Rush for male circumcision in rural areas

Young men sit outside the mobile clinic in Kayunga District moments before they were circumcised. ALL PHOTOS BY EVELYN LIRRI

Medical male circumcision is now widely seen as a key HIV prevention tool after scientific evidence showed it could reduce the risk of infection by up to 60 percent. Many countries including Uganda are embracing it and as a result, a mobile clinic is giving men in rural areas a chance to be cut at no cost, writes Saturday Monitor’s Evelyn Lirri.

Godfrey Aganza had never considered getting circumcised. The misconceptions that came with a circumcised non-Muslim man, including being considered a covert or the alleged future risk of impotence largely discouraged him from the cut. But that has changed now.

On June 7, this year, the 18-year-old senior three student of Kayunga Secondary School, joined the long queue of other men at a mobile circumcision clinic currently stationed at Bbaale Health Centre IV in Kayunga District, 74 kilometres northeast of Kampala.
Together with his peers, they arrived at the mobile clinic as early as 8am in the morning to halfheartedly give it a try.

It was only after the operation that Mr Aganza felt satisfied with the decision that he had made.
“I am happy I have done it now. It wasn’t painful and I feel okay,” he said moments after coming out of the “operating room”- a large, well equipped truck with the essential tools needed to carry out an operation.
“I have also been told of the health benefits of being circumcised and of course a circumcised man has a lower chance of contracting HIV/Aids,”he added.

Mr Anganza is not alone. I met Aaron Lubega, a 30-year-old police officer five days after he had been circumcised. When he first arrived at the mobile clinic, he did not know what to expect. Like all the other men who come to the mobile clinic, he was taken through a session of counseling so that he could fully understand the health benefits of circumcision.

Mr Lubega had heard about the free circumcision services from fellow residents in Kayunga town, many of who have already gone through the surgical procedure. “At the trading centre, the men talked about the mobile clinic and the benefits of being circumcised that’s why I came here to first hear from the health workers and then get circumcised myself,”he said.

Simple task
Mr Lubega, a single father of one, said the process was so simple and painless that shortly after being circumcised, he managed to ride a motorcycle on a 10km-long journey. In this remote region, residents have embraced circumcision almost 100 per cent.

The free medical male circumcision programme which has been rolled out in the districts of Kayunga and Mukono is being implemented by the Makerere University Walter Reed Project (MUWRP) in partnership with local governments. It’s funded through the US President’s Emergency Plan for Aids Relief.

Mark Breda, a programme manager at MUWRP, said since the initiative was rolled out in February, close to 7,000 men have been circumcised in the various sub counties in Kayunga and Mukono districts
“We shall continue with the mobile clinic. The demand is nowhere close to being met,” said Mr Breda.
The target, he says, is to have to have up to 4.5 million men circumcised over the next five years across the various sites.

Mr Peter Masaba is the surgeon who has been carrying out the operation.He is also the deputy prevention coordinator at MUWRP. According to him, the demand for circumcision has been very high, with an average of 25 to 35 men circumcised every day. “The minimum age is usually 15 and we target those who are most at risk and sexually active,” Mr Masaba said.

He explains that the surgical procedure takes between 15 and 25 minutes to be carried out. He said circumcised men are also required to abstain from sex for at least 42 days to allow the wound to heal without developing infections. Those who have been circumcised are also usually asked to return to the clinic for review to ensure they are safe from any complications. But not every man who comes to the clinic gets circumcised. “Some people come with other medical conditions which makes it hard for us to operate them immediately. We usually identify such cases and set a different date for them to be circumcised,”said Mr Masaba.

On the other hand, despite the pre-circumcision counseling, not all men who come for the services fully understand why they should go through the procedure. Mr Masaba said their clients are taken through the basics of circumcision before testing their understanding.

Those who fail to answer simple questions are told to return home, read and understand the issue and then set another date for the operation. They are usually taken though the same process to make sure they understand fully why they should be circumcised. “But this is usually a small fraction of men. Most of them understand why they have come to be circumcised and are usually eager to have the cut,” Mr Masaba further noted.

The circumcision programme also provides free HIV counselling and testing and other services for sexually transmitted diseases. “This is where we are targeting men now because men rarely visit health facilitates. We give them information about STDs, family planning and other general health information,”said Mr Masaba.

So what is getting men rushing for circumcision? Health experts say rapid roll-out of medical circumcision is crucial to reducing the rate of spread of HIV/Aids in countries with generalised epidemics and low rates of medical circumcision.

The government officially started the free circumcision programme in September 2010 after promising results of randomised trials—in 2005 and 2007 — conducted in Uganda, Kenya and South Africa showed that medical male circumcision reduced the risk of contracting the HIV virus by up to 60 per cent.

This followed the launch of an HIV/Aids policy that officially added circumcision to the traditional ABC-abstinence, faithfulness and use of condom approach. The safe circumcision policy aims at providing circumcision to 40 per cent of Ugandan men aged 14-49 over a five year period. Currently only 25 per cent of Ugandan men between the ages of 15 and 55 years are circumcised, according to the demographic and health survey.

This initiative by MUWRP is one of the ways through which this target is being realised.
The survey shows that in eastern Uganda where culturally men under go circumcision, 54.7 per cent had gone through the procedure compared to less than 10 per cent in northern Uganda. Male circumcision, according to the survey was highest among Muslims at 97 per cent and lowest among Catholics at 10 per cent.

Health experts also say men who have been circumcised have a low risk of contracting urinary tract infections and penile cancer. But officials warn that such health benefits should not excite men into leading sexually reckless lives after circumcision, stressing that it only provides partial protection. “We always tell our clients about the need to continuously practice safe sex including the use of condoms,” said Mr Masaba.

Mr Aganza is mindful of this warning. “I am fully aware about this. Being circumcised doesn’t mean I’m going to be careless with my life. I will, follow what the health workers have told me,” he said.
Aganza also want to spread the circumcision message among his fellow students.

Pros and cons of circumcision

Immediate complications: Just like any other surgery, circumcision carries a risk of bleeding, infection, swelling or problems with anaesthesia. There is risk of cutting too much flesh on the penis or cutting the urethra, plus other surgical mishaps. However, the risk reduces with the experience of the surgeon and the facility used.

Long-term complications:
Issues can arise from the wound healing process and may include meatal stenosis whereby the opening of the urethra is narrowed; scar tissue could strangulate the glans penis causing urine retention, slowing of venous flow as well as painful erections.

Benefits
* HIV: Extensive research has shown medical benefits of male circumcision in protecting against HIV spread. Research done in Uganda supported other researches in the world and at present, WHO and UNAIDS recommend mass male circumcision that the ministry of Health is already implementing.
It has been shown to provide up to 60 per cent protection but should be combined with other methods for comprehensive protection.

* Cervical cancer: Circumcision has also been shown to reduce risk of cancer of the cervix in spouses of circumcised men. It’s believed that the smegma, a whitish discharge that forms under the foreskin, and the Human Papilloma Virus (HPV) combine to cause this cancer.

* Penile cancer: Cancer of the penis rates are lower among circumcised men because of reduced HPV infection.
Hygiene and local infections: Infections of the glans penis as well as ease of hygiene are reduced after circumcision.
Other issues like failure to retract the foreskin especially in children become history.

* Sexual benefits: Reports show reduced sensitivity of glans penis after circumcision helps men hold their erection longer and in due course satisfy their women sexually. The hygiene also helps couples experiment with several sexual options.