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Uganda steps up efforts to boost male circumcision

2010; Elsevier BV; Volume: 376; Issue: 9743 Linguagem: Inglês

10.1016/s0140-6736(10)61362-1

1474-547X

Wairagala Wakabi,

Urologic and reproductive health conditions

Ugandan authorities have launched an ambitious new campaign to increase the proportion of adult men circumcised to at least 40% within 5 years. Wairagala Wakabi reports from Kampala.Uganda has started scaling up a nationwide Safe Male Circumcision (SMC) campaign that is being implemented alongside the Abstinence, Be faithful and use a Condom (or ABC) strategy in the fight against HIV/AIDS. Health Ministry officials hope that raising the number of men who undergo the procedure will help the country to bring the HIV prevalence down from the current 6·4% to less than 5% in the short term.Although the numbers of men going for circumcision have been increasing since 2007, when WHO and Ugandan authorities added medical male circumcision to HIV prevention methods, health authorities say uptake has still been too slow. Funding has been inadequate, and most donors have focused on the ABC message. Additionally, concerns about the safety of the surgical procedure, as well as various misconceptions about its effects, have prompted many men to avoid circumcision.But all this is changing, according to Alex Opio, assistant commissioner at the Ugandan Health Ministry. Key to the turnaround has been more donors beginning to support the rollout of the campaign across the east African country, and increased efforts to educate the public about the safety and health benefits of the procedure.“We are replacing ‘male circumcision’ with ‘safe circumcision’. Safe because we do not want to restrict it to medical personnel only”, Opio said in an interview with The Lancet. Because of the thin spread of medical personnel in Uganda, making circumcision their exclusive preserve would render it inaccessible to much of the population. Hence, the government, with support from various donors and non-government entities, is working to “ensure that it is safe, as opposed to having it done only by medical people”.Traditional circumcisers are being trained to do the procedure, and to use sterilised instruments. They are also being educated that unsafe circumcisions could actually lead to a rise in infections, according to Opio. Only 25% of the adult male population in Uganda is circumcised, but the new campaign seeks to raise the figure to at least 40% of the overall male population within 5 years. The campaign targets infants, teenagers, and adults.Currently, a number of donors including WHO, UNAIDS, PEPFAR (US President's Emergency Plan for AIDS Relief), and Centers for Disease Control, are assisting with the training of surgeons, nurses, and other health personnel, helping to equip health facilities, and publicising the campaign.A study done 2 years before the SMC campaign was rolled out indicated that many Ugandan men and women supported circumcision as a way of lowering the risk of contracting HIV. But respondents recommended that services should be easily accessible and affordable—if possible free of charge. The procedure costs about US$26 in public health facilities, and double this amount in private ones—but the former are moving towards offering the service free of charge.Jesse Kagimba, Ugandan President Yoweri Museveni's adviser on HIV/AIDS, says before rolling out the campaign, a lot of education campaigns had been done. Some of them targeted women. The study that paved the way for introducing an SMC policy and rollout says “women are consulted by their partners when they are going to do SMC and are generally more supportive of it for their male children, but are likely to support it after being provided with information about reduced transmission of HIV among circumcised men and inclined to pay more for SMC than men would pay”.Vincent Kawooya, an official of the safe male circumcision programme at the Makerere University School of Public Health in Kampala, says members of the public still harbour several misconceptions about circumcision. On the toll-free line set up by the initiative they receive such questions as whether it is proper for someone who is not a Muslim to undergo circumcision, and whether it is true that one would never enjoy sex again if they went for the procedure.Several men are concerned that they might not be able to perform sexually if they undergo circumcision, whereas others think they would have to go for several months without being able to have sex if they got circumcised. Since August, 2009, the Makerere programme has led a campaign about safe male circumcision for HIV prevention in Uganda, and according to officials, there is much interest in learning about the safety and health benefits of the procedure, although misconceptions remain widespread. “Some men are reluctant to get circumcised because they think they will lose their sexual power”, said Jude Ntalo, a doctor at a small clinic in Wandegeya, a suburb of the capital Kampala.Health workers are reporting that an increasing number of women now want their men to be circumcised because they have heard of the protection it offers against infection by HIV. But they say many women also fear that if their men get circumcised, they could go out and have unprotected sex with other sexual partners in the false belief that they are now immune to HIV. That is a fear which medical authorities share.Those driving the national SMC scale-up campaign are keen to emphasise that circumcision is not a stand-alone intervention but part and parcel of a comprehensive HIV prevention strategy. “This is what we are emphasising because people may think that they are protected, yet SMC is not 100% protective. It should be part of the ABC approach and not an alternative to it”, says Opio.Kawooya put it simply: “it is like wearing a helmet while riding a motorcycle. You can die if you get involved in a serious accident yet the helmet provides some reasonable protection and can't be despised”, he says.Health workers are also making it clear that men who have undergone circumcision should let the wound heal before they resume sexual activity. Research done in Rakai in southern Uganda—one of the areas with the highest HIV infection rates—showed that several men who underwent the procedure were having sex before their wounds healed. The result was a spike in HIV infection rates. Now, men are being advised to wait for at least 3 weeks before they get back to sex.Uganda reversed HIV prevalence from a national average of 17% in the early 1990s to the current level of about 6·4%, but health authorities are concerned that the rate—which had fallen to 6% around 2004—is no longer declining. Women, urban dwellers, and residents of post-conflict northern Uganda are disproportionately affected, according to the country's Aids Control Commission. Sexual transmission continues to contribute 76% of new infections, while mother-to-child transmission is responsible for 22%.Following clinical trials in Kenya, South Africa, and Uganda, which showed that circumcision could reduce the risk of HIV infection in men by up to 60%, in March, 2007, WHO and UNAIDS recommended adult male circumcision as an HIV prevention intervention.It is not only in Uganda where SMC has caught on lately. At the International AIDS Conference in Vienna, Austria, last month, plans were announced for a campaign covering 13 countries in east and southern Africa which aims to circumcise 38 million men by 2015.According to the non-government organisation Population Services International (PSI), who are among the campaign's promoters, scaling up male circumcision to reach 80% of adult and newborn males in eastern and southern Africa by 2015 could avert more than 4 million new HIV infections between 2009 and 2025, and yield a total net saving of US$20·2 billion during the same period.“With global resources spread thin, we must focus on expanding proven and cost-effective methods like male circumcision to prevent HIV transmission”, Krishna Jafa, an HIV expert at PSI, said in a July 20 press statement.Kenya has already done 120 000 circumcisions, while South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe have also seen dramatic increases in the number of men requesting the procedure. But Jafa points out that despite understanding the need for scale-up, barriers still remain in many of the countries hardest hit by HIV. “Shortages of trained health-care providers and inefficiencies in traditional delivery methods have prevented many countries from reaching their target goals for numbers of men circumcised”, he said.In many of the sub-Saharan African countries, there are concerns that a large number of unsafe circumcisions continue to be done, most of them by untrained individuals. This is believed to be particularly the case in communities where circumcision has traditionally been done by traditional surgeons.In South Africa, where male circumcision is a rite of passage that some boys must go through before they are declared men in some communities, health authorities last June said more than 30 boys had died, and several others had contracted serious injuries or life-threatening infections from botched procedures by traditional circumcisers. Experts say such reports of deaths resulting from circumcision could undermine ongoing efforts to increase take-up of the procedure. Ugandan authorities have launched an ambitious new campaign to increase the proportion of adult men circumcised to at least 40% within 5 years. Wairagala Wakabi reports from Kampala. Uganda has started scaling up a nationwide Safe Male Circumcision (SMC) campaign that is being implemented alongside the Abstinence, Be faithful and use a Condom (or ABC) strategy in the fight against HIV/AIDS. Health Ministry officials hope that raising the number of men who undergo the procedure will help the country to bring the HIV prevalence down from the current 6·4% to less than 5% in the short term. Although the numbers of men going for circumcision have been increasing since 2007, when WHO and Ugandan authorities added medical male circumcision to HIV prevention methods, health authorities say uptake has still been too slow. Funding has been inadequate, and most donors have focused on the ABC message. Additionally, concerns about the safety of the surgical procedure, as well as various misconceptions about its effects, have prompted many men to avoid circumcision. But all this is changing, according to Alex Opio, assistant commissioner at the Ugandan Health Ministry. Key to the turnaround has been more donors beginning to support the rollout of the campaign across the east African country, and increased efforts to educate the public about the safety and health benefits of the procedure. “We are replacing ‘male circumcision’ with ‘safe circumcision’. Safe because we do not want to restrict it to medical personnel only”, Opio said in an interview with The Lancet. Because of the thin spread of medical personnel in Uganda, making circumcision their exclusive preserve would render it inaccessible to much of the population. Hence, the government, with support from various donors and non-government entities, is working to “ensure that it is safe, as opposed to having it done only by medical people”. Traditional circumcisers are being trained to do the procedure, and to use sterilised instruments. They are also being educated that unsafe circumcisions could actually lead to a rise in infections, according to Opio. Only 25% of the adult male population in Uganda is circumcised, but the new campaign seeks to raise the figure to at least 40% of the overall male population within 5 years. The campaign targets infants, teenagers, and adults. Currently, a number of donors including WHO, UNAIDS, PEPFAR (US President's Emergency Plan for AIDS Relief), and Centers for Disease Control, are assisting with the training of surgeons, nurses, and other health personnel, helping to equip health facilities, and publicising the campaign. A study done 2 years before the SMC campaign was rolled out indicated that many Ugandan men and women supported circumcision as a way of lowering the risk of contracting HIV. But respondents recommended that services should be easily accessible and affordable—if possible free of charge. The procedure costs about US$26 in public health facilities, and double this amount in private ones—but the former are moving towards offering the service free of charge. Jesse Kagimba, Ugandan President Yoweri Museveni's adviser on HIV/AIDS, says before rolling out the campaign, a lot of education campaigns had been done. Some of them targeted women. The study that paved the way for introducing an SMC policy and rollout says “women are consulted by their partners when they are going to do SMC and are generally more supportive of it for their male children, but are likely to support it after being provided with information about reduced transmission of HIV among circumcised men and inclined to pay more for SMC than men would pay”. Vincent Kawooya, an official of the safe male circumcision programme at the Makerere University School of Public Health in Kampala, says members of the public still harbour several misconceptions about circumcision. On the toll-free line set up by the initiative they receive such questions as whether it is proper for someone who is not a Muslim to undergo circumcision, and whether it is true that one would never enjoy sex again if they went for the procedure. Several men are concerned that they might not be able to perform sexually if they undergo circumcision, whereas others think they would have to go for several months without being able to have sex if they got circumcised. Since August, 2009, the Makerere programme has led a campaign about safe male circumcision for HIV prevention in Uganda, and according to officials, there is much interest in learning about the safety and health benefits of the procedure, although misconceptions remain widespread. “Some men are reluctant to get circumcised because they think they will lose their sexual power”, said Jude Ntalo, a doctor at a small clinic in Wandegeya, a suburb of the capital Kampala. Health workers are reporting that an increasing number of women now want their men to be circumcised because they have heard of the protection it offers against infection by HIV. But they say many women also fear that if their men get circumcised, they could go out and have unprotected sex with other sexual partners in the false belief that they are now immune to HIV. That is a fear which medical authorities share. Those driving the national SMC scale-up campaign are keen to emphasise that circumcision is not a stand-alone intervention but part and parcel of a comprehensive HIV prevention strategy. “This is what we are emphasising because people may think that they are protected, yet SMC is not 100% protective. It should be part of the ABC approach and not an alternative to it”, says Opio. Kawooya put it simply: “it is like wearing a helmet while riding a motorcycle. You can die if you get involved in a serious accident yet the helmet provides some reasonable protection and can't be despised”, he says. Health workers are also making it clear that men who have undergone circumcision should let the wound heal before they resume sexual activity. Research done in Rakai in southern Uganda—one of the areas with the highest HIV infection rates—showed that several men who underwent the procedure were having sex before their wounds healed. The result was a spike in HIV infection rates. Now, men are being advised to wait for at least 3 weeks before they get back to sex. Uganda reversed HIV prevalence from a national average of 17% in the early 1990s to the current level of about 6·4%, but health authorities are concerned that the rate—which had fallen to 6% around 2004—is no longer declining. Women, urban dwellers, and residents of post-conflict northern Uganda are disproportionately affected, according to the country's Aids Control Commission. Sexual transmission continues to contribute 76% of new infections, while mother-to-child transmission is responsible for 22%. Following clinical trials in Kenya, South Africa, and Uganda, which showed that circumcision could reduce the risk of HIV infection in men by up to 60%, in March, 2007, WHO and UNAIDS recommended adult male circumcision as an HIV prevention intervention. It is not only in Uganda where SMC has caught on lately. At the International AIDS Conference in Vienna, Austria, last month, plans were announced for a campaign covering 13 countries in east and southern Africa which aims to circumcise 38 million men by 2015. According to the non-government organisation Population Services International (PSI), who are among the campaign's promoters, scaling up male circumcision to reach 80% of adult and newborn males in eastern and southern Africa by 2015 could avert more than 4 million new HIV infections between 2009 and 2025, and yield a total net saving of US$20·2 billion during the same period. “With global resources spread thin, we must focus on expanding proven and cost-effective methods like male circumcision to prevent HIV transmission”, Krishna Jafa, an HIV expert at PSI, said in a July 20 press statement. Kenya has already done 120 000 circumcisions, while South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe have also seen dramatic increases in the number of men requesting the procedure. But Jafa points out that despite understanding the need for scale-up, barriers still remain in many of the countries hardest hit by HIV. “Shortages of trained health-care providers and inefficiencies in traditional delivery methods have prevented many countries from reaching their target goals for numbers of men circumcised”, he said. In many of the sub-Saharan African countries, there are concerns that a large number of unsafe circumcisions continue to be done, most of them by untrained individuals. This is believed to be particularly the case in communities where circumcision has traditionally been done by traditional surgeons. In South Africa, where male circumcision is a rite of passage that some boys must go through before they are declared men in some communities, health authorities last June said more than 30 boys had died, and several others had contracted serious injuries or life-threatening infections from botched procedures by traditional circumcisers. Experts say such reports of deaths resulting from circumcision could undermine ongoing efforts to increase take-up of the procedure.