For nearly two years after the World Health Organization recommended widespread male circumcision services in countries with high HIV prevalence rates and low circumcision among men, countries had barely begun the service.
Then Kenya, in the western province of Nyanza, began a comprehensive plan to circumcise men in November 2008. In the first six months of the program, 20,000 men were circumcised – by far the most impressive result so far from WHO’s guidance in 2006.
At a panel discussion today at the HIV/AIDS Implementers’ Meeting, experts talked about lessons learned from the Nyanza experience and other early sites.
Dr. Kim Eva Dixon, a medical officer at the World Health Organization, gave a global overall of the progress – or lack of it. So far, officials have reports only from four countries on numbers of circumcisions in 13 eastern and southern African nations that were advised to begin widescale male circumcision programs.
Those results: Kenya, 20,000 circumcisions; Orange Farm in South Africa, 8300 circumcisions; UTH Zambia, 2,500 circumcisions; and Zimbabwe, 140 circumcisions.
While Dixon said that all 13 countries have demonstrated a political commitment to rapidly expanding circumcision services, she also noted a long list of challenges: lack of human resources; country plans have taken a lot of time; and elections in several countries delayed the process by months.
In addition, she said, “almost all the countries have a problem with traditional providers – they don’t know what to do with them.’’ She said WHO will be working on writing guidance for countries on approaching traditional healers.
Most countries, she said, now have “catch-up strategies’’ to reach adult men, and three countries – Botswana, Swaziland, and Namibia – also are looking to establish policies for circumcision of infants.
In Nyanza province, Emma Llewellyn, project coordinator for the Nyanza Reproductive Health Society, outlined how the Ministry-backed project circumcised 20,000 men in six months. Perhaps the most important step initially was securing political commitment, she said, because very few men in the tribal group targeted in Nyanza – the Luo – are circumcised.
Prime Minister Raila Odinga, a Luo, supported the project and he met with the Luo Council of Elders, which then backed the plan. Young people, Llewellyn said, also pushed for the intervention.
“They said this didn’t have anything to do with culture, but they wanted it for the health benefit. Youth have been very positive. They say, `This is a matter of life and death for us, this is what we want to do.’ ‘’
Still, the rollout wasn’t easy.
The Nyanza Reproductive Health Society surveyed 162 health facilities to determine which ones were ready to provide integrated male circumcision services. The finding: none. The NGO built its strategy on training a group of trainers, who then spread out and trained others. In all, it used 21 training groups to prepare those in health facilities for the service. It also provided equipment and supplies.
Some surprises were positive.
The group feared that boys and men would not accept female health workers in the surgical procedure. That turned out to be a non-issue – men accepted the female workers.
And sometimes the men didn’t come alone, Llewellyn said. They arrived with their wives or girlfriends.
“We didn’t think we’d have that happening,’’ she said. “But their female partners went right into the surgery room and watched them being circumcised.’’