July 20, 2009
South Africa Is Seen to Lag in H.I.V. Fight
By CELIA W. DUGGER
ORANGE FARM, South Africa — Young men have flocked by the thousands to this
clinic for circumcisions, the only one of its kind in South Africa.. Each of
them lies down on one of seven closely spaced surgical tables, his privacy
shielded only by a green curtain.
“I’ve done 53 in a seven-hour day, me, myself, personally,” said Dr. Dino Rech,
who helped design the highly efficient surgical assembly line at this
French-financed clinic for cutting off foreskins.
Circumcision has been proven to reduce a man’s risk of contracting H.I.V. by
more than half. Yet two years after the World Health Organization recommended
the surgery, the government here still does not provide it to help fight the
disease or educate the public about its benefits.
Some other African nations are championing the procedure and bringing it to
thousands. But in South Africa, the powerhouse country at the heart of the
epidemic, the government has been notably silent, despite the withering
international criticism the country has endured for its previous foot-dragging
in fighting and treating AIDS.
“Countries around us with fewer resources, both human and financial, are able
to achieve more,” said Dr. Quarraisha Abdool Karim, the first director of South
Africa’s national AIDS program in the mid-1990s under President Nelson Mandela.
“I wish I understood why South Africa, which has an enviable amount of
resources, is not able to respond to the epidemic the way Botswana and Kenya
have.”
Even without government involvement, demand for the surgery, performed free
under local anesthetic, has surged over the last year here at the Orange Farm
clinic. The men are counseled to continue using condoms since circumcision
provides partial, though substantial protection.
Men waited nervously one recent chilly morning for their turn. Most were hoping
the procedure would help them stay healthy here in the nation with more
H.I.V.-positive people than any other.
But some said they were also drawn by a surprising, if powerful, motivation:
They had heard from recently circumcised friends that it makes for better sex.
You last longer, they said. Your lovers think you’re cleaner and more exciting
in bed.
“My girlfriend was nagging me about this,” said Shane Koapeng, 24. “So I was
like, ‘O.K., let me do it.’ ”
As new H.I.V. infections have continued to outpace efforts to treat the sick in
Africa, there is growing concern about the ballooning costs of treatment for an
ever-expanding number of patients who need medicines for the rest of their
lives. Almost two million people were newly infected in 2007 in sub-Saharan
Africa, bringing the total of those living with H.I.V. in the region to 22
million, according to United Nations estimates.
The major international donors to AIDS programs, including the United States
and the Global Fund to Fight AIDS, Tuberculosis and Malaria, are ready to pour
money into male circumcision, but the countries have to be ready to accept the
help.
“You can’t impose it from the outside, particularly such a sensitive
intervention,” said the Global Fund’s executive director, Dr. Michel
Kazatchkine.
Public health doctors agree that circumcising millions of men will be no simple
task. Africa has a severe shortage of doctors and nurses, and circumcision is
potentially a political and cultural minefield in countries where some ethnic
groups practice it but others do not.
Still, some countries are showing it can be done. In Botswana, circumcision was
largely stopped in the late 19th and early 20th centuries by British
colonial-era administrators and Christian missionaries.
But Festus Mogae, who was president from 1998 to 2008, provided a critical
endorsement of male circumcision just before he stepped down.
Over the past year, the government has trained medical teams to do
circumcisions in all its public hospitals and aims by 2016 to have circumcised
470,000 males from infancy to age 49, which is 80 percent of the total number
in that group.
Public awareness is being raised through advertisements on radio and
television. Billboards have sprouted across the country featuring a star of the
national youth soccer team.
“Men have started to flock to the hospitals,” said Dr. Khumo Seipone, director
of H.I.V./AIDS prevention and care in Botswana’s Ministry of Health.
In Kenya, where the Luo do not generally practice circumcision, Prime Minister
Raila Odinga, himself a Luo, encouraged the procedure and lobbied elders. The
H.I.V. infection rate among Luo men is more than triple that of Kenyan men
generally — 17.5 percent versus 5.6 percent.
“Anything that could help save lives needs to be tried,” Mr.. Odinga said,
adding that he had been circumcised.
So far, more than 20,000 men in Kenya have been circumcised in hospitals,
dispensaries, village schools, social halls and tents. Teams of doctors, nurses
and counselors have even taken boats to islands in Lake Victoria to circumcise
Luo fishermen.
“If the Luo Council of Elders and local politicians had been against it, the
government would not have dared endorse circumcision,” said Robert Bailey, the
principal investigator on the Kenya male circumcision clinical trial.
In sharp contrast, male circumcision has no political champion here in South
Africa, where the largest ethnic group, the Zulus, have generally not practiced
it since the early 19th century, when it was abandoned due to protracted
warfare, according to Daniel Halperin, an epidemiologist and medical
anthropologist at Harvard University.
Thabo Masebe, a spokesman for President Jacob Zuma, said the Health Ministry
must first set a policy on circumcision before Mr. Zuma, who took office in
April, can take a position. Mr. Zuma is Zulu. The province of KwaZulu-Natal,
the Zulu heartland, has the highest adult H.I.V. prevalence rate in the
country, 39 percent, according to Unaids.
“The president gets involved when decisions are made,” Mr. Masebe said. “If the
president spoke now, and when the time comes to make a policy, a different
decision is taken, it wouldn’t sound good.”
The new health minister, Aaron Motsoaledi, spoke at length about AIDS in a
recent speech to Parliament but made no mention of male circumcision. Dr. Yogan
Pillay, a senior official at the National Department of Health, said a policy
was being drafted and would be put forward for discussion by the end of the
month.
In March 2007, the World Health Organization concluded from rigorous clinical
trials in Kenya, Uganda and here in Orange Farm township that male circumcision
reduced female-to-male H.I.V. transmission by about 60 percent.
“This is an important landmark in the history of H.I.V. prevention,” the W.H.O.
said at the time.
That same year, a committee of scientists, advocates and others advising the
South African government recommended offering circumcisions as quickly as
possible, perhaps by contracting with private doctors while public health
workers were trained. Instead, the government set up a task force to study the
issue, said Dr. Abdool Karim, a committee member.
The surgical methods developed in Orange Farm are now being copied in the
region. Population Services International, which provides counseling at the
Orange Farm clinic, is putting them into practice in Zimbabwe in collaboration
with the Health Ministry there. It also received $50 million from the Bill and
Melinda Gates Foundation to work with the governments of Zambia and Swaziland
in the hope of circumcising some 650,000 men in those two countries.
South Africa has made strides in recent years, and now provides antiretroviral
therapy to more people with AIDS than any other developing country.
But this is not the first time its policies have lagged behind. The country
delayed for years providing antiretroviral medicines to treat AIDS under its
former president, Thabo Mbeki, who denied the scientific consensus about the
viral cause of the disease. Harvard researchers estimated that the government
would have prevented the premature deaths of 330,000 South Africans earlier in
the decade if it had provided the drugs.
“South Africa has no shortage of scientists,” said Olive Shisana, chief
executive officer of South Africa’s government-financed Human Sciences Research
Council. “We have a shortage of people willing to take the evidence that exists
and use it for public health.”
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