Kenya is the leading country in Africa when it comes to expanding male circumcision as an HIV prevention tool, the 17th Conference on Retroviruses and Opportunistic Infections (CROI) was told last week.
Kim Dickson, a medical officer in the HIV prevention unit at the World Health Organization, told the conference that even though 90,000 men were circumcised in Kenya in 2009, this is still only 60% of the number the country needs to reach, according to mathematical models, in order to reduce HIV prevalence by 45-50% by 2025.
However a programme called the Expanded Access Initiative using volunteers managed to perform 36,000 circumcisions in the two months of November and December 2009: a measure of the kind of commitment needed if high-prevalence countries with heterosexually driven epidemics are to successfully use male circumcision as an HIV prevention strategy.
Dickson summarised the research evidence for circumcision – see Aidsmap’s section on circumcision for a summary of this. Circumcision prevents at least six in ten HIV infections in men, offers partial protection against herpes and human papillomavirus (HPV), and probably prevents about three in ten infections in female partners of circumcised men.
A mathematical model has suggested that if male circumcision in a country where 35% of the men were already circumcised rose to 80%, it would reduce HIV prevalence in the whole population by 25% and in women by about 20%. This proportion of men circumcised would prevent over four million HIV infections in the focus countries by 2015. This would save $20.2 billion at a cost of $4 billion.
This would require performing the huge figure of 12 million circumcisions in the peak year (2012 for the model’s purposes). Botswana alone, for instance, would spend $9 million in this year but the savings would be immediate, amounting to $13 million in the same year and rising to $23 million after four years. Botswana’s cumulative cost would be $30 million, but its cumulative saving $300 million.
Following the randomised controlled trials, a WHO global consultation in 2007 recommended male circumcision should be scaled up in 13 African countries where HIV prevalence was over 15% and where there were low levels of circumcision. These were Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.
The consultation emphasised that in each country there would be a different set of ethical issues, communication needs, cultural attitudes, health systems, political and legal frameworks, prevention strategies and funding structures, and these needed to be addressed on a country-by-country basis.
“There is a lot going on in the scale-up countries, and advocacy is vibrant,” said Dickson, but progress has varied considerably.
Kenya has made the most progress, with the figures cited above. However no other country has performed nearly as well. The next-largest number of circumcisions performed was in Zambia, with 16,800 circumcisions in 2009 and 6200 in the last two months of the year, when Kenya performed 36,000. Only four countries – these two plus Botswana and Rwanda – are delivering nationally run services (Rwanda only in the military), Tanzania, Malawi and Mozambique are piloting schemes, and South Africa has one pilot site in Orange Farm as a continuation of its randomised controlled trial there. But other countries are still at the stage of training staff or finishing off implementation and monitoring strategies.
Even getting this far has required a lot of dialogue and communication between different groups. In 2008 a meeting of African Ministers of Health endorsed the WHO strategy but there have had to be multi-level stakeholder meetings with groups ranging from traditional leaders in Kenya and Lesotho to women’s groups in Zimbabwe.
As in many other areas, the presence of strong leadership and a champion for the approach has been crucial; for instance in Botswana former president Festus Mogae is leading the circumcision drive, while in Kenya it took a personal meeting between the Prime Minister, Raila Odinga, and the Luo Council of Elders to overcome previous opposition to the concept in this traditionally uncircumcised people.
Kenya aims to have at least 84% of males circumcised by 2013, which would cost up to $56 million.
In late 2009 it launched a so-called Rapid Results Initiative (RRI) in Nyanza Province (home of the Luo), which achieved 1200 circumcisions a day in 30 working days in eleven districts. Up to 95 teams of workers undertook the programme, averaging 9.6 circumcisions per team and a maximum of 22.8, at a cost of $30 each, far less than the WHO estimate of $50.
An important aspect of the Kenyan RRI was that the country has already conducted other RRIs, for instance in HIV testing.
There remain multiple challenges and constraints to implementing the programme, Dickson commented.
Human resources are a significant barrier; not merely getting enough personnel, but sometimes revising country protocols on who is allowed to perform minor operations. Such ‘task shifting’ will be vital if programmes are to be scaled-up. Burnout is a problem too, as teams perform hundreds of circumcisions “day after day, hour after hour”.
One unsolved problem is how to promote the uptake of HIV testing prior to circumcision and how to deal with men who test positive for HIV. At present WHO does not recommend their circumcision, partly because of evidence that in the period post-operation they might actually be more infectious. However this would mean that being uncircumcised would become seen as a mark of having HIV, so how not to stigmatise them was problematic.
Countries were not clear on what funds are available and how to access them, though PEPFAR, the Gates Foundation and the Global Fund were all putting money into the field.
Traditional circumcisers exist in virtually every country, but there was still no clear policy on how to involve them. And there was no guidance on how to monitor possibly adverse societal effects, such as increased pressure on women to have unprotected sex.
Dickson concluded that political leadership was one key to a successful programme, and the earliest possible engagement and consultation with all stakeholders the other.