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MBABANE, SWAZILAND — 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.
