Zambia moving fast to scale up male circumcision

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Male circumcision (MC) was a recurring theme throughout our congressional study tour, since the intervention has been shown to provide up to 60 percent protection for men from HIV infection from a female partner. There is also evidence that it reduces the chance of the female partner contracting some genital infections that could lead to cancer of the cervix.

Access to MC is being scaled up across many parts of Africa. It is particularly important given the significant proportion of discordant couples in which the man is HIV negative and the woman is HIV positive (about 40 percent in Kenya, for instance).

Zambia has a circumcision rate of about 13 percent.  In only one area of the country, the northwest, the practice is a normal part of male initiation ceremonies.

A young man waits in line to be circumcised at the Livingstone General Hospital male circumcision unit. "It's good for my health and my parents want me to get it done," he said.

A recent study by the U.S. Agency for International Development found that a rapidly scaled up MC effort in Zambia would avert 28 percent of HIV infections, with an enormous cost savings in the long term.  The study found similar results for many other countries.

At our hotel in Livingstone, in southern Zambia, we asked some of the young male workers about the experience with circumcision, and they were not shy about the topic.  Several told us they had gotten circumcised for “reasons of hygiene,” and they said that they knew it was important still to use a condom during sex. The latest studies of MC have not shown serious problems with men engaging in riskier behavior after being circumcised.

When our congressional study tour visited Livingstone General Hospital’s MC clinic, we met several teenagers who were waiting a bit nervously to have the procedure done.  Youth are a particular target for the program and there has even been provision of MC using mobile facilities during school holidays.

Until recently the age of consent for the procedure was 21, but this has been lowered to 18.  Boys less than 18 years of age must have parental approval.  One boy whose procedure we witnessed was being comforted by his mother as the surgery was taking place.  She told us she felt it was important for her son’s health.

We had the privilege of talking about the issue with Dr. Lutangu Alisheke, the Provincial Medical Officer for the Southern Province of Zambia, the area with the highest rate of HIV prevalence in the country.  Zambia’s Ministry of Health is working with two U.S. NGOs, Jhpiego and PSI, and taking advantage of some direct funding from the CDC, to scale up access to MC at Livingstone General Hospital and other facilities. The results so far are impressive.

The medical officer told us the MC program was officially launched in the country last year, and the Southern Province has moved the fastest, he said, with 900 circumcisions performed so far this year.  Counseling is provided before and after performing the operation.

Since 2006 Jhpiego has helped a great deal with training for MC, and it has been found that nurses and clinical officers can carry out the procedure just as competently as medical officers.  The goal now is to continue to train more personnel to do the procedure, though the officials also told us that the shortage of nurse midwives is one of the biggest personnel challenges.

We asked Jeff Stringer, director and CEO of the Center for Infectious Disease Research in Zambia (CIDRZ), about MC and he praised the Zambian government for “really taking it on” by scaling up the MC effort.  Even though the public health benefit would not be seen for years to come, he also said CIDRZ was strongly supporting circumcision of infant boys.

PEPFAR Zambia’s plans for 2010 regarding male circumcision are laid out in the FY 2010 COP (see page 19).

Total investments in MC for the President’s Emergency Plan for AIDS Relief (PEPFAR) were expected to hit at least $30 million for all countries in 2009. MC advocates hope to see that number quickly increased.

8 thoughts on “Zambia moving fast to scale up male circumcision

  1. Mark Lyndon

    Circumcision is a dangerous distraction in the fight against AIDS. There are six African countries where men are *more* likely to be HIV+ if they’ve been circumcised: Cameroon, Ghana, Lesotho, Malawi, Rwanda, and Swaziland. Eg in Malawi, the HIV rate is 13.2% among circumcised men, but only 9.5% among intact men. In Rwanda, the HIV rate is 3.5% among circumcised men, but only 2.1% among intact men. If circumcision really worked against AIDS, this just wouldn’t happen. We now have people calling circumcision a “vaccine” or “invisible condom”, and viewing circumcision as an alternative to condoms. The South African National Communication Survey on HIV/AIDS, 2009 found that 15% of adults across age groups “believe that circumcised men do not need to use condoms”.

    The one randomized controlled trial into male-to-female transmission showed a 54% higher rate in the group where the men had been circumcised btw.

    ABC (Abstinence, Being faithful, and especially Condoms) is the way forward. Promoting genital surgery will cost African lives, not save them.

    1. Agboola Oyebadejo

      Circumcision is another method of fighting the spread of HIV and if carried out by properly trained personnel, poses no risk to the human health. The position or usefulness of circumcision in the fight against HIV/AIDS however needs to be properly spelt out. That is, people should be informed that circumcision does not stop people from ontractracting HIV but should practice it in conjunction with ABC (Abstinence, Being faithful, Condoms). Infact ABC should be modified to ABCC (Abstinence, Being faithful, Condoms, Circumcicion). Any method, medical or lifestyle changes, that have the smallest effect on the fight against HIV/AIDS should be embraced and implemented vigorously

  2. dadakim

    @Mark: I’m curious of the Malawi data you cite. Would you be willing to share it? Malawi is a somewhat unique case given that the population that largely practices circumcision also happens to predominantly live in the southern part of the country where there is greater mobility and a higher rate of HIV (even in non-circumcising populations).

  3. Mark Lyndon

    If you click on my name, you can see links to the figures in the six African countries I listed.

    It’s worth remembering that many of the people who circumcise do so for religious reasons, and are therefore likely to have fewer sexual partners. That alone could lead to lower rates of HIV among circumcised populations, without meaning that circumcision is the cause.

    It’s also been suggested that Ramadan (when Muslims aren’t supposed to have sex during the day for a month, and some don’t at night), disrupts the cycle of transmission (since newly infected people are more infectious to others). Some people have called for everyone to stop having sex during that time.

  4. Hugh7

    As well as the six African countries Mark Lyndon cites, in Malaysia, Muslims amount to 60% of the population, but 72% of HIV cases (and virtually all Muslim men are circumcised and hardly anyone else there).

    A confounding factor that is largely ignored is non-sexual transmission. In many parts of Africa, amateur “needle men” offer an injection for every ailment. The health and other authorities would not want it known if much HIV transmission was taking place through poor (or no) sterilization of surgical instruments, and they attack the foreskin as a scapegoat for their own failings.

  5. Gordon

    According to interviews on capacity done under SADC auspices in 2009, Zambia does NOT have the medical personnel or the medical infrastructure to sustain a massive MC campaign.

    1. ben

      Goldon, 2009 might be too general a period to site. Alot has happed in 2009 including the developing and implementation of the Zambia MC strategic plan 2010( Done in 2009).
      just briefly- the MOH is leading the program and with it is the National TWG( multi secterial)which is looking at service delivery , comunication and QA.
      strong partnership regarding implementation has been formed notably;WHO, JHPiEGO,SFH,CDRZ,ZPCT/FHI,MSL etc based on comperative advantages.
      Trainings of MOs, licentiates, clinical officers and nurses in MC has been done including refurbisments of MC sites.
      i suggest SADC auspices should do another interview and compare the results.

  6. NOJO

    Guys should not be stereo typed to talk solely about MC please talk about it fully for populations to understand the main intent, minimum package in MC, as being advocated this entails us getting men for other reproductive health services and even room to counsel them and educate them at length about HIV, this for sure has done wonders even in change of behavior


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