Male nurse Moshoeshoe Makhubu has helped in many circumcisions but is visibly nervous as he prepares to undergo the snip himself, a procedure he grudgingly admits may boost chances of remaining HIV-free.
In Swaziland, staying clear of the virus is hard as close to 40% of adults are living with HIV/Aids, the highest infection rate anywhere in the world according to the United Nations Children’s Fund (Unicef).
Trials in Kenya and Uganda have shown that circumcision, while not providing complete protection for the man, dramatically reduced the number of new infections.
Thirty-year-old Makhubu, who works at the government hospital in the Swazi capital Mbabane, says he is aware he should ”still use other preventative measures” if he wants to remain healthy.
Swaziland’s only expert in the field, urologist Adam Groenevald of Holland, says the Kenyan and Ugandan trials — which showed 53% and 48% reductions in new infections respectively — have got Swazis thinking.
”There are voices against it, but the momentum of the whole thing cannot be stopped,” he says.
Many nurses are bringing in their husbands and sons for the snip as circumcision fever begins to sweep the country. Swaziland’s health ministry is eager to roll out a mass programme but is awaiting advice first from the World Health Organisation.
”If there was a vaccine with 65% efficacy, the whole world would have jumped on it, but an operation on the penis will not be that popular,” Groenevald fears.
His office, a room in an abandoned ward, bears mute testimony to the crippling shortage of nurses and doctors that will make the fulfilment of such a programme in Swaziland even more difficult.
Only 100 or so doctors serve the population of more than one million in this south-east African mountain kingdom where two-thirds of people live in poverty.
”We have to make the medical establishment and policymakers ready for the go ahead,” says Groenevald.
”If we are not ready and the go ahead comes there will be chaos. A number of unqualified people will start offering circumcisions and we need to avoid that at all costs.”
To try and satisfy soaring demand for operations, doctors are being trained and are asked to help out on special ”circumcision days” when the procedure is offered free of charge.
These occasions typically see about 40 men operated upon, but up to 100 others are routinely turned away because there are not enough professional medical staff to carry out the circumcisions.
Groenevald highlights the need for more doctors, saying if 200 000 men wanted to get circumcised — a figure he deemed conservative — it will require 40 000 operations to be performed annually for the next five years.
Faith Dlamini from the state-run National Emergency Response Council on HIV/Aids says the government would first focus on circumcising the 15 to 30 age group as it ran the highest risk of infection.
According to the Unicef website, HIV prevalence among 20 to 30-year-olds is already nearing 50%, higher than the national adult average.
Apart from the sheer logistical problem of finding the doctors, mass circumcision faces deeper-rooted and more cultural barriers in Swaziland.
Swazi boys are not circumcised traditionally as is the case in other parts of Southern Africa. A 19th-century king banned the procedure, arguing that the lengthy healing process interfered with boys’ war-readiness.
Thoko Tsabedze, an HIV-positive mother from Macatjeni district south-east of the capital, explains a common problem.
”It is difficult even when you try to talk to your son about circumcision. He says, ‘How am I going to take a bath publicly with my friends, I will be ridiculed’.”
Vusi Dlamini from the Family Life Association of Swaziland, the country’s leading non-governmental organisation tackling HIV/Aids, believes this thinking can be overcome as people are very interested in circumcision and few view it as ”un-Swazi”.
The most popular theory behind circumcision’s protective effect is that the foreskin has a very thin epithelium, or lining, and easily suffers minor abrasions during intercourse.
These microscopic cuts make it easier for the Aids virus to enter the man’s bloodstream.
Until now, the only prevention strategies have depended on condoms and sexual abstinence, both of which are of only limited effect.
Campaigners caution that circumcision — while low-cost, one-off and effective — is no silver bullet and will not provide complete protection.
”We want people to be aware it is not the answer, but an intervention within a package,” says Faith Dlamini. – Sapa-AFP