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 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.