William Maiko, 18, waiting at the Bophelo Pele Male Circumcision Centre in the township of Orange Farm, about 45km south of Johannesburg, South Africa, is amazingly composed for someone about to have his foreskin surgically removed.
"I've heard we must come and circumcise so that we cannot get sick," he said. "My parents think it's a good thing." Maiko is one of about 100 men aged 15 and up who come to the centre every day and briefly occupy one of seven curtained-off beds in a one-room surgery.
One of the five nurses administers an anaesthetic and prepares the patient, while the doctor works his way around the room performing the surgery. An electronic cauterising device seals the wound more efficiently than stitches and the patient is usually up and out of the door in under 20 minutes.
"It was less painful than I expected," said Sibusiso Mbele, 18. "I'll tell my friends it's a good thing to come here."
No national policy
South Africa's policy on circumcision is still being finalised, guidelines need to be drafted and health workers trained, so the Bophelo Pele centre is the only one in the country offering free male circumcisions.
Other countries in southern Africa have already begun rolling out mass male circumcision programmes in response to evidence that circumcision, safely performed in a medical setting, lowers a man's risk of contracting HIV by about 60 percent.
In South Africa, public health facilities only perform circumcision for medical reasons; those choosing it for other reasons must pay a private practitioner.
Despite its limited geographical reach, Bophelo Pele has circumcised about 12,000 men since January 2008 and demonstrated that mass male circumcision is a feasible and cost-effective HIV prevention strategy.
Dirk Taljaard, the project manager, estimates that each circumcision costs between US$25 and $37, depending on the number of procedures performed that day; $17 goes on the surgical kit, the rest is spent on staff, operating costs, and an extensive outreach campaign that aims to educate every household in the township about male circumcision.
Photo: Kristy Siegfried/PlusNews
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From counselling to surgery
Before getting the cut, Maiko had to attend a group session where he received general information about how to protect himself from HIV and was shown illustrations of a circumcised and uncircumcised penis. Staff discovered early on in the project that many men thought they had been circumcised during traditional initiation rites but still had intact foreskins, or were only partially circumcised.
Maiko had attended initiation school but his father took him away the day before the circumcisions were performed. "He was thinking that it’s not safe to circumcise there."
After learning about the benefits of male circumcision, not only for protection against HIV, but also for hygiene and a reduced risk of genital cancer, men who decide to have the procedure are given an individual counselling session and offered voluntary HIV counselling and testing (VCT).
About 35 percent accept the offer - not bad in a group that HIV testing campaigns have found hard to reach - and those who test positive can still go ahead if their CD4 count (a measure of immune system strength) is above 200.
The men are encouraged to bring their female partners to the counselling sessions, or at least discuss what they have learned and tell them that they must abstain from sex for six weeks to allow the wound to heal.
Maiko has not talked to his girlfriend about getting circumcised. "It's just a surprise," he said, smiling shyly. "She'll never say nothing because she knows she will get infected from me, or I'll get infected from her if I didn't circumcise."
He knows that circumcision will only give him partial protection from HIV. "They tell us that you must [still] use condoms," he said.
Men are told to return within three days of the procedure, so staff can check for infection or failure to heal, but less than two percent have any problems.
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Taljaard said men mentioned protection against HIV and other sexually transmitted diseases as their main reason for circumcision, but a quick sample of those waiting at Bophelo Pele revealed other reasons.
The opinions of female partners appeared to carry weight. "A friend of my wife's brought his son here, so my wife told me, 'Why didn't you do this thing before?'" said Phineas Soko, 48. "Some nations do this thing, but us Zulus know nothing about this."
Soko gave in to pressure from his wife and friends. "I see some of the guys say you're supposed to cut this thing [because] sometimes you catch diseases," he told IRIN/PlusNews.
Younger men thought women preferred sex with a circumcised man - 40 percent of women surveyed by Bophelo Pele did in fact say they preferred circumcised men, but their reasons had more to do with hygiene than sex.
Brian Makholo, 25, is taking advantage of the free service to deal with a painful condition he has suffered from all his life: 'phimosis', or a too tight foreskin.
Taljaard said the centre offered men many sexual health benefits that were not readily available in the public health sector, and "It's often the first time they're offered these services."
He sees no reason to delay rolling out a mass male circumcision programme - the risks are minimal, the cost low considering how many infections could be averted, and the demand plentiful.
The South African government may struggle to finance a national male circumcision programme, but in other countries international donors have been willing to fund a relatively inexpensive intervention that lasts a lifetime. "Doing nothing, I think, is not acceptable anymore," said Taljaard.