Monday, August 6, 2007

At the Cutting edge - male circumcision and HIV

Treading softly where circumcision is not customary

Until recently, the Luvale people in Zambia's North-Western Province were widely denigrated by others for a practice many believed was barbaric: cutting off the foreskin of boys aged as young as 10 as part of their traditional initiation into manhood.

Today, the Luvale have been vindicated. Based on the results of three clinical trials showing that circumcised men are about 60 percent less prone to HIV infection than uncircumcised men, Zambia's Ministry of Health is launching a policy to promote male circumcision as a method of preventing the disease.

While they may not have been aware of the medical benefits of male circumcision, 50-year-old Emmanuel Kaleji said the Luvale had always believed that cutting off the foreskin improved cleanliness.

"We have known this all along, but I am happy that today government is beginning to appreciate it. When I was in boarding school, my mates used to laugh at me whenever we went to bath; they called me an amputee."

Kaleji said he was looking forward to inducting the younger two of his four sons into manhood in the "Mukanda" ritual, but he was afraid that the government could strip the procedure of its cultural significance in the name of science.

The chairman of the Luvale's cultural association, Marx Mbunji, shared his concern. "This policy should recognise and safeguard our culture. In areas where this is already practiced, our values dictate that a female doctor or a non-circumcised man should not practice male circumcision."

Circumcision is just one part of the traditional male initiation that lasts for two months and includes instruction in hygiene, family values, good parenting and interactions with women. Mbunji said the cultural aspect of Mukanda explained the perpetuation of the practice and its appeal even to non-Luvales, a number of whom have undergone the process.

Graduates of the ritual extol its virtues, saying that life-long relationships, which could not be formed in the impersonal atmosphere of clinical health facilities, were built between initiates and their instructors.

However, there are fears that conditions at the isolated bush camps where the ritual takes place may be unhygienic. Some Luvales are now taking their children to hospital to have the surgical procedure done by a medical practitioner before sending them to the camps.

Mbunji said these fears were unfounded. "Even previously, the complications were rare, but before HIV, the dangers were less. Now we are using one knife per child."

A key element in the government's policy of promoting male circumcision will be integrating an HIV counselling component and other essential information, such as the need to continue using condoms after being circumcised, and to abstain from sex while the wound heals.

Explicit instruction in how to prevent HIV does not form part of the two-month traditional initiation, although initiates are instilled with a sense of personal discipline and family values. "HIV is not our core business," Mbunji said.

Dr James Simpungwe, director of clinical services in the Ministry of Health, said it would be impossible for health facilities to meet some of the Luvale community's stipulations.

"For instance, the health establishment relies heavily on female nurses; also, not all male doctors who will be available to do the procedure will be circumcised. That said, we are ready to tap into the massive experience the Luvales have at their disposal," he said.

The Ministry of Health had been holding consultative meetings with the traditional leaders of circumcising and non-circumcising communities, as well as with religious and civil society leaders.

Chief Hamusonde, of the Ila ethnic group, in the Bweengwa Constituency in southern Zambia, warned that promoting a practice that was alien to his people would require treading carefully. "I will have to put it before the traditional council, so that circumcision can be considered as an HIV prevention strategy," he said.

Change would not come easily, and would require dispelling myths and stigmas about male circumcision, such as the belief held by Ila women that sex with circumcised men was painful.

"The Ministry of Health and the National AIDS Council will need to support us by giving us information, so that when we speak we know what we are talking about," Hamusonde said. Other traditional leaders have also expressed their willingness to break with tradition in the interests of public health.

In the House of Chiefs, in the capital, Lusaka, Chief Kashiba of the Chishinga people in Mwense, in the Luapula District of northern Zambia, recently called on his fellow traditional rulers to undergo the procedure.

"No-one need know," he said. "The operation may be painful, but it is very simple. By the time you return to your chiefdoms, you would have healed."