Africa: The Global Fund Should Actively Promote Male Circumcision

Male circumcision is a high-impact and cost-effective method of curbing the spread of HIV infection, Karanja Kinyanjui says. "It is time for a massive scale up of these programmes."

As the campaign for an AIDS-free generation by 2015 gains momentum, the Global Fund will play a crucial role in achieving this target because it is a major funder of health programmes globally. The Fund should actively promote the inclusion of male circumcision in programmes as it is a high impact and cost-effective method of curbing the spread of HIV infection.

Male circumcision as an effective anti-HIV strategy has already received support from influential leaders globally. In November last year, US Secretary of State Hilary Clinton said male circumcision was one of three interventions that could help achieve the goal of an AIDS-free generation, a policy that the US government would pursue. This political support is crucial for the male circumcision campaign to gain momentum.

It is with this in mind that in December last year, the World Health Organization, UNAIDS, the (US) President's Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank developed a five-year action framework which called for the immediate roll-out and expansion of voluntary medical male circumcision services in 14 priority countries in Eastern and Southern Africa.

The Global Fund should actively promote male circumcision programmes not only because science has proved it is an effective strategy in the fight against AIDS. It should also promote it because it will achieve more value for money than other HIV prevention measures currently being implemented. Studies by PEPFAR and UNAIDS show that reaching 80% coverage of adult male circumcision in the 14 priority countries would entail performing about 20 million circumcisions on men aged between 15 and 49 by 2015 at a cost of $1.5 billion. This would prevent 3.4 million new HIV infections and save $16.5 billion by 2025 that would have been spent on treatment and care costs.

To be fair, the Global Fund has recognised male circumcision, just like prevention of mother-to-child transmission (PMTCT), as one of the methods of tackling the HIV scourge. The Fund has financed male circumcision programmes in countries such as Zambia where grants were recently reprogrammed to focus on more high impact areas. However, these are piecemeal measures and involve small amounts of funding. It is time for a massive scale up of these programmes.

I am cognizant of the fact that the Fund emphasises "country ownership," where proposals originate at country-level based on the specific circumstances of the country. However, the Fund has the ability to influence countries to focus on male circumcision in their HIV proposals. And the Fund can encourage implementers to reprogramme their grants to redirect more resources to male circumcision programmes. There is already a precedent for this kind of intervention: already, the Global Fund has worked with 20 countries to reprogramme grants to increase the focus on PMTCT.

The Global Fund can learn from other organisations such as PEPFAR, which has made male circumcision a priority in its new strategy for an AIDS-free generation. By last year, PEPFAR had spent $200 million to fund male circumcision programmes, especially in sub-Saharan Africa. Swaziland, the country with the highest HIV prevalence rate in the world, received $30 million for a campaign to promote male circumcision spearheaded by the country's ministry of health. If the Global Fund can also scale up its current funding for male circumcision, the resources needed to promote this anti-HIV strategy will be greatly boosted.

I am aware that it will not be easy to implement male circumcision programmes in some parts of the world. In many parts of Africa, for instance, where 70 percent of the world's population of HIV-infected people lives, there are cultural factors inhibiting acceptance of circumcision among certain communities. This has resulted in male circumcision programmes achieving only modest success in these places. By the end of 2010, only 550,000 males had been circumcised for HIV prevention in the priority countries. This represents 2.7 percent of the estimated 20 million male circumcisions needed. Programmes to implement male circumcision will have to be carefully thought through, and will need to incorporate measures to address the cultural barriers.

In 2008, Professor Malcolm Potts of the University of California, Berkeley observed thus in relation to male circumcision as a strategy against Aids: "It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling. Large numbers of people will die as a result of this error."

Four years after Dr Potts made this observation, thousands of people continue to die from AIDS despite aggressive promotion of condoms and ARVs. However, it is not too late to reverse the trend. If the Global Fund can take the issue of promoting male circumcision more seriously, millions of people will be saved from infection and the world will move closer to the goal of an AIDS-free generation.

Karanja Kinyanjui (karanja.kinyanjui@aidspan.org) is Senior Editor at Aidspan.

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