SWAZILAND: Mass HIV infection, shortage of medical personnel, and now false hope

In a nation where the HIV infection rate is said to be nearing 50%, people are desperate. Getting sick with wholly curable diseases can be life-threatening. Getting HIV is a short-order yet slowly unfolding death sentence. It may take 10 years for HIV to begin to cause opportunistic diseases, but when it begins, it is a slow and inexorable descent into illness and agony.

Swazi men have latched onto circumcision as their silver bullet. Yet, the question remains, in a country where half of all people have HIV already, will a procedure with marginal prevention value and no curative effect mean much?

Many say no. And yet, what else is there when condoms and other methods of prevention have gone largely unused and unimplemented? The real question perhaps should be, is circumcision providing a hope that is largely absent otherwise? Is its value not in the alleged medical benefit, but rather in the hope it provides? Is it a talisman, a kind of national amulet to be carried in the loins of Swazi men?

Even the article referenced below misstates and misunderstands circumcision, repeating speculation as to its alleged protective mechanism and making the astounding claim that condoms are only of limited effect. When the national media doesn’t understand or know the facts, how can the poorly educated masses have any hope of implementing defensive measures against the disease?

Swaziland, like many poor African nations, has a massive shortage of medical personnel. Therefore, the chances of obtaining a safe circumcision are low. It is entirely possible that circumcision may result in many sub-standard procedures. It will therefore likely spawn a new pathology of its own, if it takes hold in numbers. As Thoko Tsabedze, an HIV-positive mother from Macatjeni district south-east of the capital, explains, “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’.”

At a 50% infection rate, it must be asked whether those who would contract the disease haven’t already fallen victim. Even if circumcision had some protective effect, it likely would not benefit those who are now negative. The numbers needed to treat would be so high as to make it a worthless effort. In a country with so few resources, the latest national tragedy to befall Swaziland would be implementation of a superfluous surgery in place of whatever else is medically lacking.

Complete text of the article after the jump.

Circumcision fever begins to sweep Swaziland

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


Blandy, Fran. Circumcision fever begins to sweep Swaziland. Mail & Guardian Online. February 2, 2007.


About David Wilton

fronterizo, public defender, intactivist, gay
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