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Zandi Dlamini ran a practised eye over the anxious young men in the waiting area before summoning the first one into her small counselling room. Shongwe Bonginkosi, 34, told her he was interested in having a cleaner penis, more hygienic generally. Ms. Dlamini nodded. She'd heard it hundreds of times before.

"Nobody ever says 'HIV,' " she said later. "They talk about hygiene, and better sexual performance. Never HIV." Even here, where nearly one in two men has the virus that causes AIDS, no one wants to admit to being afraid of it.

With Mr. Bonginkosi before her, Ms. Dlamini quickly explained how, in a few minutes, a doctor would make an incision at the top and middle of his penis, cut all the way around it, and slide off the "sleeve" of his foreskin. He would have local anesthetic, she said. He would have to come back a week later to have his stitches checked. He would have to abstain from sex for six weeks. The young man, a government clerk who had taken the day off, nodded, shifting in his seat, clasping and unclasping his fingers. She took him through a door to the back of the clinic, handed him a maroon surgical gown, told him to take off his pants and underwear and wait.

With the operation minutes away, Mr. Bonginkosi admitted HIV was also one of his motivations. "You can still get it if you are faithful," he said. He doesn't know about his girlfriend's previous sex life. He can't know, really, whether she is having sex only with him. He had heard that circumcision could help to protect him, and that's what brought him to the tiny clinic of the Family Life Association of Swaziland.

Once primarily a family-planning organization, the agency these days does a booming business in circumcision and has a waiting list of hundreds for its lone doctor, who does about 10 of the operations a day.

Swaziland, which has the highest rate of HIV infection in the world, 42 per cent of young adults, is eager to see as many men circumcised as possible. The government would like to offer the procedure to an estimated 200,000 sexually active men over the next five years. The problem here is a shortage of doctors, fewer than 100 for a country of one million.

The Family Life Association has been offering "Circumcision Saturdays," assembly-line procedures in various clinics around the country, but one day last fall the crowd of would-be patients was so large at a rural clinic that it turned into a small riot.

In the past few months, a piece of information long muted in the medical world has suddenly seeped into public consciousness in this tiny southern African country, and many of the other nations worst hit by AIDS: Circumcision helps to protect men from contracting HIV from infected female sexual partners. It's cheap, about $82 an operation at this clinic, although the U.S. AIDS program is helping the Swazi government to offer it free. It's relatively easy. (A wincing Mr. Bonginkosi, when his anesthetic had worn off, was quick to point out that it is, however, initially very painful.)

It isn't just Swaziland: In most countries in east and southern Africa, private urologists are reporting an upsurge in demand from educated men who have heard about the research and can afford to have it done privately. And several countries are moving ahead with national plans to increase rates of circumcision.

In the perennially bleak work of the fight against AIDS, the hope offered by male circumcision is a rare piece of good news.

Research has shown that a circumcised man is 65 per cent less likely to contract HIV from a woman who has the virus than is a man whose penis still has a foreskin.

Circumcision appears to offer protection from heterosexual transmission of HIV in a number of different ways. First, the fragile inside of the foreskin is rich in a kind of white blood cell, called the Langerhans cell, which are favoured targets of HIV, which hooks itself on to them to gain entry to a new body. Remove the foreskin, and remove a key entry point.

Also, a circumcised penis develops a toughened layer of skin that is much harder for the virus to penetrate. And finally, circumcised men are less likely to contract herpes, syphilis, genital ulcers and other infections, all of which increase the likelihood of contracting the virus.

Research has not shown that a woman having sex with an HIV-infected circumcised male would be less likely to get the virus than one whose HIV-positive partner was not circumcised, but women do benefit from a larger "herd immunity" effect, in that if more men are circumcised, women are less likely to encounter an HIV-positive partner.

AIDS researchers often note that although hundreds of millions of dollars have been spent on research into vaccines and microbicides trying to figure out how to stop the virus, the condom remains the only successful piece of technology for blocking its spread. Meanwhile, behaviour-change campaigns pushing abstinence, fidelity or condom use have limited impact. In Africa, home to 70 per cent of the world's HIV-AIDS cases, where nearly half of men are not circumcised, the procedure could prevent millions of infections.

Kenya has decided to offer circumcision to men of all ages, and public health officials are working on how to do that safely, cost-effectively and with cultural sensitivity.

"It certainly is an appropriate strategy from a scientific and public-health perspective, but must be reconciled with the deep culturally embedded issues that define the procedure as a rite of passage, for circumcising communities, and more so as a mark of identity for the non-circumcising communities," said Peter Cherutich, who heads the team making the plan.

In January, Rwanda kicked off a campaign to get more men circumcised, targeting soldiers, police officers and university students first. While the government said the campaign would be voluntarily, Rwandan media said soldiers were seeing it more as an order. Very few men in the predominantly Christian country are circumcised. The Ministry of HIV-AIDS is also working to make the procedure more commonplace for newborns.

Back in July of 2005, French and South African scientists working together on a study outside Johannesburg called it off early when midpoint results revealed that men who were being circumcised through the research were contracting HIV 65 per cent less often than the young men in the control group who were not circumcised. Ethically, they were obliged to offer the control group circumcisions as well. That study started the buzz, but many in the AIDS field were skeptical, fearing that its results were an anomaly and attributable to some other cultural factor.

But two more large trials were under way, both funded by the United States National Institutes of Health, and when their results were announced in December of 2006, they were nearly identical. Adjusted for factors such as the fact that some of the non-circumcised men did not have sex during the course of the study, the protective effect looked to be as high as 70 per cent.

The trial results show a protective effective over the course of 18 months. Over a lifetime, depending on their behaviour, circumcised men could end up with rates of HIV infection as high as non-circumcised men. But the herd immunity effect would serve to slow the spread of the virus in the population as a whole.

In March of 2007, the World Health Organization and UNAIDS endorsed the procedure as a good way of preventing HIV infection, and the major donors began talking to African governments about how to make the procedure widely and safely available.

Yet many advocates of the procedure are angry that it has taken this long for circumcision to begin to be adopted. It was the early 1980s when the U.S. anthropologist Priscilla Reining noticed the correlation between circumcision and low HIV infection rates among people she was working with in Tanzania; she started discussing it back then. Many others working in HIV, both Africans and outsiders, also noticed the link through the 1980s and early 1990s.

In Kenya the general HIV prevalence is about 6 per cent of the population, but among the Luo, the only tribe that does not routinely circumcise, 20 per cent are infected. Across the continent, the lowest rates of infection are in West Africa, where circumcision is widely practised, and highest in the regions of southern Africa where it is not. By the end of the 1990s, 30 different pieces of research suggested a correlation.

Yet it was after 2000 that scientists started the randomized, controlled trials that are considered the necessary level of proof before the practice becomes public-health policy.

Why the delay? In part, no doubt, because the procedure is not, in the words of researcher Robert Bailey of the University of Illinois, "just a shot in the arm," but rather surgery to chop something off, of a body part about which most people are emotional.

Daniel Halperin, a Harvard University public health researcher, a former HIV prevention adviser to the United States development agency and a leading proponent of scaling up circumcision, sees other factors at work.

"The tendency is to look for biomedical, technological solutions, and while circumcision is biomedical, in Africa it's always been a traditional, 'savage' practice so it has not been on the radar," he said.

Cultural factors, and ignorance thereof, have played a role, Dr. Halperin said. The AIDS "elite" in the developed world assumed, inaccurately, that the practice would be culturally rejected in non-circumcising areas.

"They don't realize that circumcision is part of the African landscape and has been so for many hundreds of years."

The challenge, Dr. Halperin said, is to find the medical personnel and equipment safely to do hundreds of thousands, possibly millions, of the operations in the next couple of years.

"But then it's done. It's like a mass vaccination campaign. ...We're not still looking for it, we have it and we know it works."

Foreskin faults

Studies have shown circumcised men have a lower risk of several reproductive tract infections, including HIV, than uncircumcised men.

Outer foreskin

Inner foreskin

Urethral meatus

Glans penis

Frenulum

The cells in the inner foreskin and frenulum of an uncircumcised penis are exposed to vaginal secretions during intercourse, increasing the risk of infection.

HIV entry

Inner foreskin

Frenulum

HOW THE FORESKIN INCREASES HIV RISK

1. Increased risk of genital ulcer diseases. Ulcers in turn increase risk of HIV acquisition.

2. Tissue on the shaft and outer foreskin has more keratin, providing some protection from infection.

3. The cells that HIV targets are closer to the surface on the frenulum and inner foreskin.

SOURCES: WORLD HEALTH ORGANIZATION