Malawi’s Secret Weapon Against HIV: Male Circumcision

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The small African country has significantly lowered its rates of HIV/AIDS — in no small part through circumcising men and adolescent boys.

By Sarah Witman

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Locals near the Ntaja Health Centre in Machinga, Malawi, August, 2015. (Photo: Sarah Witman)

Five hundred miles inland from Africa’s southeastern coast, wedged between Tanzania, Mozambique, and Zambia, lies the small, landlocked country of Malawi. With a population of 18 million, more than a million Malawians are living with HIV/AIDS — the 10th-highest rate in the world.

As devastating as that statistic looks, it actually represents a sizable improvement. The first case of AIDS in Malawi was reported in 1985, and by 1990 — the first year the United Nations started keeping global HIV/AIDS records — Malawi had the third-highest rate of HIV/AIDS in the world. At the height of the worldwide AIDS pandemic, in 1997, it was No. 5, with about 14.7 percent of Malawians ages 15–49 living with HIV/AIDS.

Since then, that figure has been steadily decreasing. This is thanks, in part, to a nationwide scale-up of antiretroviral therapy beginning in 2004 that has helped extend the lives of infected patients, as well as a 2011 initiative that began offering lifelong care to all HIV-positive pregnant or breastfeeding women to prevent mother-to-child transmission (early reports show that mother-to-child transmission may be down to 5 percent).

One of Malawi’s most recent efforts to combat HIV/AIDS may also be one of its least well known: voluntary medical male circumcision. The reasons why it works remain unclear (tougher and quicker-drying skin may be contributing factors, as well as a reduced surface area for the virus to proliferate in), but three separate studies have shown that male circumcision reduces the risk of sexual transmission from HIV-positive women by 50 to 60 percent. As the author of one of the studies (conducted in the Orange Farm region outside Johannesburg, South Africa) puts it: “This is equivalent to what a vaccine of high efficacy would have achieved.”

Since 2007, the World Health Organization and the Joint United Nations Program on HIV/AIDS have recommended voluntary medical male circumcision as a preventative measure against HIV transmission, especially for countries where HIV/AIDS is prevalent and male circumcision rates are low. Fourteen such African countries, including Malawi, have responded by launching and expanding male circumcision programs.

Three separate studies have shown that male circumcision reduces the risk of sexual transmission from HIV-positive women by 50 to 60 percent.

Walking on any given day through the sunlit halls of Ntaja Health Centre, a modest-sized clinic in the southern region of Malawi, one might see a line of nervous-looking adolescent boys sitting on a bench, waiting to be circumcised.

“Right now, during the holiday, a lot of boys are coming into the health center for this service,” says Dennis Mbulaje, the center’s health surveillance supervisor. “Last year we had a lot of men even. Usually you don’t have a lot of men coming in, very few, but the young ones (ages 10 to 12) are coming in large numbers.”

Mbulaje, a grandfatherly Malawian man, has worked at the Ntaja Health Centre for 15 years, and several other health centers before that. He and his team of health surveillance assistants often make home visits, providing a crucial link between community members and medical care.

He explains that, since the district he serves, Machinga, has a higher Islamic population than the rest of Malawi, many boys are circumcised when they are young for religious reasons. But in the past three years, he says, the number of procedures performed at the health center has gone steadily upward.

“The government has been campaigning for men to come in for circumcision to protect themselves from HIV,” Mbulaje says. “And now it is free; before that, people had to pay a little amount. Almost all health centers in Machinga are now giving out this service for free.”

This is progress, but Malawi must pick up the pace to meet its own projected goals. A “plan for scale up” published by Malawi’s National AIDS Commission in 2014 reported that 150,000 medical circumcisions had been performed since 2011 when the nationwide initiative began — not even close to meeting its original goal of having 80 percent of Malawian males between the ages of 15 to 49 circumcised in a five-year period. Limited sources of funding, and a lack of trained staff and time to devote to performing the procedure, have caused delays. Plus, adult men are less inclined to volunteer for the procedure, whether or not they are aware of its health benefits.

While the explanations are complex, aversion to care is a perennial problem that Malawian health workers face in combating HIV.

“The challenge is that when most people come to the health center to get tested, they are still healthy,” Mbulaje says. “They are not sick. Sometimes they think, ‘Why should I receive drugs when I am not sick? I am all right.’ So we need to give them a lot of counseling. Counseling must be included in the medical care; they should know what drugs they need and when to take them, and know what will happen if they don’t take the drugs.”

To try to maximize its ongoing efforts, the Malawi Ministry of Health asked the President’s Emergency Plan for AIDS Relief to conduct a modeling study on voluntary medical male circumcision, the results of which were published earlier this summer. Generally speaking, the study recommended focusing on recruiting men and boys between the ages of 10 and 34, and prioritizing urban areas — where HIV is nearly twice as prevalent — in order to have the most impact.

In response to these findings, the Malawi government has shifted its focus, aiming to have 60 percent of males between the ages of 10 and 34 in 14 of Malawi’s 28 districts circumcised by 2025 (though, of course, men and boys outside this demographic will not be turned away from care). If the country reaches that goal — given that it costs $100 to perform a circumcision, and a year’s worth of antiretroviral drugs costs $451 per person — the study calculates a potential total savings of $344 million.

It may seem a bit callous to distill potentially lifesaving aid down to a dollar amount (and not even the nation’s own currency, at that). But Katharine Kripke, a senior health policy analyst for Avenir Health in Washington, D.C., and lead researcher on the modeling study, has made cost-comparing infectious diseases her life’s work. Having performed extensive research in sub-Saharan Africa, Europe, and Asia, she’s devoted more than 20 years to research, project management, and community engagement for both HIV/AIDS and tuberculosis. For this study, Kripke traveled to Malawi twice: once to outline the process and go over the sources of data with the Ministry of Health and other collaborators, and once more to present the results of the study and offer additional support.

Voluntary medical male circumcision “remains critical for HIV epidemic control, even in the new era of ‘treatment for all,’” Kripke says, referring to the WHO’s announcement last fall that every person in the world who has been diagnosed as HIV-positive is now eligible to receive antiretroviral therapy, regardless of viral load, and should seek treatment as soon as possible.

For now, HIV/AIDS is still the leading cause of death in Malawi. But the line of defense has more than one weapon in its arsenal, bringing us one more step toward ending a global pandemic.

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