Each day at the Bophelo Pele male circumcision center in the Johannesburg township of Orange Farm, South Africa, a medical team of three doctors and 16 nurses performs about 100 circumcisions for adult men in the community.
The procedure is relatively simple, and so is the goal - to help prevent HIV transmission. But despite high-profile studies in recent years showing circumcision reduces the risk of heterosexually acquired HIV infection by approximately 60 percent, getting the message out about the importance of the procedure is not always easy.
"It's a 20 minute surgery but the whole process takes much longer because we are visiting households one by one in the community, delivering information," said University of Versailles professor Bertran Auvert, who heads the program with South African-based doctor Dirk Taljaard.
For now, Bophelo Pele, which is funded by the French National Agency for Research Against AIDS, is the only center in the HIV-plagued country that provides free circumcisions for the purpose of HIV prevention.
But the South African department of health and the South African National AIDS Council are considering providing the service in the future and are in the early stages of assessing how to proceed.
"The discussions are still at very, very early stages," said Fidel Hadebe, spokesperson for the South Africa department of health. "But male circumcision is going to form part and parcel of HIV prevention in this country."
While many in the medical field had long observed a connection between HIV prevalence and circumcision rates, it wasn't until 2005 that the scientific evidence started to catch up. The first of the three major studies that bore out the results was done at the Bophelo Pele center and is known as the Orange Farm trial after the community it tracked.
The study was stopped early because the evidence proved overwhelmingly strong that circumcision was providing a significant degree of protection compared to those in the trial's control group.
It's believed that removal of the foreskin reduces the ability of HIV to penetrate the skin on the penis, and there is also evidence that HIV targets cells from the inner surface of the foreskin.
After the Orange Farm trial, two more studies done in Uganda and Kenya in 2006 supported the results that circumcision reduces HIV transmission by about 60 percent, leading to the World Health Organization issuing recommendations for the procedure as an HIV prevention method in 2007.
With the WHO go-ahead, a number of countries with high HIV prevalence are now considering how to integrate the procedure into their existing health services.
"What is critical for all involved is to make sure that enough ground work is done that if a policy is implemented in this country it would not encounter problems," Hadebe said.
Cultural considerations are also especially important for South Africa to resolve before any policy can be created, said Hadebe.
"Circumcision is more than just a male reproductive issue, it is a cultural issue ... you have to bear in mind that if somebody's culture does not allow them to be circumcised, how do you manage those dynamics?" said Hadebe.
According to a UNAIDS report, a self-reported 35 percent of men in South Africa are already circumcised. Circumcision is a cultural tradition for some groups in South Africa, including Jews and Xhosa, but it is often included in a tribal initiation ritual that has resulted in injuries and several deaths, creating negative press around the issue. The government is including tribal leaders in discussions about male circumcision to work through such concerns.
Taljaard hopes that some of the lessons learned in Orange Farm about scaling up the provision of services and how to reach out to the community will apply to a future national campaign.
"I think that it is still going to take some time before the man in the street understands what this means," said Taljaard. "I think for someone to volunteer for a small surgery to a rather sensitive part of this body is a huge thing. He has to think about it carefully."
Communication and education are key parts of the process, he said. One of the biggest concerns about male circumcision as an HIV prevention method is that while it does not provide 100 percent protection from HIV, it could encourage risky behavior from those who undergo the procedure and believe they are fully guarded.
Most of the trials showed no increased risky behavior, but one did show a higher level of unprotected sex reported by circumcised individuals than the control group.
While the behavioral effects of the procedure are still not completely known, Taljaard emphasizes that circumcision should always be presented to the patients as part of a package of HIV prevention methods.
Patients undergo counseling before the surgery and learn other ways to prevent transmission, and they receive information about allowing time for proper healing after the surgery.
Taljaard and Auvert agreed that the surgical nature of the procedure will complicate national roll out of circumcision in many African countries.
"In South Africa we are lucky that we have fairly good infrastructure in terms of clinics,' said Taljaard. But "the government will have to look at innovative ways of doing this because ... we need to circumcise a huge number of people in the beginning, then as other generations come up, we will add them."
One of the potential measures to relieve pressure on health systems would be training non-physician clinicians, like nurses, to perform the circumcisions.
Michael Stalker is the deputy director of the Male Circumcision Consortium in Kenya, a partnership between Family Health International, the University of Chicago at Illinois, and EngenderHealth, which is working with the government to develop a national strategy around the procedure. He echoed the concern about health system capacity.
"You've got a health system in many countries that is working on many fronts that is being asked to do more and more as science proves that things like male circumcision are effective," said Stalker. "The policy-makers have to consider how to integrate male circumcision in health systems, many of which may be over burdened and under resourced."
Kenya is still in the planning stages of providing circumcisions, but the government has voiced its commitment to offering the service and has released an official national guide for voluntary male circumcision.
"It's in its early stages of being rolled out, we are focusing on training providers and making sure that the necessary systems and resources are in place," said Stalker.
With a flurry of activity in many countries to develop solutions, a new Web site was launched in February by a partnership of groups including FHI and the WHO, to synthesize and share best practices on male circumcision. The aim of the Clearing House on Male Circumcision, www.malecircumcision.org, is to connect the medical community and policy makers so they can learn from each other's mistakes and successes.
"It's moving so fast right now in public health terms," said Stalker. He said he hopes that during the process his group will "learn lessons, to generate a type of road map that can help other countries."