Circumcision – dating back to Abraham – is the oldest surgical procedure in the world. It has always represented entry to membership in the Jewish people among males, whether in infancy or later in life. Yet, an Israeli circumcision initiative that has nothing to do with religious identification and is performed on teens and men in sub-Saharan Africa, has saved hundreds of thousands from being infected with HIV, the AIDS virus.
Only a minority of men around the world have been circumcised for religious, medical or cultural grounds. In the US, nearly 60% of boys are circumcised immediately after birth, most of them for hygienic reasons.
“Operation Abraham,” a cutting-edge consortium of Israeli medical institutions working voluntarily and facilitated by the Jerusalem AIDS Project (JAIP), has trained African medical professionals both in their home countries and in Israel.
JAIP, an international HIV/AIDS-focused non-governmental organization was founded in 1986 by Dr. Inon Schenker and based in Israel as a national, regional (Middle Eastern) and international leader in HIV/AIDS prevention efforts in young people, including school pupils, university students and men and women in uniform.
It has developed models for HIV prevention that have been adopted in 27 countries in Latin America, Asia, Africa and Eastern Europe – in cooperation with professional international bodies such as World Health Organization (WHO) and UNAIDS.
Schenker, a former senior director of global public health at Teva Pharmaceutical Industries, is regarded as Israel’s leading professional in HIV/AIDS prevention. A graduate of the Hebrew University of Jerusalem with a doctorate in public health and science education, he also has a master’s degree on public health and bachelor’s degree in sociology and political science.
Schenker, son of a former chairman of obstetrics and gynecology at Hadassah University Medical Center in Jerusalem, began his global public health journey as a volunteer graduate student, training school teachers in HIV/AIDS education during the early days of the epidemic in Latin America. He next teamed up with professionals from the Middle East to develop and implement the innovative “HIV/AIDS as a Bridge for Peace” model.
His first UN job was with the WHO in Geneva, where he applied lessons learned from his doctoral research to advance a UN strategy on HIV prevention in adolescence. Moving to UNESCO, he led the development of new criteria for school curricula and training in HIV prevention and set up a new global clearinghouse in this area. Subsequently, he returned to Israel, equipped with a new skill and interest – global health employment and internships.
At the first WHO consultation on male circumcision and HIV infection, which was held back in 2000 in Durban, South Africa, those involved had no idea that they would be making history, wrote Schenker in his just-published journal article. “That hot day in July marked an important milestone of the largest multinational public health intervention for HIV prevention in African men. To date, it has directly impacted over 15 million men; engaged leading research institutions in the US, France, South Africa, Kenya, and Uganda; and attracted over $2 billion in investment, while presenting numerous challenges to policy makers, governments, implementers, funders, researchers, and practitioners.”
The success of the trials of voluntary medical male circumcision (VMMC) induced the WHO and national governments and voluntary organizations to aim in 2006, for circumcising 27 million men in sub-Saharan Africa by 2021, wrote Schenker in the latest issue of AIDS Education and Prevention. Male circumcision has also been shown to reduce transmission of syphilis, gonorrhea and human papilloma virus, thus lowering the prevalence of cervical cancer in female sex partners of circumcised men.
Publication of his article coincided with the holding in late July of the 22nd annual International Aids Conference in Amsterdam, where the first such gathering appeared in 1986, just five years after AIDS reached public consciousness and aroused great concern among governments. This year’s conference was attended by 15,000 scientists and physicians. “I was at the first conference in Amsterdam as a student,” recalled Schenker. “So much has happened since then.”
It is estimated that by 2030, male circumcision will avert at least 500,000 HIV infections in Africa. A unique Israel-Senegal-South Africa collaboration led to 100 VMMC procedures per day, with less than 2% minor adverse events procedures – establishing voluntary male circumcision as “one of the most impressive public health collaborative interventions in HIV/AIDS prevention globally.”
There are a handful of different circumcision procedures on teen and adult men. Most can be carried out with just local anesthesia in 18 minutes at clinics working like an assembly line, if experienced doctors and nurses are involved. The patients return the next day and a week later for checkups.
Schenker noted that many obstacles remain in the effort to circumcise males, from infants through adults. There are opponents to infant male circumcision from some extreme groups who claim that it should not be done without the child’s consent and who thus oppose Jewish and Muslim ritual circumcision, as well as non-ritual procedures aimed at promoting health. While there have been some efforts in Europe to make the procedure illegal, the American Academy of Pediatrics and the US Centers for Disease Control and Prevention, among other organizations and institutions, have come out strongly in favor of medical circumcision.
The mechanism by which HIV infection is riskier in the uncircumcised is well-understood: Removal of the foreskin minimizes the ability of the AIDS virus to penetrate the skin. In addition, Langerhans cells, HIV receptors and other special immunological bodies are located on the underside of the foreskin, and these are targeted by the virus. It may also be that tiny lacerations in the inner surface of the foreskin during sex may allow easier entry for HIV.
Schenker noted that heterosexual HIV transmission is the main mode of infection in both men and women in sub-Saharan Africa, where 5.6% of the population is infected. In 2005 alone, 2.1 million Africans died of AIDS.
He added that VMMC in Africa must be accompanied by existing prevention strategies, including condoms, HIV testing, education and abstinence, being faithful and condom-use programs. The WHO and UNAIDS have identified 13 countries in southern and eastern Africa – Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe – as urgently needing vigorous VMMC programs. Boys as young as 10 years old voluntarily undergo the minor surgery. “Sometimes their mothers bring in several of their sons together,” said Schenker.
Circumcision can be dangerous if carried out in unhygienic environments and by an inexperienced practitioner, so the WHO was determined to improve the skills of circumcisers and the sanitary conditions of clinics.
Yet a major problem was that before 2006, very few African physicians had ever performed adult VMMC, and certainly not at the scale and pace needed to reach the goal of circumcising 20 million men by 2015 and beyond. The problem was that vast experience in mass male circumcision of adults was not available except in one country – Israel!
Between 1989 to 2000, over 1.1 million Jews emigrated from the former Soviet Union and Ethiopia to Israel. When they arrived, it was discovered that over half of those born to Jewish parents had not been circumcised due to social, persecution and other non-medical reasons but wanted themselves, their children and even grandchildren of various ages to be circumcised in their new country where nearly every male has undergone circumcision.
Here there are a few hundred non-physician mohalim (ritual circumcisers), who perform the procedure on Jewish infants, plus several dozen urologists and surgeons – all religiously observant – who operate on older boys and men in clinics and hospitals.
The Health and Religious Services Ministry set up a national program to supply this unexpected demand of more than 200,000 newcomers and support their fast integration into the Jewish state by opening free VMMC services in all major hospitals. A few dozen urologists and general and pediatric surgeons with supporting nurses were assigned to the task, gaining expertise and experience in high-volume VMMC.
A WHO workshop held in Jerusalem, organized in collaboration with Schenker’s Jerusalem AIDS Project, served as the basis for a manual on VMMC that was distributed around the world; a consortium of 11 Israeli hospitals, medical and nursing societies and public health organizations was set up to support the launching of VMMC services in Africa. “Today, Israeli circumcisers and doctors no longer have to teach them. Local African physicians and nurses know how to do it properly themselves. We established the basis, and they now have the know-how they needed. This is Israel’s biggest contribution to AIDS prevention in the world.”
VMMC, concluded Schenker, “is now a well-established, evidence-based, proven and recommended HIV prevention intervention for all men, adolescents, and boys living in high-HIV-prevalence countries. The international collaborations, sharing of expertise across different cultures, and the many innovations VMMC has generated from its earliest days of implementation are great examples of a world united in the fight against AIDS.”