"It's not a difficult procedure to do well," Venkataramani says. "Once someone is trained, you can knock out hundreds of procedures a day." But finding medical personnel to train can be a challenge. "If you have limited health care, are you going to be drawing from the labor pool?" he asks. "And will that divert them from doing other things," such as giving vaccinations to children or helping to deliver babies?
The term for the procedure, voluntary medical male circumcision, might sound almost outlandish. Yet in the past few years some public-awareness campaigns have been so effective in educating men about the benefits of circumcision (which also extend to decreased risk of other sexually transmitted infections) that "creating the right balance of demand and service" has become the new challenge, says Caroline Ryan, director of technical leadership at the Office of the U.S. Global AIDS Coordinator.
For groups in which male circumcision is an integral part of the culture, the move to a more medicalized procedure can be dicey. "If you bring in something that gets at the core of people's beliefs, and it’s perceived as being disrespectful, that might be your last chance to reach that population," Venkataramani says. He also found that males who had incomplete or delayed circumcisions were more likely to contract HIV than those who had early, medical procedures. "You can't count on the traditional circumcision on being the protective circumcision," he says.
Some groups and villages have adopted a medicalized approach, however. In Zimbabwe, for example, village boys would not always return from their rite of passage after a traditional circumcision went awry. Thus, some village chiefs have encouraged the use of medical circumcision, by having doctors and nurses attending at the ceremonial camps, by allowing boys to make a trip to a clinic or by training traditional healers in how to perform a safer operation.
"There has been a change in social norms, where the community has completely embraced medical male circumcision," Njeuhmeli says of some of these villages. Many local women also support the move. "You can see a mother so happy that the boys, all of them, will come back," alive and well.
Nevertheless, as one of the papers on research led by Zebedee Mwandi of the U.S. Centers for Disease Control and Prevention Global AIDS Program Kenya shows, so far only Kenya is in good shape to meet the 80 percent goal, with more than two thirds of its men already circumcised—which is more than twice the global average.
Not everyone in the AIDS-prevention field is convinced that this approach will be as effective as promised. As the old economic logic goes, once people think they are protected against something, they will be more likely to take on more risks. So a circumcised man might be more inclined to have unprotected sex or sleep with more partners. As yet, however, research has yet to bear this out.
"It's also a very good way to get access to men," Ryan says of the increasingly common procedure. Women spend much more time in the health care systems in many of these countries because they often seek care during pregnancy. But with adult and adolescent males coming in for circumcision, doctors and nurses have the opportunity to give them information about condoms and other ways to reduce their risk of HIV, as well as to identify men who already have the retrovirus and get them started on treatment earlier in their illness.
With circumcision being an imperfect protector, why not put the money toward a more sure thing, such as condoms? Despite years of campaigns and distribution, neither male nor female condoms have become as widely used as previously hoped. As Ryan points out, many other groups are supporting condom programs, so she and others working with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) are looking for approaches that are not covered by other programs.