This was a hot topic at the 20th International AIDS Conference in Melbourne, Australia (20-25 July), as AIDS advocates stressed that 20 million men in 14 African countries with high HIV prevalence will need to undergo the procedure.
“Fifteen years ago, no one thought male circumcision had any correlation with HIV incidences,” says Bryan Callahan, communications officer at the Bill and Melinda Gates Foundation. Since then, three controlled and randomised studies in South Africa, Tanzania and Uganda have confirmed that male circumcision can decrease the risk of HIV infection by around 60 per cent.
“HIV can’t get through normal skin,” Roger Short, Wexler Professional Fellow in Obstetrics and Gynaecology at the University of Melbourne, explains to SciDev.Net.
“But there are certain parts of the body where thick keratin of the outer skin is missing, like inside the mouth, inside the vagina and inside the foreskin. Circumcision works because you remove most of the foreskin, the inside of which is not protected by keratin.”
Far from being the “gay disease” as HIV was labeled in the 1980s, the majority of new infections occur in heterosexual couples. In Mozambique, where 11 per cent of the population is living with HIV, a combination of poverty, risky sexual behaviours and low rates of male circumcision all contribute to the epidemic.
Studies have shown approximately three million new HIV infections can be prevented if 80 per cent of the males in HIV-endemic countries choose to be circumcised within the next five years, which could save US$16 billion in future healthcare costs. The focus is on sub-Saharan Africa, which is home to 70 per cent of the world’s population living with HIV.
Developing a non-surgical procedure for circumcision is seen as essential to increase uptake, as trained physicians are costly and scarce in many of the countries where HIV is most prevalent.
In 2013, the WHO approved a non-surgical device called PrePex, which can be used even by nurses. The PrePex technique takes longer to heal, but does not require anaesthesia or sutures and takes much less time than conventional surgery. PrePex units currently cost around US$20.
For Callahan, bridging cultural norms is crucial. He points to research from Tanzania indicating that most women prefer a circumcised penis. “Success in upscaling voluntary circumcision will only happen if you can talk about girlfriends preferring it, men your age preferring it,” he says.
Krishna Jafa, vice president of sexual and reproductive health and TB at Population Services International, a nonprofit health organisation, agrees. She says that PSI circumcision programmes in nine countries work on engaging with traditional power structures and leveraging traditional rites.
“Being patient and willing to listen are most important given that our audiences are savvy and clued in,” says Jafa. She highlights PSI’s work in Zimbabwe where a group of famous artists recently chose circumcision to promote healthy lifestyles to other men.
Similar government campaigns have been rolled out in South Africa, Uganda and other African countries to increase cultural acceptance of circumcision. The Indonesian government is set to begin a pilot study this year.
PrePex spokesperson Adi Kadussi says, in Rwanda, men are “lining up” to have the procedure done. The men reported feeling their penis looked “very smart” after the procedure.
This article has been produced by SciDev.Net's South-East Asia & Pacific desk.