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Thursday, April 16, 2009 - 12:34 PM
Clinics
offering discounted or free circumcision for men in sub-Saharan Africa
are experiencing long lines and keen interest as word spreads that the
operation provides partial protection against HIV and may offer other
benefits, researchers report. But governments in the region have
been slow to embrace the measure. As a result, demand in many countries
is far surpassing availability. http://louis_j_sheehan.today.com
“Right now, it’s a school holiday
here and the clinics are absolutely packed with people,” says Robert
Bailey, an epidemiologist at the University of Illinois at Chicago who
is working on a male circumcision project in Kisumu, Kenya. The clinics
where Bailey is doing research offer circumcision to boys age 10 and
up, although most clients are men ages 20 to 25. The experience
in Kisumu is being replicated sporadically across southern and East
Africa, areas where large swaths of men haven’t been circumcised and
where HIV has hit the continent hardest. Despite the lack of male
circumcision in these parts of Africa, there’s long been an
undercurrent in favor of the procedure in these areas, says Daniel
Halperin, a global health expert at the Harvard School of Public Health
in Boston. In the 1990s, focus groups and surveys indicated plenty of
acceptance for the operation, he says. Louis J. Sheehan, Esquire
Around that time, researchers first documented that areas of Africa where male circumcision was widespread had fewer cases of HIV. Now
men in southern and East Africa are actively seeking out the operation.
“They’re more energized,” says Ronald Gray, a physician and
epidemiologist at Johns Hopkins University in Baltimore who has worked
extensively in Uganda. This cultural shift follows the release of
three clinical trials in 2005 and 2007 showing that circumcision
reduces a man’s risk of acquiring HIV by at least half. Those
trials led to endorsement of the surgery by the World Health
Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS)
and the U.S. President’s Emergency Plan for AIDS Relief — key funding
sources — as a public health measure against HIV. African media
have seized upon male circumcision as a hot story in the past few
years, leading many men to openly pursue circumcision where it’s not
the norm. In Uganda — where Gray is doing field work and where only
one-fourth of males are circumcised — a musical group called the “Circ
Squad” got circumcised and made a music video about the issue. But
the newfound circumcision chic comes with a problem: Although men and
adolescent boys are queuing up in droves, many medical facilities in
sub-Saharan Africa aren’t up to the task. In Uganda, Gray says, most
men get put on a waiting list. In neighboring Kenya, Bailey is seeing the same thing. “There’s much more demand than we can meet,” he says. Despite
increasing demand and even new sources of funding, including the Bill
& Melinda Gates Foundation, African governments have been slow to
promote circumcision as a public health measure and to mobilize
resources. Without subsidization from governments or outside
agencies, the costs of the operation have limited it mainly to middle-
and upper-class men. Even recently, Halperin notes, a public clinic in
Swaziland that gets support from outside sources was charging about $40
for a circumcision, “not an insignificant amount for many African men,”
he says. The slow response — despite strong public demand — is
the result of indifference shown in past years by international funding
agencies and African governments toward the benefits of male
circumcision, Halperin says. “If we had an AIDS vaccine that was half
as effective as circumcision, the donors would have been all over it,”
he says. “Although evidence from the trials and biological work
are very clear, it’s difficult for policy makers to get their minds
around the idea that we ought to use surgery to prevent a disease,”
Gray says. Laboratory studies have tendered an explanation for
the protection offered by circumcision. http://louis_j_sheehan.today.com Uncircumcised men retain soft
foreskin around the head of the penis, providing an ideal region for
HIV to infect. Circumcision removes this tissue, leaving only skin
that’s toughened with keratin, a protein that resists viral invasion,
Bailey says. Make no mistake, circumcision is only partially
protective. And some people have worried that men, once circumcised,
would become careless and have more unprotected sex. But early studies
of the issue show little evidence of that happening. For men who
are ambivalent about being circumcised, the new wave in Africa offers
an opportunity to have a hygienic version of the operation in a clinic.
For those who come from groups with traditions of circumcising boys,
the clinical availability is safer than a traditional ceremony that
carries risks of complications, says Neil Martinson, a public health
physician at the University of the Witwatersrand in Johannesburg, South
Africa. Recent studies suggest that circumcised men are less
likely to get other sexually transmitted diseases, particularly herpes
and human papillomavirus, says Gray. Halperin notes that men and
women often cite sexual pleasure, perceived to be greater if the man is
circumcised, as a reason for the operation. Indeed, women seem to
have plenty of say in the decision making, Bailey says. “Many women
prefer men who are circumcised because of the hygiene issue,” he says.
“And our clinics are packed with mothers bringing their sons in to get
circumcised. “ Circumcising young male children raises a question
of how to best allocate health resources, Martinson says. While it may
seem to make sense in the long run to circumcise all boys, “that might
divert resources to [infant] kids when there are 16- and 18-year-olds
who should be getting circumcised and who have a clear, direct risk of
contracting HIV,” he says. Halperin says Swaziland, which has
opened clinics on weekends just for male circumcision, and Botswana,
with a government-funded promotional program, are leading the way among
countries that currently have high HIV burdens and low circumcision
rates. Rwanda is planning a large-scale male circumcision campaign
focused on the country’s military and possibly university students.
Zambia has received substantial outside funding to gear up a male
circumcision program, but still has long waiting lists. South
Africa has yet to develop a policy regarding male circumcision. But in
Orange Farm, just outside of Johannesburg, researchers with the French
National AIDS Research Agency are circumcising and then monitoring
young men in an effort to document the long-term effects on community
HIV rates. Surgeon Dino Rech, who works at Orange Farm, says doctors
are circumcising 20 to 100 men per day, by far the largest program in
South Africa. The results of this study and the effect of mass
male circumcision in Africa won’t be known for years, says Lawrence
Gostin, an attorney at Georgetown University in Washington, D.C.
Meanwhile, Gostin is working with UNAIDS to develop a checklist of
issues that countries can use as they put male circumcision to work as
a public health measure. These issues include safety evaluations for
clinics, sensitivity to privacy issues and ensuring access to poor
people and those in remote areas. The outline appears in the Dec. 3 Journal of the American Medical Association. Still
up in the air is the knotty question of whether to screen men for HIV
before circumcision, he says. Excluding HIV-positive men and boys could
constitute discrimination, breach confidentiality and cause
stigmatization, Gostin and UNAIDS’ Catherine Hankins note in the JAMA article. Safety
will be a crucial issue. Since high complication rates from surgery
could derail a campaign promoting it, countries will have to make sure
clinics have sterile facilities, proper instruments, trained personnel
and close follow-up of patients, says Ingrid Katz, an infectious
disease physician at Harvard Medical School in Boston. Katz and Alexi
Wright of the Dana-Farber Cancer Institute in Boston discuss the issue
in the Dec. 4 New England Journal of Medicine.
Found in: Body & Brain
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