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Are Circumcision Programs Succeeding in Southern Africa?

Countries Participating in the Voluntary Medical Male Circumcision Project
Countries Participating in the Voluntary Medical Male Circumcision Project
At least 13 east and southern African nations introduced medical male circumcision five years ago following scientific findings indicating that the removal of the male organ's foreskin reduces HIV transmission by 60 percent.

The multi-million dollar program is succeeding in certain communities but struggling in others, due to strong cultural beliefs, lack of knowledge and fears over impotence.

One of those, who decided to undergo voluntary medical male circumcision in the city of Manzini, Swaziland, is Mxolisi Kunene.

February 19th was a big day for Kunene when he finally walked into a theater at the Youth Center of the Family Life Association funded by various international donors.

Kunene says he decided a couple of months ago to undergo a circumcision procedure despite the fact that male circumcision is not part of the traditional culture of this African nation with over 1.2 million people.

Swaziland with a population of just over 1,000,000 people has an HIV prevalence rate of 26%, the highest in the world. An estimated 60,083 voluntary medical circumcisions were conducted between 2009 and 2012" - (WHO)
After applying only localized anesthesia, Kunene remains wide awake, as a nurse and physician conduct the 20-minute circumcision.

The physician, who requested anonymity, said, "You should make sure that the client has gone through all the processes including counseling and checks to ensure that he is not HIV positive. After that we take the person into the theater, apply anesthesia and then cut off the foreskin. The whole process takes at least 20 to 25 minutes.”

Kunene says there are many benefits for undergoing circumcision. “I have seen some of the benefits but this does not give me any reason to be promiscuous.”

Young men volunteer for free surgical circumcision at the Harare Central Hospital.
Young men volunteer for free surgical circumcision at the Harare Central Hospital.
​According to figures released by Population Services International, Swaziland intends to circumcise 45 percent of all males between the ages of 10 to 49 by 2015 and at least 70 percent of the male population by 2018. About 10,000 adults and 2,000 children were circumcised in 2013.

Kelvin Sesimbonile Dhlamini is among the first people who were circumcised when the country's circumcision program was re-started following a disastrous start in 2006.
Dhlamini says he had his own fears when the scalpel pierced his foreskin in 2009.

"Personally I had my fears. I was concerned about being impotent. However, I was supported by my wife who attended the whole circumcision process. This is good medically as men sweat a lot and tend to accumulate a lot of bacteria in their private parts. This causes a lot of diseases that can be transmitted to women."

He says large numbers of circumcised men are believed to have abandoned condoms and are engaged in unprotected sex. They believe they are now immune to acquiring HIV.

"To be honest with you there is something in your mind that tells you that you should engage in sex without condoms,” says Dhlamini, a father of two.

South Africa has an HIV prevalence rate of 18%. Current statistics indicate that over 130,000 circumcisions were performed in 2012, 296,729 in 2011 and 422,009 in 2012." - (WHO)
In Zimbabwe and South Africa, circumcision has been welcomed largely by the Xhosa, Shangaan and other communities which have been practicing traditional circumcision ceremonies for centuries.

Zimbabwe, Swaziland and South Africa are targeting millions of males to be circumcised by the year 2015. The circumcision program is funded primarily by the United States President's Emergency Plan for AIDS Relief (PEPFAR), the Bill and Melinda Gates Foundation and the World Health Organization.

Rwanda, Uganda, Kenya, Zambia and Botswana are among nations where experts say the program may prevent up to up to 4 million new infections, saving $20 billion.

Dr. Owen Mugurungi, head of the Zimbabwe's AIDS and Tuberculosis Unit in the Ministry of Health and Child Welfare, says almost 90,000 men were circumcised in 2013, more than double the number of those that had the procedure last year.

"This output marks a significant increase compared to 2012 when a total of 40,755 males were circumcised."

Opponents of this program say it is a waste of national and international resources. John Hhombane who lives in Swaziland's capital, Mbabane, believes that there is no need to be circumcised once you are married.

"If you are young it's possible to benefit but now I am too old to undergo medical male circumcision. Children can do it, depending on their parents,” says the 40-year-old taxi driver.

In some cases, potential clients are not yet prepared to be tested for HIV/AIDS before undergoing the procedure, as Melusi Moyo of Zimbabwe's Grassroots Soccer, which promotes circumcision through a program called 'Making the Cut', says they are too scare to be tested.

Melusi Moyo of Grassroots Soccer says men aged 18 and above are resisting circumcision due to HIV testing.
Melusi Moyo of Grassroots Soccer says men aged 18 and above are resisting circumcision due to HIV testing.

“Most of the young people do not want to know their HIV status. The number of those responding positively is below the ages of 18. Maybe this is due to peer pressure. Once school children are circumcised, they tend to influence others to undergo the procedure. I think there is need to teach everyone a lot about these programmes."

In most of the African nations where the program is underway, proponents are in a difficult fight against myths and cultural barriers.

According to the World Health Organization, the program is designed to achieve 80% voluntary medical male circumcision coverage among men ages 15-49, requiring approximately 20 million men to be circumcised, and to establish sustainable services for adolescents and /or infants to maintain coverage.

The WHO says more than 3 million procedures were performed among males of all ages in priority countries from 2008 to 2012. The number of procedures performed in 2012 was almost double the number performed in 2011.

Targeted circumcisions in five years: Zimbabwe (1,912,595), Swaziland (183,450) and South Africa (4,333,134). 20,855,905 - estimated number of males to be circumcised in African nations with medical male circumcision programs. (WHO)
It says the number of procedures performed increased in 2012 (in comparison to 2011) in all countries except Swaziland, where the number of male circumcisions declined in 2012 due to a major funding reduction at the end of the Accelerated Saturation Initiative (ASI) implemented from 2010 to 2011. South Africa performed more male circumcisions than any other priority country, followed by Uganda, Tanzania, Zambia, Kenya, Rwanda and Mozambique – with each country performing more than 130,000 medical circumcisions in 2012.

Acceptance of HIV testing and counselling (HTC) ranged from 75% in South Africa to 100% in Zambia, with 8 countries reporting acceptance rates above 90%.

The WHO further says inadequate financial resources pose a challenge in most countries. "There is need for increased government contribution with less reliance on partners for financial."

External partners provide the bulk of funding for circumcision activities in most countries and such countries, according to WHO, must increase their financial contributions to reduce dependency on international donors and inadequacy of resources for voluntary medical male circumcision scale-up.

“Although voluntary medical male circumcision coverage remains well below the 80% target, uptake is accelerating in many countries.”

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In the next edition of our three-part series, we will focus on why circumcised men are abandoning the use of condoms.