November 4, 2008

Swaziland Turns To Circumcision To Reduce HIV

Nelson Mdlovu moved past his fear to line up with nine other anxious men for a 30-minute circumcision procedure. Shortly thereafter, he left the small clinic with a skip in his step and smile on his face. 

Mdlovu, who believes the circumcision "will change my life", is among of hundreds of Swazi men who have chosen to be circumcised following the U.N.'s conclusion last year that the procedure could reduce the risk of HIV by up to 60 percent.

With training provided by Israeli surgeons, Swaziland now leads the African initiative to utilize circumcision to reduce the spread of HIV. The AIDS epidemic has devastated the nation, reversing all of its economic and social gains since its independence from Britain four decades ago.

Swaziland currently suffers the highest AIDS rates anywhere in the world, with roughly 40 percent of pregnant women and 19 percent of its 1.1 million citizens infected. By comparison, those numbers are equivalent to 56.6 million Americans, 248 million Chinese, 11 million Britons and 212 million Indians.  

And while helpful, mass male circumcision will create additional challenges to overstretched facilities in a country with only 170 doctors.  And there are growing fears that the "kindest cut" may actually be a double-edged sword if patients deceive themselves into thinking they are now immune to developing HIV.

"It doesn't mean you are 100 percent protected," nurse Prudence Mkhatshwashe instructs the men in the clinic's waiting room.

"You are just 60 percent protected, and you can get infected with the other 40 percent."

"Use a condom always. Don't compromise," she tells the men after their procedure, in addition to further instructions on care and hygiene. Mkhatshwashe tells the men they shouldn't run or play football, and above all need to refrain from any sexual activity for six weeks. It's a scene that repeats itself daily at the clinic run by Swaziland's Family Life Association.

Both the government and the family life association believe the benefits of the operation, which requires a local anesthetic and a surgeon, far outweigh the costs.  

"If you had a vaccine with a 60 percent effectiveness rate, every government would force people to line up and have it," Derek von Wissel, director of Swaziland's National Emergency Response Committee on HIV/AIDS, told the Associated Press.

Indeed, modeling studies cited by the U.N. show that universal male circumcision in sub-Saharan Africa could prevent 5.7 million new infections and 3 million deaths over the next 20 years.

The World Health Organization (WHO) and other organizations are working to assist the Swazi government. Teams of Israeli surgeons, who circumcised thousands of men in the 1990s during the mass migration of Jews from the former Soviet Union, have trained 10 of Swaziland's doctors and backup staff on performing the procedure safely and quickly with limited resources.

Inon Schenker, the Israeli mission coordinator, says the Jerusalem AIDS Project has scores of surgeons ready to assist the African countries by training local health workers in counseling and surgical techniques. And although Swaziland is currently the only country in which the Israelis are working, other nations, such as Rwanda, Namibia and Zambia, have also requested help.

It is estimated that 665 million men, or 30 percent of the world's total number of men, are circumcised according for cultural or religious purposes.  However, the procedure remains rare in Swaziland and many other southern African nations.

Circumcision is only a small part of a much broader AIDS prevention package, which includes testing, counseling and condom promotion. In many African countries, such as Swaziland, less than one in ten men have been tested for AIDS.

Last year, WHO and UNAIDS recommended against the circumcision of HIV-positive men.  Kim Eva Dickson, a WHO HIV prevention expert, says countries that provide male circumcision can only encourage, not force, men to first take an AIDS test.

"What we want to avoid is that men who are circumcised think they are HIV negative," she said. 

She cited a follow-up study of circumcised men in Kenya that found no conclusive evidence of increased risky sexual behavior.

For Mdlovu, the thought of taking an AIDS test produced more anxiety than the operation. He was also concerned at the thought of sleeping alongside his wife for more than a month without being able to have intercourse, a worry echoed by many of the other men. "Six weeks, six weeks?" the men repeated at regular intervals.  The risk of HIV increases if men have sex before the wound is healed.

But despite the challenges, the Family Life Association says it is pleased with the results of the program.

"We are proud of ourselves," Dudu Simelane, the organization's executive director, told the AP.

"It was an area where not many people were ready to tread."

Von Wissel, the head of the emergency committee, says spending on HIV/AIDS this year stands at $36 million. But even that is not enough to fight an epidemic that is devastating Swazi society. Food production has plummeted as sick families are too poor to purchase seeds and too weak to plant crops. School attendance is down with an estimated 130,000 orphans and vulnerable children.

"How do you socialize children with nobody hugging and kissing them?" said von Wissel.

"What will be the result in society in 10-15 years' time? Nobody has walked this path before."

Von Wissel's fears are summarized by an extract pinned on his office wall from a speech given by King Mswati III in 1999 at the opening of parliament that reads: "There is a real possibility that the Swazi nation will cease to exist unless we change our behavior and attitude."


Image Caption: Swazis dancing in a cultural village show. Courtesy Christoph Riedl - Wikipedia