Public Health January/February 2011

The Kindest Cut

Swaziland turns to mass circumcision.
Leif Parsons

Banele Shabangu is scared because he should be scared. Because a man in a mask is about to stick a needle into the base of his penis. “Are you ready?” the man asks.

“No one could be ready for this.”

“Don’t touch, don’t jump,” says Nurse Justin, the man with the needle. Then he injects Banele with a local anesthetic. Banele shouts. It hurts, but it’s more where it hurts than how much it hurts.

Banele, an 18-year-old in his last year of high school, has come to the clinic in Matsapha, Swaziland, to get circumcised. Like the dozens of teenagers and men packed into the waiting room, he’s doing so because he heard that circumcision offers partial protection against HIV, the virus that is obliterating the future of his country.

Slideshow: Photos from Swaziland's circumcision campaign

But first he needs another injection. “Wait, wait, please,” he says. “I’m sorry for screaming, you’ll forgive me, sir.” He clenches his teeth as the nurse sticks the needle in again.

Just under 20 percent of Swaziland’s 1 million people are HIV positive, an epidemic fueled by poverty, a lack of medical resources, and a male-dominated and promiscuous culture in which polygamy is still common. Look more closely, and the numbers get uglier. Nearly half of women ages 25 to 29 and men 35 to 39 are infected. Since 1998, according to one report, the average life expectancy has dropped from about 61 years to 47. “With the highest prevalence of HIV in a population ever recorded, we have got to do something to intervene,” says Dr. Vusi Magagula, chair of the government’s male-­circumcision task force.

Swaziland has been preparing its men for mass circumcision since 2006. The previous year, a randomized controlled trial in South Africa (later confirmed by studies in Uganda and Kenya) found that circumcised men are as much as 60 percent less likely to contract HIV through heterosexual sex. Scientists do not yet know exactly why, but the study was so convincing that it was stopped after 18 months, because preventing the uncircumcised control group from getting the procedure would have been unethical.

Now a nationwide campaign is under way to circumcise 160,000 HIV-­negative males by the end of this year. That’s the number organizers believe will walk willingly into the operating theater. The government’s task force plans to recruit additional doctors from around the world, train them, and send them throughout the country to perform the surgeries. At the campaign’s peak, the organizers expect to have 35 doctors and 245 nurses. “This will prove to Africa that together we can fight HIV,” says Ayanda Nqeketo, of the ministry of health. “It will be a historic moment.”

To encourage men to have the surgery, outreach teams are traveling to all areas of Swaziland. When I visited the small city of Nhlangano on a hot August day, four agents were pulling aside men and boys in the town center. “Hey, brother, are you circumcised?” they asked. “No? Why not?” A DJ played loud dance music. Every 10 minutes he got on the mike and said, “Circumcision reduces the risk of HIV and other STIs. It’s easy and not painful. Go to the tent and register.”

Presented by

Shaun Raviv is a Fulbright scholar in Swaziland.

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