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AIDS prevention: Africa’s circumcision challenge

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Marvin is 22 years old, single and — like many men of his age -thinking about girlfriends. But for the next six weeks, he will have to give his love life a rest. On this sunny morning in the Zambian capital, Lusaka, Marvin is waiting to get circumcised.

Along with three of his friends, he sits tensely on a bench outside the operating theatre, a room usually used for abortions. Are they nervous? Marvin cracks a wide smile. “A little,” he says. In Lusaka, young men like Marvin have grown up with daily reminders of the risks that can accompany sexual relationships. For years, billboards and adverts painted on walls have espoused the importance of safe sex and testing for HIV, which currently infects more than one in five Lusaka residents. But more recently, a new message has been popping up in public spaces and the media: a call for men to get circumcised to reduce their chances of contracting the virus. Marvin’s friends told him about the procedure. “A lot of them have been circumcised so I thought of doing the same thing,” he says, adding that it may increase his odds with women. “I hear that the first thing they ask you is ‘have you been circumcised?’” he says. But, ultimately, he hopes the surgery will help him “just to stay healthy”.

Scenes like this have become familiar across much of southern and eastern Africa. Since 2007, 14 nations have taken part in a massive public-health campaign aimed at circumcising millions of men in an attempt to drastically reduce the spread of HIV (see ‘Making the cut’). About 3 million men in the region have been circumcised since the start of thecampaign, and the initiative was made a high priority in late 2011 by the World Health Organization (WHO), the Joint United Nations Program on HIV/AIDS (UNAIDS) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) — which are funding part of the program. The rest is being provided by the Bill & Melinda Gates Foundation, the World Bank and other global health organizations. The targets are ambitious: 80% of men of reproductive age in these countries need to be circumcised by 2015. That means more than 20 million circumcisions.

If these efforts succeed, the payoff could be considerable. Reaching the 80% goal could cut the number of new HIV infections in the target countries by as much as half, says Bertran Auvert, a public-health specialist at the University of Versailles Saint-Quentin-en-Yvelines in Paris. “The goal is to have a huge impact on the overall HIV epidemic in Africa.”

But some scientists worry that the benefits reported for circumcision in clinical trials will not bear out to the same degree when scaled up to tackle a messy epidemic that is spread as much through behavior as biology. In particular, they say that men are getting mixed messages about the benefits of circumcision. Another concern is the effect on women, who gain no direct protection from the circumcision campaign, and may even face greater risk. Critics say the programs could increase the risk of HIV infection in some populations by encouraging people to engage in risky sexual behaviors, such as forgoing condoms.

“It’s only been shown to decrease to some degree transmission from the female to the male, and yet we are acting as if it’s the only thing to do,” says Philip Thuma, a doctor who runs the Malaria Institute at Macha in southern Zambia. “Our job as scientists is to step back and be a bit skeptical. Should we really be putting this much emphasis on something at the expense of other things that are just as important?”

 

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