Beyond the Cut

Lutgard Oketch raised her finger and used it to mimic a penis. She sat surrounded by roughly three dozen men, most of them bikers, who run motorbike taxis in Nyanza, western Kenya. With a job title of a “circumcision mobilizer,” she traverses villages in Siaya County in Nyanza calling men who haven’t been circumcised to take up the practice as a way to protect themselves against HIV.

That sunny morning, Lutgard arrived at a dusty road crossing where the bikers were packed chatting away about gigs and girls. They greeted her eagerly, making a ring around the wooden bench where she sat. They called in their questions. She posed to explain where a plastic ring used in circumcision would sit on the penis and whether circumcision makes the penis less sensitive.

Here in Nyanza, where the Luo – a traditionally non-circumcising community – live, male circumcision has faced resistance. Lutgard and her colleagues at ICAP, an agency that conducts male circumcision, are helping to oil the wheels of the cultural change to circumcise. And they are winning. In an effort to fight against HIV, men are embracing a cultural practice that was foreign to their forefathers. Medical male circumcision prevents 60 out of every 100 HIV infections that would have otherwise occurred. As male circumcision campaigns seek to enlist as many men as possible to adopt the practice, public health officials are recognizing the sway of women in bringing more men to the circumcision clinic. Success relies on going beyond the cut to encompass a broad package of services such as HIV testing and counseling, correct and consistent use of male and female condoms, treatment of sexually transmitted infections and promotion of safer sex behaviors.

Beyond the Cut – In Nyanza Province

On a recent morning, Lutgard talked to the bikers -- popularly known as boda boda riders – about taking up medical male circumcision. Public health officials have identified the riders as a key group in HIV response. A group of young men with relatively more money than the general population are likely to be involved in buying sex. Together with sex workers, they can drive up HIV infections.

The boda boda riders huddled around Lutgard, craning their necks and jostling to call in their questions, talking bluntly about genitalia, sex and HIV. “How does an uncircumcised man increase the risk of cervical cancer to his female partner?” one asked. “If I have sex with a woman with HIV and I take a shower immediately, can I succeed in washing away the virus?” another man called. Circumcision programs in this part of the world have found women tremendously successful in persuading men to circumcise. Lutgard says that men find it disarming that she can talk about sex with them in a frank manner. The programs are employing more women, allowing them to enter the workforce and to contribute to transforming gender roles in their communities.

To the hilarity of the men gathered to watch the theatrical show, the mobilizers made the show a little too real, using a penis and a vaginal model to demonstrate correct use of both male and female condoms. They also took questions about pain during circumcision, sex after circumcision, among a host of other sexual and reproductive health inquiries.

George Obongo, 35 (right), arrived at the clinic after learning about the benefits of circumcision at the theatrical show. During a counseling session – usually scheduled before surgery – he spoke about why he wanted to circumcise. He would do it, he said, not just for himself but also for his 16-year-old son, whom he hoped would also take the cue from him and come to the clinic for circumcision.

Zedekiah Owino, 18, arrived at the clinic for circumcision. He said he first heard about the benefits of male circumcision from his mother. But it is the messages by the theater group that morning that had won him over. He went through a counseling session and took free HIV test as part of the circumcision package.

At the operating table, Owino lay down on his back, stoic, as the knife sliced through his foreskin. Perhaps the only bit of nervousness was given away by the beads of sweat collected on his brow. The surgical procedure takes between 15-20 minutes under local anesthesia. Afterwards, Owino received an emergency phone number, which he could call in case of complications. He would come for a follow-up meeting after seven days.

When he finally climbed down after a 15-minute job, Owino was elated that he had finally done it. He now wants to become a medical circumcision ambassador in his village.

In Kenya, HIV prevalence is highest in the same province where male circumcision is lowest.

In 2007, trials for medical male circumcision as an HIV prevention tool in Kenya, Uganda and South Africa returned strong evidence for its success, prompting the World Health Organization and UNAIDS to recommend it as a key component in the fight against HIV. Global health partners moved swiftly to engage traditionally non-circumcising communities with the science, which showed circumcised men were much less likely to sexually contract HIV than non-circumcised men.

Over the years, science has also pointed to male circumcision’s benefits to women, such as an indirect link to reducing HIV incidence. A study conducted in South Africa in 2014 showed that male circumcision roll-out was associated with a reduction of HIV incidence among women who had only circumcised sexual partners. The practice also reduces the likelihood of women getting infected with the Human Papilloma Virus (HPV), which can cause cervical cancer.

Moreover, medical male circumcision goes beyond the cut to encompass a broad package of services such as HIV testing and counseling, correct and consistent use of male and female condoms, treatment of sexually transmitted infections and promotion of safer sex behaviors.

Health authorities in Nyanza, where the HIV epidemic has had a devastating impact on communities, took a bet on the practice. That was 2008. They shifted their culture to accommodate circumcision. Less than a decade later, the progress has been remarkable.

To let the numbers speak, Kenya has circumcised more than a million men – most of them in Nyanza – through voluntary medical male circumcision since 2008. That has taken the overall percentage of circumcised men aged 15‐49 in the country to more than 90 percent.

In Siaya County alone, where Lutgard works, local partners working together with the Kenya’s National AIDS and STI Control Program (NASCOP) have led a campaign that has seen more than 200,000 men adopt medical circumcision since 2008.

As the Global Fund’s principal partner in the fight against HIV in Kenya, NASCOP has led the medical male circumcision revolution by coordinating the implementation of medical circumcision in 10 priority counties, including Siaya. Global health partners in Kenya who are investing to increase the number of men who adopt medical circumcision use NASCOP’s infrastructure, such as technical working groups and taskforces, to coordinate their work at national and county levels.

The thousands of men who are lining up for circumcision are radically changing the picture of HIV prevention in Kenya. At about a 100,000 a year, new HIV infections in the country have remained stubbornly high. Kenya sees medical male circumcision as key to cutting down new infections. And there is evidence that the long-term impact of the program could be enormous.

Studies by researchers from the Imperial College London and Institute for Disease Modeling show that for each medical male circumcision performed today, an estimated 5 to 15 new infections will be averted by 2030. These benefits, which will go to both men and women, will continue to grow. In about 10 years, gains from medical male circumcision will outweigh the investments as future treatment costs will be cut.

Achieving those targets will hinge not only on engaging men but also on enlisting the support of women as mobilizers and support partners.

“I follow them to their places of work, I follow them to their homes,” Lutgard says. “We must do this for the community.”

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HIV and AIDS

Published 08 June 2016

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Beyond the Cut

Beyond the Cut – In Nyanza Province