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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.

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.

Mixed Messages

Yet ask Swazi AIDS professionals about the campaign and many will privately — for fear of jeopardizing future US funding — term it a ''disaster,'' a ''nightmare'' and ''an exercise in bullying.” Prominent AIDS activists said the regular meetings they attended were used by Futures Group to rubber stamp decisions, rather than consult. 

Mahlubi Hadebe, prevention coordinator with Swaziland's National Emergency Response Council of HIV/AIDS (NERCHA), was among those critical of the Futures Group and its approach.

Hadebe said, ''It went wrong from the outset. Futures Group just would not listen. The promotional materials featured drawings of people. But I as a Swazi, want to see a real Swazi's face. The demand-creation approach was all wrong: To convince a Swazi man you need time, you need to go and see him. You have to identify thought leaders in communities and use them to convey the message. Billboards do not work.

''Some of the messaging hit the wrong note. 'Lisoka lisoka ngekusoka' — which literally means 'the lover boy is a lover boy thanks to circumcision' — appeals to the playboy in the man. It is off-putting to married men,'' said 47-year-old Hadebe.

Family Life’s Nhlabatsi said the Soka Uncobe name sent the wrong message.

''To me it does not to so much mean 'circumcise and conquer' but more 'circumcise and be done with it' which is a dangerous message. It could be interpreted as meaning that once men are circumcised they no longer need to use condoms,'' said Nhlabatsi.

Studies in South Africa, Kenya and Uganda have found that circumcised men are at least 60 percent less likely to pick up HIV. Still, the groups carrying out the circumcisions must grapple with conveying the message that even after the procedure — which requires men to abstain from sex for six weeks — condom use remains crucial.

Rhoy Shoshore is a 31-year-old doctor with the Family Life association who has carried out the procedure on more than 1,000 Swazi men.

He said, ''We talk to the clients about the importance of condoms before the operation. … But you can never be sure how much they are taking in. And with teenagers it is difficult as the Education Ministry does not want us to talk about condoms in schools, only fidelity and abstinence.''

Emma Llewellyn, the British HIV technical services director at PSI, previously worked in Kenya where she spearheaded the country's first ''rapid results'' circumcision campaign in 2009, but she said Swaziland’s culture has presented challenges to the campaign.

In Kenya, she explained, ''We did 30,000 men in 30 days. The campaign is now repeated by local organizations during every Christmas holiday. But Kenya is very different. The majority of the country's 42 tribes traditionally circumcise.''

Futures Group’s Shannon Hader, the organization’s director of health and systems solutions, told GlobalPost that the results of Soka Uncobe had indeed been something of a disappointment. But she dismissed most of the criticism of Futures Group’s approach, and particularly its failure to consult the Swazis themselves.

Hader said, ''This was the first time any country, starting from a fairly low base, tried an accelerated saturation initiative aiming to capture essentially a whole population in 12 months. We learned — and this was a global 'learn' that will serve us elsewhere — that it is not because you build the service that you create the demand.”

Motor mechanic Billy Saulus is concerned that if he goes to a circumcision clinic he may have to undergo an HIV test. In fact, even though circumcision campaigns are aimed at HIV-negative men, a test is not obligatory.
(Alex Duval Smith/GlobalPost)

She specifically denied that the campaign had led to risky practices, adding, ''I have not seen any evidence that that is what played out.”

Moving Forward

At the US embassy in the capital, Mbabane, PEPFAR country coordinator Chris Detwiler insisted that Soka Uncobe had been born out of a request from the Swazi government in February 2010. He explained that Futures Group was awarded a contract without a competitive bidding process based on the need to ''implement a stand-alone, time-limited campaign that did not overburden an already strained health system.”

Detwiler denied the campaign had misfired, saying, ''We have heard that accusation but the process was not a top-down approach. It was driven by the Swazi government and came with extensive consultation in the form of weekly and monthly meetings. We will do better going forward.''

Around the country, three months after the Soka Uncobe campaign ended, publicity material is still visible on some billboards and minibuses. Clinics have large boxes full of its distinctive orange leaflets. But PSI and others say they are in a ''taking stock'' phase.

''We have to look at how to move forward,'' said Llewellyn. ''We need to look at what we do with the Soka Uncobe brand, which after all, the king launched.”

Both PSI and the Family Life association are concentrating on 'back to school' campaigns.

'Teenagers are an easy target group,'' said Nhlabatsi. ''You get parental approval and then you have a busload of them.''

The future, said NERCHA's Hadebe, is in expanding the circumcision of baby boys within seven days of birth.

''I think we may just have to accept that we are going to miss much of the population which is currently sexually active,” Hadebe said. “I think we need to put our energy into neo-natals. But even there we have obstacles to overcome. We are still legally obliged to obtain paternal approval to circumcise a boy. This is a challenge given the number of single women giving birth.''

The men at the bar in Ezulwini have other concerns. One man, a divorced 45-year-old lawyer who did not wish to be named, said he used condoms with all his partners, except his steady girlfriend. ''She does not want me to be circumcised because she thinks it will make me reckless,” he said. “She believes I will take less care to use condoms. Personally, what makes me reluctant is the requirement that you have to go without sex for six weeks. I would find that difficult.”

The motor mechanic Saulus added that he had heard stories of circumcision clinics selling foreskins to witchdoctors. Someone he had spoken to knew someone who had become sterile, he claimed. Saulus and several other people at the bar also said the book of Deuteronomy in the Hebrew Bible, or Old Testament, condemns the practice. In fact, the Hebrew Bible is consistently in favor of circumcision, which is still observed in modern secular and religious Jewish communities.

But Maseko dismissed his buddies' claims. Sex, he insisted, was better than ever and he said he would be sure to continue telling his friends.

Asked whether he had continued to use a condom since the operation, he said he hadn't because he had only had sex with his wife.

''They are all just afraid of the pain,” he said of his drinking buddies. “They will come around to it.''