Uganda's campaign to encourage male circumcision - part of its effort to reduce HIV transmission - has attracted an enthusiastic response, but the bigger challenge is rallying resources so the health system can meet the demand for circumcision before it wanes.

In 2006 the results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent. This prompted the UN World Health Organization (WHO) to recommend that countries offer voluntary medical male circumcision as part of their prevention strategies.

The US President's Emergency Plan for AIDS Relief (PEPFAR) and UNAIDS projected that if 4.2 million Ugandan men were circumcised in five years, it could halve the country's HIV incidence - three-quarters of the men are uncircumcised. The Ministry of Health launched a circumcision campaign in 2010, and government officials say they hope to circumcise as many as one million men in 2012.

"We said we were offering this service... and people were really there to be circumcised," said Paul Mayende, public relations coordinator at the Baylor College of Medicine Children's Foundation-Uganda, a government partner in the circumcision programme. The organization is responsible for the scale-up of male circumcision at 20 facilities in two regions of Uganda.

Ministry officials confirm Mayende's observation that demand for the operation has been high, and WHO found that 9,052 men were circumcised in 2010. More than 450 men were circumcised at Baylor's facilities on World AIDS Day in 2011.

Media campaign

The response to the campaign has not all been positive. In an effort to encourage men to be circumcised, the ministry, in collaboration with partner organizations, rolled out an extensive media campaign. It includes a billboard with snapshots of women over a tagline reading: "I am proud I have a circumcised husband because we have less chances of getting HIV", and another of a woman expressing shock over discovering that a sexual partner is uncircumcised.

Some of the listeners to the breakfast show on Sanyu FM, one of the country's biggest radio stations, interpreted the billboards to mean, "you don't have to worry about getting AIDS" if you have the procedure, said James Onen, the show's host.

The advertising message is the result of research among Ugandan men, who said a wife or long-term partner was the "important person who can give you information about [medical circumcision] you will listen to," said Paul Bishop Drileba, a programme officer at the Health Communication Partnership (HCP), which helped the ministry develop the campaign.

The billboards used a "feminine face" to encourage men to undergo medical circumcision Drileba said. They also included the key underlying message that circumcision reduces the risk of HIV transmission, but does not eliminate it.

The debate over the advertisements came shortly after another challenge to the campaign. In January, a Ugandan newspaper reported that a three-week-old baby died after being circumcised at a health centre in western Uganda, and that he was the fourth child to die this way. Ministry of health officials would not comment until an investigation is completed.

Health system challenges

The story reflected wider concerns about inadequate patient care. Only 56 percent of positions in government health facilities are filled and the gap is frequently blamed for the high maternal mortality rate and other shortcomings in emergency care.

Medical male circumcision advocates said the campaign - including a national health hotline to answer questions from concerned men - has allayed most safety concerns, but the health worker shortage still poses a significant hurdle to national goals.

Given the problems in health infrastructure and personnel, Richard Hasunira, a coordinator at the Uganda Civil Society HIV Prevention Working Group, said the ministry's plans to reach one million men in 2012 would be a stretch.

The current health system is "inadequate" to achieve the kind of numbers Uganda is targeting, Hasunira said. There is often only one clinical officer per facility, but circumcisions cannot be safely offered without a doctor, nurse and counsellor, and men seeking the operation are turned away.

Hasunira said the only solution was to find more money for circumcisions during the parliamentary budget debates, which have just started. Almost all of Uganda's funding for circumcision comes from PEPFAR. Even if more money is allocated in the budget, it will not become available until August at the earliest, which will be too late to hit the mark of one million circumcisions this year.

Another major hurdle is that most of the population live in rural areas, far from medical facilities that can provide the service, but setting up circumcision facilities in smaller health centres closer to rural populations is expensive.

The PEPFAR programme at the Makerere University Walter Reed Project in the capital, Kampala, offers HIV care, prevention and treatment programmes in three districts, and also has a mobile circumcision clinic. "It's become really clear to us that if we are to reach the rural populations that are most at risk, maybe the way forward is through mobile circumcision," said programme manager Mark Breda.

Like male circumcision generally, the mobile clinic has been extremely popular. "We've had no problem with demand," he said. "At this point, it's meeting the demand that's the problem."

[This report does not necessarily reflect the views of the United Nations]