Editor's note: Africa has the world's largest number of HIV infections and AIDS cases. Across the continent the disease is being battled with public education and antiretroviral drugs. A new additional strategy is male circumcision. Several tests show that circumcised men have substantially reduced risks of contracting HIV. In response, several campaigns have been launched to circumcise men.
GlobalPost has investigated this public health effort in eastern and southern Africa. The series starts in Kenya in the fishing villages by Lake Victoria and includes a video of a circumcision. Also, a Kenyan doctor describes his work running a circumcision clinic, health writer Mercedes Sayagues gives her controversial opinion on the issue and a South African doctor describes the circumcision campaign in several southern African countries.
NAIROBI, Kenya — Kenya is at the forefront of countries using male circumcision as a way to fight the spread of HIV/AIDS. Last November the government launched a male circumcision campaign in Nyanza province, in western Kenya on the shores of Lake Victoria.
The target is men from the Luo tribe which, unlike many other Kenyan tribes, traditionally does not circumcise and among whom HIV rates are double the national average as a result.
Since the launch of the campaign 40,000 men have been circumcised and in October the government launched a renewed drive aiming to circumcise 30,000 men in just seven weeks.
Wickliffe Omondi, a 34-year old doctor who lives in Mamboleo, close to Kisumu in Nyanza province, is one of those leading this new fight against HIV/AIDS. During a visit to Nairobi he told GlobalPost about his work:
"I get up at six in the morning. By then the sun is not even up. I normally take a heavy meal in the morning of ugali [maize porridge] and meat and vegetables. It's important because I work the whole day and at times even forgo my lunch.
"I leave my home by 7 a.m. I used to drive myself to work but six months ago I had a road accident so my vehicle just stays in the compound where I live. Since then I have been taking a matatu [minibus taxi] to Kisumu.
"It takes just 15 minutes because Kisumu is not like Nairobi with a lot of traffic jams and heavy traffic.
"When I arrive at the UNIM Clinic at the Lumumba Health Centre — the same place where they did the study that showed how circumcision can help prevent the spread of HIV — I check the patient files to see who will be coming today, but if there is nothing in the tray I walk straight to the office to check my emails. Then I prepare for work: I go through all the theaters [operating rooms] making sure all the supplies are there and in good condition.
"At times the patients come as early as 7 a.m. The clinic operates from eight in the morning but if they come early, we start early.
"When the client arrives he is registered and given a consent form before he sees the counselor. If there are more than five clients they have group counseling. They are taken through the risks and the benefits of circumcision, and how the procedure is done, and how to take care of the wound at home.
"For example, how to keep the wound clean, to remove the dressing on day three, avoid alcohol for some time and also to abstain from sex for six weeks.
"Most of our clients are coming for male circumcision for the purpose of preventing HIV infection so we also sell the idea of testing for HIV. If the client accepts, he is tested — just a quick prick — it takes around 15 minutes and he gets his result.
"The clients are as young as eight years I have had one or two as old as 85, but the majority are teenagers up to around 45.
"We screen the clients to ensure they are fit and healthy and ready for an operation, then he comes into theater [operating room] where I explain what will happen and he climbs onto the surgical couch.
"When they are here in the theater I'd say around 90 percent are anxious. They have never had any experience with such things so most are scared. We reassure them as best we can. I tell them the injection will remove the pain, but even so they are scared, for the site of the injection is in the penis.
"It is a minor surgical procedure that takes between 15 and 30 minutes. First we clean the surgical area with an antiseptic then inject a local anesthesia into the base of the penis.
"It takes up to five minutes for the anesthetic to take effect and then we test for any pain sensation by pinching the tip of the penis with tweezers. If there is pain we give it more time; if there is no pain we mark the incision sites, estimate how much skin to remove then we cut it off.
"Afterwards we arrest the bleeding with sutures and apply a dressing. That is it. Then we admit the client for 30 minutes for observations and after that they can go on their way, returning for review after seven days. Then, if the review is fine, I don't have to see them again.
"In a few cases clients asked for their foreskin to go home with, because it is part of them, but it is human tissue so we cannot allow it. After cutting it we show them the foreskin and explain we are going to burn it in the incinerator.
"I work until around 4 p.m. by which time I might have circumcised 22 clients and seen another 20 for review from the week before plus some others who are having problems before day seven or after day seven. It's quite busy and tiring because it involves standing for long, that is why I have to take a heavy breakfast.
"Now I'm just circumcising all the time, and I am the head of circumcision training at the clinic. In fact I train the trainers so I can't know how many have learned to circumcise because of me. There are so many.
"After 5:30 p.m. I leave for home though we give the clients a hotline number which I have with me — even now — so in case of any problem they call. If it is severe I tend to the client, if he needs reassurance I talk to him.
"Finally I take a matatu back home. When I get home I enjoy being with my family — my wife, my six-year old daughter and four-year old son — I like to watch movies or television programs or I go out with my friends for a beer and a chat.
"I think it was not so difficult to persuade Luo men to abandon the tradition of not circumcising because, as much as it involved cultural issues, we still used to have many clients who sneaked in secretly, who would come for circumcision then go back and keep quiet. But they were coming.
"Now that it has become public, men are coming openly. Some politicians from Nyanza even came in and due to their influence they persuaded most of the community and they are coming in large numbers.
"I was circumcised when I was in college. I made the decision myself for hygienic reasons. It was done by a fellow classmate; in fact we were doing it for each other. It was in 1996 and then it was quite unusual for me to be circumcised as a Luo man.
"I am Luo but I was not born in Nyanza so as a young boy I saw my neighbors and friends going for circumcision so even then I wanted it. But even as an adult I could not tell my parents. In fact I never told them even until they passed away.
"My son is not circumcised — he is scared — but I will allow him to make his own decision when he is older. Being circumcised or not circumcised does not make you Luo or not Luo."
"There are still some misapprehensions, though not much. Some clients think that after circumcision they have a natural condom so we have to tell them it is around 60 percent effective and they must continue to use the condom even after circumcision. Also, some men find that six weeks is a long time to abstain.
"When I go back to Kisumu I'm really going to be very busy because the government has said it wants to circumcise 30,000. I will be going around and checking on how the doctors and nurses are working and also assisting in the operations. I think we can reach the target. It just depends on the logistics because in some places the terrain is a bit tough and clients have to travel far, but we can beat that target."