Ugandan effort to constrain HIV spread hampered by systemic and cultural obstacles to male circumcision.

CMAJ • NOVEMBER 18, 2008 • 179(11) © 2008 Canadian Medical Association or its licensors 1119 The president of the country once scoffed at the notion. Some scientists fear it may ultimately prove counterproductive because it may persuade some men to take fewer precautions during sex. Others say the country’s primitive health care system compounds the problem. The system lacks the resources and the capacity to implement a nation-wide program, while the procedure, when it is performed as part of tribal rituals, is often botched because it is undertaken with unsterilized and unspecialized instruments. Yet, the World Health Organization (WHO) recommends it as an HIV prevention strategy and clinical trials indicate that, on average, the procedure could reduce men’s risk of contracting HIV from females by up to 60% (Lancet 2007;369:657-66 and Lancet 2007;369;643-56 and PLoS Med 2005; 2[11]:e298). Such is the controversy surrounding male circumcision in Uganda, where President Yoweri Museveni last year rebuked claims that circumcised men are less likely to contract HIV/AIDS but where the government plans to introduce circumcision as an HIV strategy. Government health officials are banking on existing cultural practices to push the strategy into other parts of the country as it seeks to curb the spread of HIV, which the World Health Organization in 2005 estimated infects 6304 of every 100 000 Ugandans over the age of 14. A projected 1 million Ugandans now live with the virus. Circumcision has long been practised by the Bagisu tribe in Eastern Uganda on boys aged 12–18 as an initiation into manhood. This year, an estimated 3000 boys will undergo the “Imbalu” ceremony during circumcision season (July-January). Health authorities say their studies indicate that even communities with no history of the practice will be amenable to circumcision of their youths. “Acceptance is high but we have to bring the services to the small health centers and 49 remains one of the lowest in sub-Saharan Africa at about 25%. But systemic problems may undermine the Ugandan effort. According to a ministry of health analysis, a shortage of health workers is an obstacle. Uganda’s health worker figures remain low at one physician per 1000 populations. Most workers trained leave the country for better pay, especially to South Africa and Britain. “Although circumcision is a minor operation and most trained health for easy accessibility in order to get a good turn out.” says Dr. Alex Opio, an official at the National Disease Control Department which is charged with developing the program. WHO projects that the introduction or scaling-up of circumcision services will have a huge effect on HIV prevention, noting that full circumcision coverage could avert about 5.7 million new infections in the next 20 years in subSaharan Africa. But Uganda’s circumcision rate among males between 14 Ugandan effort to constrain HIV spread hampered by systemic and cultural obstacles to male circumcision