Editor's note: Africa has the world's largest number of HIV infections and AIDS cases. Across the continent the disease is being battled with public education and antiretroviral drugs. A new additional strategy is male circumcision. Several tests show that circumcised men have substantially reduced risks of contracting HIV. In response, several campaigns have been launched to circumcise men.

GlobalPost has investigated this public health effort in eastern and southern Africa. The series starts in Kenya in the fishing villages by Lake Victoria and includes this video of a circumcision (below). Also, a Kenyan doctor describes his work running a circumcision clinic, health writer Mercedes Sayagues gives her controversial opinion on the issue and a South African doctor describes the circumcision campaign in several southern African countries.

KATITO, Kenya — The men snickered awkwardly as they discussed their sex lives.

At first, they dutifully recited talking points — “I want to be protected from HIV” — like school children trying to say exactly what the teacher wanted to hear.

But as they loosened up, their questions became more pointed: How much will it hurt? Will I become impotent? Will I become better at sex? Will I be more sensitive? Will girls like me more?

It was male circumcision day in this village in southwestern Kenya.

The weekly clinic of medical professionals is part of an internationally funded fight against HIV and AIDS. Research in Kenya, Uganda and South Africa has shown that circumcision can reduce a man’s chances of infection by as much as 60 percent during heterosexual sex.

Kenyan doctors circumcise a man to reduce rates of HIV infections
Kenyan doctors perform a circumcision.
(Adam Jadhav/GlobalPost)

For a year, the Nyanza Reproductive Health Society has operated the Katito clinic here in Nyanza province. Each week, as many as two dozen men and boys as young as 10 shuffle their feet and kick the dust as they wait in a courtyard also occupied by goats.

The region is home to Kenya's portion of picturesque Lake Victoria as well as Kisumu, the country's third-largest city. It is also Kenya’s HIV hotbed, where more than one in seven people between the ages of 15 and 64 are infected, more than double the national rate.

Five at a time crowd into a small room to speak first with counselor Japheth Ouko, who explains the circumcision procedure, the risks and the proper post-op care. Using a brown wooden model of male genitalia as a prop, he occasionally waves it like a pointer. His details elicit some squirming and lip biting.

Ouko grills the men to think about why they are there: Are you afraid? Do you understand that this is not a fail-safe prevention?

“You must practice safe sex, protected sex,” Ouko says. “Circumcision is not a permanent condom.”

Health officials worry that men will mistake circumcision for foolproof protection against HIV/AIDS, as some rumor has promised. Ouko cautions them against thinking of the procedure as a cure. He tries to keep the conversation serious, his tone grave, lecturing that circumcision’s protective benefits are nullified if it leads to more risky behavior.

Ouko clarifies another important point: So far, circumcision offers no reduction in HIV/AIDS transmission during homosexual sex. Nor does it protect women from men infected with the virus.

The men meekly profess to understand the importance of safety. Later, while talking with a reporter, they hem and haw, some quietly admitting their dislike for condoms. Others confess to having multiple sexual partners simultaneously, hardly uncommon for Kenyan men.

During the counseling session, Philip Augustine, 31, puffs out his chest and announces earnestly: “I came to face the sword, to be circumcised.” The subsequent burst of laughter from the group cuts the building tension.

In the room next door, surgeries get underway. One after another, the men are led into the two-table operating theater. After a blood pressure check, they are prepared for surgery.

A clinical officer swabs each man with iodine, and a nurse covers the patient’s midriff with a surgical blanket that has a strategically placed opening. The large shot of painkiller produces the loudest response, accompanied by cringing and twitching and yelping.

After the anesthetic deadens all sensation, the surgeries proceed methodically: forceps and clamps to pull the foreskin forward, one swift slice of a scalpel and several minutes of dabbing blood, stitching and bandaging.

Augustine occasionally looks down his chest during the 30-minute procedure, but almost immediately turns away and shutters his eyes. The nurse teases him, saying friends from a nearby village had the procedure done long ago.

An observer winces just watching. But the all-male operating team barely flinches. They have performed the surgery hundreds of times.

Joseph Nyola, 24, withstands the surgery stoically, making hardly a sound. He says little afterward, except to joke that because of the six weeks of prescribed sexual downtime, his wife would sleep in the kitchen.

When Augustine leaves the surgical suite, a cluster of younger boys anxiously huddles near him in the hallway, wanting to know how it went and how much it hurt.

While circumcision is common in some countries, such as the United States and even most of Kenya, the practice has been nearly unheard of among the Luo tribe, which inhabits most of Nyanza province. Here, circumcision has been viewed almost with disdain, as a ritual of outsiders, namely the rival Kikuyu, Kenya’s largest tribe.

“We had to be very careful,” said Emma Llewellyn, who heads the Health Society’s male circumcision program. “People didn’t want to be seen as forcing cultural practices on people. There was a lot of dialogue with the Luo Council of Elders, opinion leaders, the youth … to discuss this and how to take this forward.”

Researchers believe circumcision protects men from infection because it removes tissue dense with cells that are more receptive to HIV, and also removes soft tissue that is prone to cuts and abrasion. In addition, after circumcision, the skin beneath the foreskin hardens, offering further protection from the virus.

Today, the Health Society has seven teams of clinical officers, nurses, counselors and outreach workers that run weekly clinics, like the one in Katito. Circumcision days often coincide with bustling village market days.

Teams visit schools and have set up mobile surgical camps in the rural bush.

The clinics around the region frequently have lines. Parents bring their children at increasingly younger ages. Even a few elderly Luo men have come to be circumcised, mostly as a show of support.

After surgery, the men lounge in the grass outside the clinic to recover. They crack jokes at the restlessness of those who had yet to be called into the operating room. It doesn’t hurt that much, Augustine tells a younger boy repeatedly.

Several men say they hope the rumors are true, that performance in the bedroom improves with circumcision. Nearly all say they are sure the procedure will open up their dating pool to other tribes where uncircumcised men are sometimes seen as not having attained manhood.

“When we are outside, in the other tribes, the girls don’t like men who are not circumcised,” said Stephen Onyango, 17, who was circumcized four months earlier and came to cheer on friends.

This is becoming a pressing issue for Augustine, who at 31 is still unmarried. He says he wants to find wife, but needs a job first.

“Without employment, I will not marry because the wife won’t eat stones.”

Circumcision, he said, may be his ticket to both. The procedure now allows him to seek work in other areas and still be able to look for a wife among women who wouldn’t consider him before.

“The girls like it,” Augustine says shyly, almost guiltily. “I will have more chances now to find a wife.”

More GlobalPost dispatches about male circumcision in Africa:

A report from a fishing village on Lake Victoria, a Kenyan doctor gives his personal thoughts about circumcision, a South African doctor talks about the drive in southern African countries, a health specialist gives her controversial opinion about the male circumcision campaign.

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