Monday, December 22, 2008

Uganda: Circumcision for All in 200

Uganda: Circumcision for All in 2009

Hilary Bainemigisha
19 December 2008

Kampala — All boys and men in Uganda will be mobilised for free circumcision beginning next year, the assistant commissioner for national disease control, Dr. Alex Opio, has said.

Opio said Government plans to introduce free mass circumcision before the end of 2009 as one of the ways to reduce HIV spread.

He said the free circumcision would in the long run be available in Government hospitals and health centres.

But every male will be expected to make an informed consent.

"A national policy on circumcision is coming out soon and a national task force has been appointed to speed up the process, effect mass communication and train more personnel in medical male circumcision," he said.

Whereas various researches have demonstrated that circumcision reduced a man's risk of getting HIV, 75% Ugandan men are not circumcised, according to the 2006 National Sero-Survey.

Health experts hope that new approaches like circumcision would further reduce Uganda's HIV prevalence, which has stagnated at 6.5%.

Having a circumcision policy will enable Uganda to receive funding from development partners for circumcision programmes.

"PEPFAR, the Global Fund, the World Bank and many others have all indicated willingness to fund," says Sereen Thaddeus, a USAID senior reproductive health adviser, who represented development partners at a circumcision stakeholders' meeting at Imperial Royale hotel last Wednesday.

Depending on the funding, circumcision may also be accessed from subsidised private centres at the lowest possible cost. It will be performed only by medically trained personnel in order to reduce the risk of complications.

Results from three randomised trials in South Africa, Kenya and Uganda proved that medical male circumcision (MMC) reduces sexual transmission of HIV from women to men by at least 50%.

According to Dr Angela Akol of Family Health International, this means whereas 100 uncircumcised men may all get HIV from sex with infected partners, 50 of them may escape it if all the 100 men were circumcised.

Dr. David Serwadda, Director of the Makerere University School of Public Health, who led the four-year study in Uganda, says all the studies produced similar results yet they were conducted in different countries, on different populations using different techniques.

Serwadda explains that the foreskin is vulnerable to tears and ulcers that provide an entry point for HIV. The inner skin is very soft and allows HIV to easily penetrate.

When this is cut off, the tip of the penis hardens making it difficult for HIV to penetrate.

Recent evidence from the Rakai study suggests that men with multiple partners
may get
the greatest benefit from circumcision, partly because it reduced the risk of sexually transmitted infections.

The protective effect grows over time, possibly due to the hardening of the skin on the head and shaft of the penis after circumcision.

Using computer modelling, the World health organisation (WHO) estimated that implementation of mass circumcision could avert up to 5.7 million HIV infections and three million AIDS deaths worldwide by 2026.

Based on that, WHO and UNAIDS, a UN body charged with HIV matters, issued a set of recommendations last year for the use of medical male circumcision in HIV prevention efforts.

Based on WHO recommendations, some African countries like Rwanda and Kenya have developed a national circumcision policy and are implementing mass circumcision programmes.

Opio told the circumcision stakeholders' meeting that even before free circumcision becomes available, Government is encouraging Ugandans to get the cut at hospitals and health centres that have the facilities.

However, he emphasised that circumcision does not guarantee full protection from HIV and should only be considered as one part of a comprehensive package to prevent HIV.

"People must be told that even if they are circumcised, they can still contract HIV and transmit it to their partners. Therefore, circumcised men should continue to practice abstinence, have fewer sex partners and use condoms," he said.

Opio said the national task force for male circumcision has been finalised and will include officials at the national level, those from the Ministry of Health, Uganda AIDS Commission and development partners.

Others on the task force are representatives from NGOs, districts and hospitals. "We are soon giving them appointment letters. They will be answerable to the Director General for Health Services," Opio said.

On why it has taken Uganda this long to come up with a policy, Opio explained that Government opted for a cautious approach to avoid a situation where the policy is announced and the system is not ready to absorb the demand. "We have to first build capacity, consensus, acceptability, a right communication strategy and a national task force," he said.

"The task force will now develop the policy, an implementation plan and programme as well as tools for monitoring and regular evaluation," Opio says.

However, there are still many issues to consider. Currently, doctor:patient ratio is 1:22,000 and many of these are busy with the various diseases that afflict Ugandans. The task force needs to train personnel especially midwives and nurses to back up the qualified surgeons.

Stakeholders expressed concern that political support is necessary for the programme to succeed. In Kenya where circumcision has tribal ego implications, it took the Prime Minister Raila Odinga, three ministers and six MPs to announce at a rally in Kisumu that they had undergone the operation.

President Yoweri Museveni has in the past questioned the usefulness of circumcision in HIV prevention.

But Opio said the President only raised concerns about the implication of poor communication on circumcision. "We have looked at these concerns and we are going to meet him to address them."

The presidential advisor on HIV/AIDS, Dr Jesse Kagimu, said the president has always insisted on well researched and proven scientific information on preventive HIV methods. He will support any intervention that can help roll back the scourge, he said.

Dr. Freddie Ssengooba of Makerere University School of Public Health added that a good communication strategy is needed to avoid inappropriate uptake, quarks and unsafe practices.

In his presentation on MMC communication strategy, Ssengooba said priority will be on explaining its role in HIV prevention and directing people where to go for it.