For the Xhosa in South Africa, a boy's coming of age is often marked by an elaborate and lengthy set of rituals. One of the ordeals is circumcision, which is traditionally performed by a healer and occasionally leads to an ineffective cut, infection or even death. The young men who emerge from the ceremony healthy, however, achieve not only new social status but are also much less likely to become infected with HIV.
Adult male circumcision, in which the foreskin of the penis is surgically removed, has emerged as one of the more powerful reducers of infection risk. Some studies are finding that it decreases the odds that a heterosexual man will contract HIV by 57 percent or more. With HIV vaccine research still limping along, condoms being underused and the large-scale vaginal gel trial Vaginal and Oral Interventions to Control the Epidemic (VOICE) just called off early last week after disappointing results, the operation has been gaining ground.
For the past three years 13 countries in southern and eastern Africa at the heart of the HIV/AIDS epidemic have been on a mission to circumcise 80 percent of their men by 2015 in an effort to cut in half the rate of sexual transmission of the disease from 2011 levels. And a new series of nine papers, published online Tuesday in PLoS Medicine, assesses whether the ambitious goals could work—and whether they are worth it.
The analyses "give a pretty optimistic assessment," says Atheendar Venkataramani, a resident physician and researcher at Massachusetts General Hospital, who was not involved in the new papers. But from his own research in the field, he says, he is inclined to share the optimism.
Because HIV and AIDS are still incurable, infection means a lifetime of antiretroviral therapy. So with more people getting infected every day, the cost of treatment for the ever growing global HIV population is increasing. A surgical procedure, such as a circumcision, is not cheap either, but when compared with indefinite treatment, the one-time cut is poised to be a cost saver.
The estimated price tag for all of the 13 countries (Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe) to reach the 80 percent male circumcision rate by 2015 would be somewhere on the order of $1.5 billion, the authors of one of the papers suggest. To keep that saturation constant for another 10 years would cost a further $500 million. These 20.3 million circumcisions, however, could prevent some 3.4 million new HIV infections in both men and women, according to the new findings. From 2016 to 2025, after accounting for the initial expenditures, the programs would save some $16.5 billion.
Previous research had concluded that male circumcision programs would be cost-effective, but this is some of the first large-scale work to incorporate information specific to country—and in some cases, region—to assess costs and savings. The recent data can go straight to the countries' respective ministers of health and, perhaps even more important, to the countries' ministers of finance, points out Emmanuel Njeuhmeli of the U.S. Agency for International Development, who is a co-author of several of the papers. "Understanding the science is not enough—they need to have the resources," he says of the countries' health ministries. And that can be a lot to ask of a sub-Saharan African country such as Lesotho, which has a GDP of $2.1 billion and where much of the population lacks even basic medical care.