIV testing.

There remain multiple challenges and constraints to implementing the programme, Dickson commented.

Human resources are a significant barrier; not merely getting enough personnel, but sometimes revising country protocols on who is allowed to perform minor operations. Such ‘task shifting’ will be vital if programmes are to be scaled up. Burnout is a problem too, as teams perform hundreds of circumcisions “day after day, hour after hour”.

One unsolved problem is how to promote the uptake of HIV testing prior to circumcision and how to deal with men who test positive for HIV. At present, WHO does not recommend their circumcision, partly because of evidence that in the period post-operation they might actually be more infectious. However, this would mean that being uncircumcised would become seen as a mark of having HIV, so how not to stigmatise these men is problematic.

Countries were not clear on what funds are available and how to access them, though PEPFAR, the Gates Foundation and the Global Fund were all putting money into the field.

Dickson concluded that political leadership was one key to a successful programme, and the earliest possible engagement and consultation with all stakeholders the other.