Young men have flocked by the thousands to this clinic for circumcisions, the only one of its kind in South Africa. Each of them lies down on one of seven closely spaced surgical tables, his privacy shielded only by a green curtain.
“I’ve done 53 in a seven-hour day, me, myself, personally,” said Dr. Dino Rech, who helped design the highly efficient surgical assembly line at this French-financed clinic for cutting off foreskins.
Circumcision has been proven to reduce a man’s risk of contracting H.I.V. by more than half. Yet two years after the World Health Organization recommended the surgery, the government here still does not provide it to help fight the disease or educate the public about its benefits.
Some other African nations are championing the procedure and bringing it to thousands. But in South Africa, the powerhouse country at the heart of the epidemic, the government has been notably silent, despite the withering international criticism the country has endured for its previous foot-dragging in fighting and treating AIDS.
“Countries around us with fewer resources, both human and financial, are able to achieve more,” said Dr. Quarraisha Abdool Karim, the first director of South Africa’s national AIDS program in the mid-1990s under President Nelson Mandela. “I wish I understood why South Africa, which has an enviable amount of resources, is not able to respond to the epidemic the way Botswana and Kenya have.”
Even without government involvement, demand for the surgery, performed free under local anesthetic, has surged over the last year here at the Orange Farm clinic. The men are counseled to continue using condoms since circumcision provides partial, though substantial protection.
Men waited nervously one recent chilly morning for their turn. Most were hoping the procedure would help them stay healthy here in the nation with more H.I.V.-positive people than any other.
But some said they were also drawn by a surprising, if powerful, motivation: They had heard from recently circumcised friends that it makes for better sex. You last longer, they said. Your lovers think you’re cleaner and more exciting in bed.
“My girlfriend was nagging me about this,” said Shane Koapeng, 24. “So I was like, ‘O.K., let me do it.’ ”
As new H.I.V. infections have continued to outpace efforts to treat the sick in Africa, there is growing concern about the ballooning costs of treatment for an ever-expanding number of patients who need medicines for the rest of their lives. Almost two million people were newly infected in 2007 in sub-Saharan Africa, bringing the total of those living with H.I.V. in the region to 22 million, according to United Nations estimates.
The major international donors to AIDS programs, including the United States and the Global Fund to Fight AIDS, Tuberculosis and Malaria, are ready to pour money into male circumcision, but the countries have to be ready to accept the help.
“You can’t impose it from the outside, particularly such a sensitive intervention,” said the Global Fund’s executive director, Dr. Michel Kazatchkine.
Public health doctors agree that circumcising millions of men will be no simple task. Africa has a severe shortage of doctors and nurses, and circumcision is potentially a political and cultural minefield in countries where some ethnic groups practice it but others do not.
Still, some countries are showing it can be done. In Botswana, circumcision was largely stopped in the late 19th and early 20th centuries by British colonial-era administrators and Christian missionaries.
But Festus Mogae, who was president from 1998 to 2008, provided a critical endorsement of male circumcision just before he stepped down.
Over the past year, the government has trained medical teams to do circumcisions in all its public hospitals and aims by 2016 to have circumcised 470,000 males from infancy to age 49, which is 80 percent of the total number in that group.
Public awareness is being raised through advertisements on radio and television. Billboards have sprouted across the country featuring a star of the national youth soccer team.
“Men have started to flock to the hospitals,” said Dr. Khumo Seipone, director of H.I.V./AIDS prevention and care in Botswana’s Ministry of Health.
In Kenya, where the Luo do not generally practice circumcision, Prime Minister Raila Odinga, himself a Luo, encouraged the procedure and lobbied elders. The H.I.V. infection rate among Luo men is more than triple that of Kenyan men generally — 17.5 percent versus 5.6 percent.
“Anything that could help save lives needs to be tried,” Mr. Odinga said, adding that he had been circumcised.
So far, more than 20,000 men in Kenya have been circumcised in hospitals, dispensaries, village schools, social halls and tents. Teams of doctors, nurses and counselors have even taken boats to islands in Lake Victoria to circumcise Luo fishermen.
“If the Luo Council of Elders and local politicians had been against it, the government would not have dared endorse circumcision,” said Robert Bailey, the principal investigator on the Kenya male circumcision clinical trial.
In sharp contrast, male circumcision has no political champion here in South Africa, where the largest ethnic group, the Zulus, have generally not practiced it since the early 19th century, when it was abandoned due to protracted warfare, according to Daniel Halperin, an epidemiologist and medical anthropologist at Harvard University.
Thabo Masebe, a spokesman for President Jacob Zuma, said the Health Ministry must first set a policy on circumcision before Mr. Zuma, who took office in April, can take a position. Mr. Zuma is Zulu. The province of KwaZulu-Natal, the Zulu heartland, has the highest adult H.I.V. prevalence rate in the country, 39 percent, according to Unaids.
“The president gets involved when decisions are made,” Mr. Masebe said. “If the president spoke now, and when the time comes to make a policy, a different decision is taken, it wouldn’t sound good.”
The new health minister, Aaron Motsoaledi, spoke at length about AIDS in a recent speech to Parliament but made no mention of male circumcision. Dr. Yogan Pillay, a senior official at the National Department of Health, said a policy was being drafted and would be put forward for discussion by the end of the month.
In March 2007, the World Health Organization concluded from rigorous clinical trials in Kenya, Uganda and here in Orange Farm township that male circumcision reduced female-to-male H.I.V. transmission by about 60 percent.
“This is an important landmark in the history of H.I.V. prevention,” the W.H.O. said at the time.
That same year, a committee of scientists, advocates and others advising the South African government recommended offering circumcisions as quickly as possible, perhaps by contracting with private doctors while public health workers were trained. Instead, the government set up a task force to study the issue, said Dr. Abdool Karim, a committee member.
The surgical methods developed in Orange Farm are now being copied in the region. Population Services International, which provides counseling at the Orange Farm clinic, is putting them into practice in Zimbabwe in collaboration with the Health Ministry there. It also received $50 million from the Bill and Melinda Gates Foundation to work with the governments of Zambia and Swaziland in the hope of circumcising some 650,000 men in those two countries.
South Africa has made strides in recent years, and now provides antiretroviral therapy to more people with AIDS than any other developing country.
But this is not the first time its policies have lagged behind. The country delayed for years providing antiretroviral medicines to treat AIDS under its former president, Thabo Mbeki, who denied the scientific consensus about the viral cause of the disease. Harvard researchers estimated that the government would have prevented the premature deaths of 330,000 South Africans earlier in the decade if it had provided the drugs.
“South Africa has no shortage of scientists,” said Olive Shisana, chief executive officer of South Africa’s government-financed Human Sciences Research Council. “We have a shortage of people willing to take the evidence that exists and use it for public health.”