Arthur Okwemba
10 April 2008
Nairobi — It is now official. A new circumcision policy for men aimed at reducing HIV infection rates has been published by the Government.
The policy, stipulating how all willing Kenyan men, irrespective of their age, will undergo circumcision, sets into motion the use of the surgical procedure as a standard HIV prevention strategy for the country.
Health personnel from Government health facilities at various levels are to undergo in-service training to hone their skills on the new procedure.
A Male Circumcision Task Force that will guide male circumcision in Kenya will be set up soon.
Titled Policy on Male Circumcision in Kenya 2008, the document also wants circumcision to be promoted and delivered to males of all ages in a manner that is culturally sensitive to minimise the stigma that may be associated with an uncircumcised person.
In the past, fears been raised over the possible conflict between this policy and the traditions of some of Kenya's communities, which, as a custom, do not practise circumcision.
While some Kenyan communities invoke religious, cultural or social reasons for circumcision, others like the Teso, Luo, Turkana, and a few groups in the Coast undertake other rites of passage, which do not include circumcision.
Circumcision involves the removal of the foreskin of the male member.
Studies have shown the skin's inner mucosal surface to be the breeding ground for the virus. This is because compared to the external surface, more of its cells are vulnerable to HIV infection.
Circumcisers will, therefore be required to counsel males and use techniques that reduce or eliminate the pain associated with such a surgical procedure so as to encourage more men to opt for circumcision.
Says the policy: "Ensure that male circumcision is performed by well-trained practitioners in antiseptic settings under conditions of informed consent, confidentiality, risk reduction counselling and safety."
Health facilities from the dispensary to the district hospital levels are to be strengthened to ensure that they cope with the expected demand from men seeking to be circumcised.
Those implementing the policy will be required to put in place appropriate laws, regulations and supervisory mechanisms that are going to ensure that circumcision services are accessible and provided safely without any discrimination.
The Government's move to adopt the policy comes at time when results from HIV vaccine trials indicate that circumcised volunteers had a lower risk of HIV infection compared to their uncircumcised counterparts.
Scientists are trying to investigate this development further to see if there is any correlation between the HIV vaccine and circumcision.
Likewise, the policy is also being implemented at time when there are fears that the number of males being circumcised may be reducing.
According to the 2003 Kenya Demographic and Health Survey, close to 72 per cent of men aged between 15 and 19 years were circumcised compared to 84 per cent above this age. However, the survey does not analyse HIV prevalence in regions that predominantly circumcise compared to those which don't.
The new policy has generated excitement and disquiet among members of the public who talked to Nation, with some praising it and others saying it will worsen the vulnerability of women to HIV infection as men are likely to refuse to have protected sex.
Unprotected sex
"Circumcising every male is good because it will reduce chances of HIV infection," says 25-year-old Brian Okila from Westlands in Nairobi.
But Ruth Njeri, an anti HIV/Aids campaigner, fears that the idea behind the new policy may make circumcised men engage in unprotected sex thinking they are safe.
"Men who have been using condoms or those who have been faithful to their spouses will now opt for unprotected sex," Ms Njeri says.
In Kisumu, for instance, there have been reports of circumcised males engaging in unprotected sex and then ending up with HIV infection.
Such tendencies are bothering the Ministry of Health as well.
In the proposed policy, the Government says those promoting circumcision should ensure it does not replace the known effective HIV prevention methods and that it should always be considered as part of a comprehensive prevention package.
The policy further states: "Community and individual education programmes provide sufficient and correct information on the partial protection provided by male circumcision and the continuing need for other HIV and sexually transmitted infection prevention measures."
Fourth component
This means circumcision will be treated as the fourth component of the popularly known ABC - Abstinence, Being faithful to one's partner, and Condoms - methods of prevention. As such, health providers and communicators are now going to adopt the ABCC slogan, with the last C representing Circumcision.
"What we are trying to pass across is that a circumcised man who either uses a condom or is faithful to his partner has a reduced risk of HIV infection," says Prof Alloys Orago, the director of the National Aids Control Council.
The other issue the Government has to grapple with is the cost of circumcision. While it acknowledges that the intervention is expensive, it does not specify where resources for implementing it are to come from.
It just calls on the Ministry of Health to "strengthen health systems to ensure that male circumcision programmes do not interrupt or divert resources from other primary healthcare services".
To achieve this, the Ministry is required to integrate the management of reproductive, sexual health and HIV prevention programmes to provide male circumcision services.
Strengthening the services through monitoring and evaluation to guarantee quality control and planning purposes are other issues that are to be addressed before the programme gets fully underway.
The proposed Male Circumcision Task Force is expected to help the Government confront these challenges.
Some of its functions include:
The decision to adopt circumcision as one of the HIV prevention strategies is informed by research findings of three main studies done in South Africa, Uganda and Kenya, which showed that circumcision can reduce the risk of HIV infection by up to 60 per cent.
World Health Organisation and UNAIDS have already issued a strong recommendation calling for increased male circumcision rates in countries where HIV infections are high.
Kim Dickson, the coordinator of the joint WHO/UNAIDS team that came up with the recommendations, is quoted in the March 2007 edition of New Scientist magazine as saying: "We reviewed all the evidence, and it is compelling."
In the South African study, circumcision was found to reduce HIV infection rates by more than 60 per cent in a group of 3,000 HIV-negative men
Of the 1,546 circumcised men, 20 became infected with HIV, while 49 of the 1,582 uncircumcised men were infected.
Funded by the French Agence Nationale de Recherches sur le Sida (ANRS), the study sent a strong message in 2005 on the effectiveness of circumcision in HIV prevention.
Buoyed by results
Buoyed by these results, South African scientists supported large-scale male circumcision as a possible strategy for preventing two million HIV infections and 300,000 deaths in their country during the next 10 years.
In December 2006, the Data Safety Monitoring Board that was overseeing the Kenyan and Ugandan male circumcision trials announced that the operation was a safe and effective way to reduce HIV infections among men.
The two-year trials in Kisumu and Rakai, Uganda, involved adult HIV-negative heterosexual male volunteers who were randomly divided into two groups - one group was circumcised and the other wasn't.
In the Kisumu trial, circumcision reduced the chances of getting infected with HIV by 53 per cent. Similar results were registered in the Rakai trial in Uganda.
When these trial results came out, National Institute of Allergy and Infectious Diseases (NIAID) director, Anthony S Fauci, whose organisation supported and conducted the studies, said: "We now have confirmation showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse."
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Circumcision can only possibly help men who have unsafe sex with HIV+ partners, so why this bizarre obsession with genital surgery when we know that ABC works better than circumcision ever could? (ABC=Abstinence, Being Faithful, Condoms). The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than in intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, and Tanzania. Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives.
Latest news is that HIV+ men are more likely to transmit the virus to women if they are circumcised.
Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.
It sounds like those in HIV/AIDs are so frustrated by their failure to deliver message and create prevention programs that work that they are resorting to the mutilation men as a form HIV prevention.
Once men are mutilated and told that they are now better protected from HIV who will be able to convince them that they must still use a condom to be fully protected - or is circumcision being presented as a substitute to circumcision?
Someone please explain this circumcision movement to me in a way that makes sense.
Big policy flaw. There is no medical reason for removing healthy living tissue from a human body whether it is the vulva, clitoris, foreskin, etc. One man who agreed to circumcision in adulthood once said of his new sexual experience, " it's like having sex with your elbow". If there is any policy expert who can "think", in Kenya, please tell people in a clear intelligible way that this practice( may not) but if it does take off, it's countereffects will be more far reaching)and will wipe out all gains achieved in the last few years.
This is a clear case of a disfunctional government, run by folks who are ill-informed to say the least, and would welcome any idea desperately because after all it's from a Robert Bailey and Stephen Moses. The male penis becomes blunt and as insensitive as a finger months after circumision. Imagine if the hood of the clitoris was removed and it's left to rub against the hard linen for life! Africa will for eternity remain a testing ground for both the "germ and the cure" and is destined for a steep abyss. This is a sad day for people who love life, have brains and can think! Will Africans ever chart their own paths out of their problems? Will we ever understand the big picture. DRs Moses and Bailey are going to return with a foresking "regrowth" idea in the future, and we will be on the world spotlight with a new alarming story about 5K rapes a day!Is it in our genes not to think!!!!!!
Alem, USA