WHO coordinates health provision for quake survivors.

Male circumcision is the surgical removal of all or part of the foreskin of the penis. There are several biological explanations at to why this operation may reduce the risk of HIV infection. Removal of the foreskin reduces the ability of HIV to penetrate the skin of the penis. In addition, on the underside of the foreskin are located many special immunological cells such as Langerhans cells which are prime targets for HIV. Another possible explanation is that small tears in the delicate skin of the inner surface of the foreskin during sexual intercourse could allow a portal of entry for HIV. Men with a foreskin are more prone to have some infections, including sexually transmitted infections, which can enhance HIV transmission. Male circumcision is associated with a much lower risk of penile cancer. Several studies now suggest that female partners of circumcised men have a lower risk of cancer of the cervix. Other benefits include prevention of inflammation of the glans and foreskin (balanitis) and prevention of scar tissue causing an inability to retract the foreskin (phimosis). place and who performs it. However, data from Nyanza, Kenya suggesç that circumcision can be done in medical facilities for about US$ 25 per procei dure. This includes US$ 8 for medii cal expendables such as sutures and needle, bandaging and analgesics, US$ 7 for surgical preparation (preparing the room, cleaning linens, sterilizing instruments, and US$ 10 in overheads (physician’s fee, maintenance of room and equipment). Professor Tom Quinn from Johns Hopkins University told the 2006 Conference on Retroviruses and Opportunistic Infections that he calculated that 16 operations would prei vent one incident HIV infection over 10 years. The cost per HIV infection averted could be as low as US$ 1052, if protection occurs in both sexes, making circumcision extremely cost effective. The current position of WHO is that safe circumcision should be proi vided where people want it but that a policy decision on whether to promote it should wait until the results of the Kenya and Uganda trials are available. In the meantime a UN Work Plan on Male Circumcision is being implei mented to help countries improve the safety of their circumcision praci tices. WHO has produced a technical manual, Male circumcision under local anaesthesia, which addresses the provii sion of safe male circumcision services for newborns, adolescents and adults and gives detailed technical information on the different surgical approaches. If the two ongoing trials are positive then governments in subiSaharan Africa may want to decide whether to commit funds to train medical staff and provide appropriate equipment and facilities. Dr Puren says: “It will put further stress on a healthicare system already straini ing to roll out an ARV (antiretroviral) programme.” Bailey warns: “People want the services. If they are not provided with the services they will seek unqualified practitioners who will exploit the situai tion. We have to build the capacity to provide safe and affordable services.” Venter adds: “There are already long queues for circumcision in South Africa so there will need to be careful planning. We need to train more people to carry out the operations safely. There is no need for doctors to do it. It is a simple procedure that trained technicians could carry out.” When should circumcision take place? One option would be to promote routine circumcision of infants, possibly as part of the antenatal care package. Botswana, in fact, took a policy decision to offer this some years ago but it has not been implemented. Circumcising at this age would reduce the complications that result from traditional circumcision rites in adolescence. But the major benefits of preventing HIV infections would take more than 20 years to be realised. The other alternative is to offer circumcision through health facilities, and possibly schools and youth centres to young men before they become sexually active. Dr Venter believes a proi active recruitment programme should be carried out. “We need to incentivize circumcision. For example every man who comes forward should be given 100 rand (US$ 14.50).” O Jacqui Wise, Cape Town