Circumcision programs are slowly beginning to be rolled out in sub-Saharan Africa in hopes of reducing the toll of HIV infections in the area, researchers said Tuesday at the International AIDS Conference in Vienna. Some predicted that more than 4 million new HIV infections could be prevented in eastern and southern Africa by 2025 if the circumcision rate could be increased to 80%, saving more than $20 billion in HIV-related healthcare costs over the period.
Sub-Saharan Africa accounts for about two-thirds of the more than 33 million HIV-positive people worldwide, with an estimated 1.9 million people in the region newly infected each year. Studies sponsored by the World Health Organization have shown that circumcision reduces the risk of HIV infections in men by 60%, although results so far show no benefit for blocking transmission to women.
Some of the research is sponsored by the Gates Foundation. In a speech Monday at the meeting, Microsoft founder Bill Gates said he was surprised by the positive response to circumcision programs. "I was doubtful that a large number of men would sign up for it. I'm glad to say I was wrong. Wherever there are clinics available, men are volunteering to be circumcised in large numbers — far more than I expected."
Dr. Bertran Auvert of the French agency INSERM in Villejuif reported at the meeting and in the journal PLoS Medicine on the rollout of a Bophelo Pele (Health First) project in Orange Farm, South Africa. The project offers free, safe adult male circumcision services to all men over the age of 15 in the township, a low-income region where adult HIV prevalence is 15.2% and circumcision prevalence is about 25%. They reported that the response to be program has been good, with an estimated 39.1% of adult uncircumcised men in the village having undergone the procedure. With three teams consisting of one physician and five nurses, the group has performed as many as 150 procedures per day under local anesthesia. As of November 2009, 14,011 men had been circumcised, averaging about 740 per month. The rate of adverse events, none of which resulted in permanent damage or death, was 1.8%.
The researchers' biggest concerns was that only about a quarter of the participants were willing to undergo HIV testing and education programs.
Researchers from the nonprofit Population Services International in Washington, D.C., reported on a new "conveyer belt" approach to implementing circumcision in Zimbabwe, where the group is working with the government to get mass circumcisions underway. The prevalence of HIV is 13.7% among men younger than 49 in the country, and the goal is to circumcise at least 80% of men ages 15 to 29, a total of 1.2 million men. Dr. Karin Hatzold, director of HIV services for the agency, said one new infection would be averted with every seven procedures.
The team uses pre-assembled, pre-sterilized surgical kits and cauterizes the surgical wounds rather than using stitches. A team of doctors and nurses operate on four patients at a time in adjoining cubicles. A physician administers anesthetic to all four patients. By the time he is done, the first patient is ready for the procedure. Each team can now perform eight to 10 procedures per hour, compared with the one to two that was possible before, Katzold said.
Not everyone thinks that circumcision is a good idea, however. The groups Intact America and the International Coalition for Genital Integrity urged a halt to the procedures at the Vienna meeting, calling the plans "exorbitant, dangerous and unethical." The groups argue that many recipients think they no longer need to use condoms, which actually increases the spread of HIV. They also cite a high rate of complications from the procedures — as high as 18% under clinical conditions and up to 35% for traditional circumcisions.
Increased promotion of condoms is 95 times more cost-effective than male circumcision in preventing new HIV infections, said Dan Bollinger, director of the international group.