Lessons from Swaziland: male circumcision

Wilson Johwa

31 May 2010

We already know that male circumcision is the next biggest frontier in South Africa's fight against HIV-AIDS.

Enabling policy guidelines are still being finalised before the expected roll-out. This could be anytime soon, most definitely after the FIFA 2010 Soccer World Cup which, mind you, is expected to chew up an extra 1.5 billion condoms that the government is providing.

While doubts and counter arguments follow male circumcision, it is possible that South Africa can learn something from Swaziland. However, unlike South Africa which has a mixed experience regarding male circumcision, the Swazi kingdom has one of the lowest circumcision rates in the world, most of which are performed for medical reasons.

But the scale of the AIDS epidemic made it consider any intervention that would help reduce the scale of the AIDS epidemic. Swaziland has among the most acute HIV epidemics in the world, with HIV prevalence among pregnant women attending antenatal clinics estimated at 42% in 2008.

In July last year the country published its policy on male circumcision to prevent HIV. This followed the findings of three trials – Orange Farm, South Africa, in 2005; Kisumu, Kenya, in 2007 and Rakai District, Uganda, in 2007.

The outcome of the three studies have since been challenged by critics of medically-supervised male circumcision who argue that the studies were not conclusive. However, endorsement of male circumcision by WHO and UNAIDS provided Swaziland with enough reason to draw up its own policy.

The thinking is similar to that of authorities in SA who are considering offering male circumcision as part of a comprehensive package. This includes behaviour change communication, HIV testing and counseling and condom use.

Derek von Wissel, director of Swaziland’s National Emergency Research Council on HIV-AIDS, says male circumcision started with pilot programmes, encompassing “circumcision Saturdays”, that were meant to prepare for a mass roll-out. “We’re now reaching a level where we can say it’s an active programme,” he says. The target is 120 000 circumcisions over the next five years, targeting mainly 18-24 year olds.

Driving the intervention is the Swaziland Male Circumcision Task Force mandated to provide “technical guidance”. Among the members of the task force are health providers, policy makers, people living with HIV, the government’s partners in the health sector and even the media.

The policy says scaling up of male circumcision should be “sensitively handled, with respect shown for Swazi culture and gender implications.” It does not name these gender implications, or dwell on the likely cultural, social and sexual ramifications of male circumcision.

Instead it urges research into the “socio-cultural meanings and impacts of male circumcision” but also says “the need for ongoing consultation and social mobilisation should not hold back policy implementation.” Emphasis on a biomedical intervention is typical of the region’s response to HIV-AIDS.

The policy does not seem to sufficiently interrogate the possibility that support for male circumcision runs the risk of giving the impression that process makes condoms look like an unnecessary extra. This gap was no doubt left for counsellors to fill. Von Wissel says the messaging is strong on the point that male circumcision offers only 60% protection.

Swaziland’s policy on male circumcision came as the WHO and other agencies were already providing technical support to the Swazi government. For example, teams of Israeli surgeons — who circumcised thousands of adult men in keeping with religious traditions during the mass migration of Jews from the former Soviet Union in the early 1990s — had trained at least 10 Swazi doctors and backup staff on how to perform the operation quickly and safely with limited resources.

Inon Schenker, who coordinated the Israeli missions to Swaziland told the Associated Press in 2008 that his organization, the Jerusalem AIDS Project, had several dozen surgeons ready to help African countries scale up adult male circumcision by training local health workers in both surgical techniques and counseling.

As public policy scholars know, policy intentions and consequences barely ever amount to the same thing. South Africa would do well to closely study the Swazi experience before promoting male circumcision as a barrier against HIV. However, Von Wissel says each country must look at its own circumstances, providing for decentralisation and adequate human resources. He plays down the social effects of male circumcision, saying the process is not entirely new to the country. “Swaziland is a country that used to circumcise. The social aspects are not an impediment,” he says.