Pretoria curbs circumcision

In the year since a major South African study indicated that circumcision reduced the rate of HIV infection among men, several African countries hit hard by the disease have moved toward embracing the procedure in the battle against Aids. But not South Africa.

Swaziland and Zambia have begun offering discounted circumcisions in pilot programmes to men who want them or to boys whose parents request them, and Botswana, Uganda, Lesotho and Tanzania are contemplating the idea. Yet in South Africa, where more people are infected with HIV than in any other African country, the results of the research have rarely been reported, much less publicly discussed. If anything, Aids activists say, circumcisions will soon become less common because of a law signed by President Thabo Mbeki.

"They might have made it more difficult to implement what may be our most important HIV-prevention strategy ever," said Francois Venter, president of the Southern African HIV Clinicians Society.

The law bans the circumcision of boys younger than 16. It was aimed at curbing circumcisions performed as a tribal rite, a practice that leads to dozens of deaths and injuries each year. The measure includes exceptions for religious reasons, meaning it will have no effect on the country's small Jewish and Muslim communities, and on medical grounds, though they were not defined.

In debating the law, the research into the procedure's effect on the transmission of HIV was not discussed, participants said. "That was not the issue at all," said Tseliso Thipanyane, chief executive of the South African Human Rights Commission, a leading supporter of the law, which addresses several issues regarding the rights of children. "The concern in our country has been the number of kids who have been dying, the number of kids who have lost their manhood."

Circumcision removes a penis's foreskin, which is made up of cells particularly susceptible to receiving and also possibly effective at transmitting HIV. In addition, researchers believe that a foreskin traps fluid, allowing the virus to live longer on a penis after intercourse and increasing the likelihood of infection.

Jews and Muslims worldwide have practiced circumcision for centuries, and it is common among most ethnic and religious groups in the United States. In Africa most tribes historically included circumcision as part of coming-of-age rituals, but the tradition has faded as countries have become more urbanised. Researchers have noted for several years that African countries with the highest HIV rates generally have low rates of circumcision.

The South African study, conducted at the impoverished, densely populated Orange Farm township south of Johannesburg, was the first to measure experimentally the effects of circumcision on the spread of HIV. Researchers recruited 3,274 young men there and performed the surgery on half. After 18 months, 49 of the uncircumcised group had become infected with HIV, but only 20 who had been circumcised were infected. The researchers suggested that circumcised men were 60% less likely to contract HIV than uncircumcised men.

Articles on the study and on similar ones under way in Uganda and Kenya have appeared in dozens of journals and newspapers throughout Africa and the world. But in South Africa, where discussions of Aids frequently are tense and highly politicised, a search of online databases found only one reference to the research in a publication.

The polarised nature of the Aids debate in South Africa dates to 2000, when President Mbeki questioned whether HIV was the sole cause of the disease and whether antiretroviral treatment was safe and effective. Activists have long argued that President Mbeki's doubts undermined the South African response to Aids.

At a recent meeting on circumcision at Chris Hani Baragwanath hospital in Soweto, the first gathering of its kind in South Africa, Martin Veller, a University of the Witwatersrand medical school professor, argued that South Africa could reduce its HIV rate by two-thirds by circumcising males between 15 and 24.

Veller estimated a one-time cost of $32m to set up surgical facilities and annual operating costs of $32m for the first few years. Over time, Veller said, the intervention would prevent 150,000 infections a year and save nearly $1bn in annual medical costs in treating HIV patients.

An estimated 5 million South Africans now have the virus in a country with a population of 46 million.

South African officials say they will continue to monitor the research on circumcision and change policy and law if the evidence becomes sufficiently compelling.

"The research is ongoing," said Joel Netshitenzhe, a senior policy adviser to President Mbeki. "Once they've finalised it, there would have to be policy work based on the outcomes."