JOHANNESBURG -- A three-year-old push by the local government and international organizations to circumcise men throughout South Africa has reaped huge rewards for the country and the region, operating on hundreds of thousands of men and decreasing the risk of H.I.V. transmission in the hardest hit area in the world.
The initiative has not been without controversy, and one of its major objectives -- to simplify circumcisions and allow people with minimal training to perform the operations -- has given rise to a slew of new devices that some argue cause more problems than they solve.
The most popular and controversial of these new, non-surgical instruments is the Tara KLamp, a Malaysian-manufactured device that has wide government support. The clamp is at the heart of an effort to circumcise men in KwaZulu Natal Province, home to many of South Africa's Zulus, the country's largest ethnic group and the group with the lowest rate of male circumcision.
Circumcision has been shown to decrease the risk of H.I.V. transmission by as much as 60%. Follow-up studies done in the Orange Farm community south of Johannesburg have said that this benefit increases over time, reducing the rate of new infections by as much as 76% over a three-year period. In a country grasping for solutions to the pandemic -- the infection rate is one of the highest in the world with roughly 5.6 million H.I.V.-positive South Africans, more than in any other country -- circumcision is one of the easiest and most cost-effective ways to prevent the spread of H.I.V.
Tariq Yusif, who along with his father controls the distribution of the device in South Africa, said the Tara KLamp offers a "simple" way to get large numbers of South Africans circumcised because "you don't need a surgeon to perform the procedure." It's possible to give the clamp to nurses with a minimal amount of training in rural communities where doctors may not be available.
"It's perfect for mass circumcisions because one guy, fully trained, can do up to 200 a day," added Yusif.
The clamp is a plastic device that works by cutting off blood supply to the foreskin for a little over a week, at which point it's removed by a trained technician. Unlike the most common circumcision technique -- which requires a doctor and weeks of recovery -- the clamp makes no incisions and promises fewer follow-ups at a clinic.
Some of the country's AIDS activists are wary of the clamp, claiming that it is dangerous to use, especially in untrained hands. The device has only been studied once in a peer-reviewed journal, and the results were abysmal. The article said that 37% of the men who used the clamp experienced complications, compared to only 3.4% of men who were circumcised with forceps.
Dr. Davis Nalumango, the South African technical director for the clamp, said the study was "a kind of disaster." Nalumango blames the results on untrained technicians who managed to get their hands on the clamps without proper training. He points to the tens of thousands of successful circumcisions carried out in the subsequent KZN program.
The clamp has not been approved by the World Health Organization, a prerequisite for funding from large external groups like the Bill & Melinda Gates Foundation.
Critics at South Africa's Treatment Action Campaign has led the fight against the clamp, alleging corruption played a part in the handing out the KZN contract. "The TK is a dangerous device," the TAC said in a statement published last year. "That the KZN government continues to roll out the TK against the advice of the country's foremost medical practitioners and scientists is arrogant and irresponsible."
The business dealings of the Tara KLamp's distributors have been called into question, as have the company's close ties with the national and provincial government.
The government has been an enthusiastic supporter of the clamp. Soon after the government program began, KZN's health minister Sibongiseni Dhlomo told the Mail & Guardian: "The Tara KLamp is more cost-effective. Whereas surgical methods can be administered only by a doctor and require three or four subsequent visits to a clinic for replacement bandages and check-ups, the Tara KLamp method can be done by a male nurse and needs only one further check-up. This reduces patients' bus fares back and forth, sick-leave days, and so on."
Since the initiative first launched in 2010, 243,000 men have been circumcised in the province, and the Tara Klamp was used on more than 42,000 of them.
Most of these circumcisions have happened in the country's Zulu community. Circumcision was a taboo amongst the Zulus for more than a century, dating back to when the powerful king Shaka Zulu suspended the practice during a prolonged time of war. For years this cultural hang-up has prevented many Zulu men from getting their foreskins removed. It's only recently -- after carefully timed messages from the Zulu king, Goodwill Zwelithini, and current president Jabob Zuma -- that many young Zulu men have opted to have the surgery. The new wave of young patients is having the procedure performed in clinics by nurses, not traditional healers, and often they are carried out by the new clamp.
There are currently two more similar products undergoing WHO testing that may compete with the Tara KLamp in the near future. One, an Israeli device called PrePex, is being tested in 14 African countries including South Africa. The other, a Chinese instrument called the Shang ring, is being used in Kenya and Zambia.
Photos: Phalinn Ooi/Flickr