The demand is there; so is the evidence that male circumcision can work, and even some national policies are in place, but staff shortages and constraints in local health systems are slowing down implementation.

"Even if we want to train, who are you going to train? Because there is not enough staff to do the procedure," said Kim Dickson of the World Health Organisation (WHO), speaking at the International Conference on AIDS and STIs (sexually transmitted infections) in Africa (ICASA) in Dakar, Senegal.

Countries in east and southern Africa were moving forward with plans to scale up male circumcision. Botswana and Swaziland had drawn up policies, while Kenya had set up centres to train health care workers in the procedure.

Dickson admitted, however, that implementation had been slow and that countries needed the support of organisations like the WHO and UNAIDS.

Lesotho

Lesotho recently completed a situational analysis to determine whether it had the capacity to roll out a male circumcision service at public health facilities. The survey found that over 80 percent of Basotho were aware of the benefits of circumcision in preventing HIV, and many men were willing to be circumcised.

The tiny mountainous kingdom had about five doctors per 100 000 patients, so health services were largely run by female nurses. Most men regarded it as "shameful to go to a woman and ask to be circumcised", said Dr Mpolai Moteetee, of the ministry of health and social welfare.

Nurses were not authorised to perform male circumcisions but the country would consider allowing them to do so, "but I don't know how many male nurses we will find in the system", Moteetee remarked.

Male circumcision was traditionally practiced in some parts of Lesotho, so any official policy would have to involve traditional leaders. Two task teams had been set up, one focused on addressing these concerns and another on technical issues, but this had been a "protracted" process and there was still no resolution on how to move forward, Moteetee said.

Cost was another major barrier. "I am not sure how we will manage, but this will have implications for access [to the procedure]."

Namibia

Namibia is developing a strategy for a roll-out and identifying pilot sites, but Dr Ndwapi Hamunime, a ministry of health official, said the estimated cost of about US$200 (about R1 880) per adult was "a bit expensive - we are not going to be able to scale up male circumcision on our own ... we will have to seek funding for this".

Swaziland, one of the first countries in the region to endorse male circumcision for HIV prevention, is still waiting for parliamentarians to approve a policy. "We are not moving as fast as we would like ... the demand is there but the health system is weak," acknowledged Vusi Magagula, the chairperson of the country's male circumcision taskforce.

In an effort to speed up training local junior doctors in the procedure, teams of Israeli surgeons were brought in under the Operation Abraham initiative, organised by the Jerusalem AIDS Project and family planning organisation, and the Family Life Association of Swaziland (FLAS).

Inon Schenker, the director of Operation Abraham, told IRIN/PlusNews that 10 surgeons out of a total of 20 in the country had been trained so far, and the number of male circumcisions performed at FLAS clinics had gone up from three a week to about 12 a day.

Dickson said there were concerns about "foreign volunteer doctors flying in to circumcise African men", and that the WHO was drawing up guidelines on the matter. - PlusNews

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