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GlobalPost's John Donnelly and a team of reporters investigate what experts are calling a 'turning point' in the global fight to reduce HIV infection rates. Successes in southern African countries have produced valuable lessons on effective approaches to fight AIDS, lessons that need to be learned in US cities where infection rates remain persistently high — particularly among African-Americans. Meanwhile a political confrontation looms in Washington over critical funding which could threaten gains already made.

In the waiting room at the long-established Family Life Association of Swaziland (FLAS), which begun promoting and offering adult male circumcision in 2006. (Alex Duval Smith/GlobalPost)

Adult circumcision campaign fails in AIDS-plagued Swaziland

US effort doesn't go over well in the country with the highest HIV infection rate in the world.

EZULWINI, Swaziland — At a working men’s bar in a down-at-the-heel part of town, a group of laborers are ordering a round after a long day when the talk turns to the uncomfortable subject of adult male circumcision. The procedure is being carried out as part of a campaign to reduce the spread of HIV here in this tiny kingdom in southern Africa, which has the world’s highest prevalence rate for the AIDS virus.

For S.K. Maseko, a 41-year-old father of five who works as a caddie at a local golf course, the decision to lose his foreskin in March was a good one.

Like most men interviewed for this story, Maseko explained that apart from a moment of pain from the jab of a localized anesthesia and a bit of discomfort for a few days of healing, the process of circumcision was relatively painless. And, he added, there are distinct benefits beyond that fact that it affords protection against HIV.

"Sex is better now,” he says.

"With circumcision, my wife is happy," he adds with a smile.

“To convince a Swazi man you need time, you need to go and see him.”
~Mahlubi Hadebe, HIV/AIDS prevention coordinator

But his drinking buddies at the Makhonkhosi Wine & Malt bar are not convinced and not certain they would volunteer for the procedure – even if it could save their lives at the epicenter of the AIDS epidemic in southern Africa.

Billy Saulus, 49, an auto mechanic, has refused to go, fearing that he may already be HIV positive.

''What if I go along to be circumcised and the doctors insist I be tested? What if I am HIV positive and the wound does not heal properly? I think I will just continue with condoms,'' said Saulus, who has three grown children.

In an ambitious goal – some would say audacious – the United States wants to accelerate the pace of male circumcisions to support 4.7 million procedures in the developing world by the end of next year, up from 1 million at the beginning of this year. But its failures in Swaziland have given everyone – even the US global AIDS Ambassador Eric Goosby – great pause whether that goal announced by President Obama can be reached.

Late last month, Goosby said the US could still do it, but he acknowledged that scaling up male circumcision was much harder than expanding AIDS treatment or protecting newborns from infections by their mothers.

The goal here was to circumcise 80 percent of all men aged 15 to 49 in a year. The result was that roughly one in four underwent the procedure.

What went wrong? What are the lessons from this landlocked country between Mozambique and South Africa with a population of just 1.3 million?

Here, say experts, a concoction of long-entrenched local traditions, false rumors, economic pressures, and gender imbalances added up to falling far short of the goal.

But there was another problem: the US government and others simply misjudged how long it takes to institute a procedure in a culture that has no history with circumcision. US experts set expectations far too high, many believe.

Since 2007, the United States, through the President's Emergency Plan for Aids Relief (PEPFAR), has spent more than $140 million from 2007 through 2011 on every aspect of the battle against AIDS in Swaziland, including institutional support, training, care and prevention. But prevalence rates have remained high. Among men between 15 and 49 years of age, 26 percent are HIV positive.

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Based on evidence from other African countries that female-to-male transmission of the virus can be reduced by 60 percent if men are circumcised, PEPFAR last year added an additional $15.5 million in funding for an ambitious ''accelerated saturation initiative'' to circumcise 80 percent of HIV negative men between ages 15 and 49. A year later, 23 percent had undergone the procedure. Some critics suggest the campaign, called Soka Uncobe (''circumcise and conquer''), may have been counter-productive to on-going efforts to promote condom use and behavior change.

Tough Sell

Muhle Dlamini, a 50-year-old environmental health scientist with the Swaziland National Aids Programme, which is part of the health ministry, said that officials knew the campaign would be a tough sell. 

''We are not, culturally, a circumcising country, though some people believe the practice was current until the 19th century and was stopped because the king, in war time, could not afford for his warriors to lose time healing," he explained.

''In 2006, when we started circumcising on a routine scale, 8 percent of Swazi men were circumcised — generally for health or religious reasons — and sometimes because they had worked in South Africa where the practice is often a rite-of-passage to manhood. In some South African workplaces, for example mines, Swazis are bullied and called 'boys' if they are found to be uncircumcised,'' he said.

Migrant work, which causes men to spend months at a time away from home, has contributed to the spread of AIDS. Swaziland may be ranked as a middle-income country but its economic heyday dates back to the years leading up to the mid-1990s, when it was a haven of tranquility between war-torn Mozambique and apartheid South Africa.

In the aftermath of those conflicts, Swaziland’s economy depends on its own sugar and fruit production and custom dues it collects from transit traffic. Indian investors recently reopened an old iron-ore mine, but the country has very few natural resources. According to the United Nations, 52 percent of people in the 15-to-24 age group are unemployed, 63 percent of the population lives in poverty and 29 percent is food insecure.

Dr. Rhoy Shoshore who has circumcised more than 1,000 Swazi men, pictured at the FLAS clinic in Manzini which was refurbished with PEPFAR money in 2010.
(Alex Duval Smith/GlobalPost)

The country is culturally polygamous, but economic hardship has led to the decline of legal marriages in favor of sex with multiple partners.

''Men cannot afford dowry payments,'' said Dlamini, ''but they continue to have sex … So you find that multiple concurrent partners are increasingly the norm. Economic pressures also lead to more inter-generational sex with so-called 'sugar daddies' and other sex for money or favors.''

Many Swazi men aspire to be dubbed ''inganwa,'' a word that roughly translates as a ‘playboy’ with several girlfriends. But traditionally, a man would not have penetrative sex with his girlfriends before marriage. Within this cultural context, the only Swazi man permitted to do otherwise was the king who, for reasons justified by the importance of succession, did not have to marry a girl until she became pregnant.

A range of rituals also exist to protect the chastity of girls. Virgins proudly still wear colorful sashes, called ''umcwasho'' and it is incumbent on men to respect them. Once a year, boys pick a shrub, called ''lusekwane'' which they are expected to tend or face embarrassing accusations that it had wilted because they had had sex. While the rituals still exist, including an annual ''reed dance'' at which thousands of Swazi maidens dance before King Mswati III, their meaning is slipping away.

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The 2011 mass circumcision effort started from a low base, and there appeared to be considerable demand from men. The government, as well as several non-government organizations — such as the long-established Family Life Association of Swaziland (FLAS) and Population Services International (PSI) — had begun promoting and offering adult male circumcision in 2006.

Zelda Nhlabatsi, director of the Family Life program, said her organization could not keep up with demand.

''People had heard of the Orange Farm experience, a celebrated study in South Africa in 2002 to 2004 which found that circumcision cut transmission (by as much as 60 percent). South Africa being next door, people felt that if it worked for them it could work for us. The government brought in Israeli doctors to train Swazi doctors in how to circumcise under local anesthetic. PEPFAR supported the renovation of our clinics. Demand was enormous. We were really keen to take the program to scale.''

Enter the Futures Group, a Washington, DC-based company that was awarded a contract by PEPFAR for the $15.5 million circumcision program without a competitive tender. The project management firm was tasked with using the $15.5 million in funding to turn the culturally conservative, non-circumcising Swaziland into a land where 160,000 men would be willing to volunteer for the procedure. It was a tall order to begin with.

US army mobile surgical tents were brought in and about half the total budget was spent on hiring expatriate surgeons to train 200 clinicians. Celebrity endorsements were secured from a leading musician and from “Mr. Swaziland,” the annual winner of a national pageant for men. Matchboxology, a South African advertising agency with a track-record in AIDS messaging, produced films, livery for minibus taxis, flyers, and billboards.

The Futures Group seemed to have thought of everything, including royal backing. In July 2011, King Mswati III stood before an audience of 3,000 people and declared, ''Soka Uncobe must be the motto now for all men to go for male circumcision.''