AIDS-hit Swaziland promotes circumcision

[November 03, 2008]  MBABANE, Swaziland (AP) -- Nelson Mdlovu strides out of the small clinic with a spring in his step and a smile on his lips just minutes after being circumcised.

Mdlovu swallowed his fears to line up with nine other equally nervous men for the 30-minute operation. They joined the ranks of hundreds of Swazi men who have opted for circumcision, after the U.N. said last year that it could cut the risk of contracting the HIV virus by as much as 60 percent.

With the help of training from Israeli surgeons, Swaziland now leads the African rush to embrace an ancient surgical intervention against a modern scourge.

Its zeal is born of desperation. Swaziland suffers from the world's highest AIDS rates -- nearly 40 percent of pregnant women and 19 percent of its 1.1 million people are infected. This is the equivalent of 56.6 million Americans, 11 million Britons, 212 million Indians and 248 million Chinese. Life expectancy has halved to 31 years in just a decade.

Mdlovu says he thinks circumcision "will change my life."

But there are rumbling fears that the "kindest cut" may actually be a double-edged sword, if men fool themselves that circumcision gives them immunity and indulge in risky sexual behavior.

"It doesn't mean you are 100 percent protected," nurse Prudence Mkhatshwashe tells the men clutching pink numbered tickets in the freshly painted waiting room. "You are just 60 percent protected, and you can get infected with the other 40 percent."

"Use a condom always. Don't compromise," she orders, before giving care and hygiene instructions like no running and no playing football -- and above all no sex for the next six weeks until the healing process is complete. The scene repeats itself daily at the clinic run by the Family Life Association of Swaziland.

The AIDS epidemic has reversed all Swaziland's economic and social gains since independence from Britain 40 years ago. Mass male circumcision, which requires local anesthetic and a surgeon, will add additional demands to overstretched facilities in a country which has only 170 doctors.

But both the government and the family life association are determined to press ahead, saying the benefits of the operation far outweigh the costs.

"If you had a vaccine with a 60 percent effectiveness rate, every government would force people to line up and have it," says Derek von Wissel, director of Swaziland's National Emergency Response Committee on HIV/AIDS.

Universal male circumcision in sub-Saharan Africa could prevent 5.7 million new infections and 3 million deaths over 20 years, according to modeling studies cited by the U.N.

The World Health Organization and other agencies are trying to provide technical support to the Swazi government. Teams of Israeli surgeons -- who circumcised tens of thousands of adult men in keeping with religious traditions during the mass migration of Jews from the former Soviet Union in the early 1990s -- have trained 10 Swazi doctors and backup staff on how to perform the operation quickly and safely with limited resources.

Inon Schenker, who coordinated the Israeli missions to Swaziland, says his organization, the Jerusalem AIDS Project, has several dozen surgeons ready to help African countries scale up adult male circumcision by training local health workers in both surgical techniques and counseling. Swaziland is the only country in which the Israelis are working, though they've been asked by Rwanda, Namibia and Zambia, among others.

An estimated 665 million men, or 30 percent of the world's total, are circumcised according to religious and cultural practices. But in Swaziland and many other southern African nations it is rare.

The snip of the foreskin is just one small part of a much wider AIDS prevention package, which also includes testing, counseling and condom promotion. In many African countries -- including Swaziland -- less than 10 percent of men have had an AIDS test.

WHO and UNAIDS recommended last year that HIV-positive men should not be circumcised. But Kim Eva Dickson, an HIV prevention expert at WHO, says countries offering male circumcision can only encourage men to take an AIDS test first, not force them.

"What we want to avoid is that men who are circumcised think they are HIV negative," she says, adding that it's important to spread this message among women as well. She says a follow-up study of circumcised men in Kenya had no conclusive evidence of an increase in risky sexual behavior.

Only one of the men attending the Mbabane clinic the day an AP reporter visited had already had an AIDS test, although all were offered it at the clinic.

Mdlovu said he was more nervous about the test than the operation. He was also alarmed at the prospect of sleeping alongside his wife for more than a month without being able to have sexual intercourse. His concerns were shared by the other men, who repeated "six weeks, six weeks?" at regular intervals. If men have sex before the wound is healed, the risk of HIV infection increases.

Despite all the difficulties, the Family Life Association says it is pleased with progress.

"We are proud of ourselves," comments its executive director, Dudu Simelane. "It was an area where not many people were ready to tread."

Von Wissel, the head of the emergency committee, says spending on HIV/AIDS this year is $36 million -- and even that's not enough to tackle an epidemic that is destroying the fabric of Swazi society. Food production has plummeted because sick families are too poor to buy seeds and too weak to plant crops. School attendance is down. There are an estimated 130,000 orphans and vulnerable children.

"How do you socialize children with nobody hugging and kissing them?" agonizes von Wissel. "What will be the result in society in 10-15 years' time? Nobody has walked this path before."

His fears for the future are summarized by an extract pinned on his office wall from a speech given by King Mswati III at the opening of parliament in 1999.

"There is a real possibility that the Swazi nation will cease to exist unless we change our behavior and attitude."

[Associated Press; By CLARE NULLIS]

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