Breaking traditional barriers in fighting HIV

It is three hours to sunset, but the long queue to the Voluntary Medical Male Circumcision (VMMC) surgical room at Thyolo District Hospital is far from over.

Jhpiego Malawi, a non-governmental organisation advocating VMMC has entered the fifth week of its annual campaign. On this day, almost 40 surgeries have been done already at the hospital.

The centre of attraction is the young men who have come from initiation camps—commonly known as Jando—to access VMMC services.

Yamikani Kalima, team leader for Thyolo Jhpiego office, explains that the campaign started on July 26 and ends on September 6. They have set eight sites and are targeting to circumcise about 8 000 clients in Thyolo.

She says the timing for the campaign is strategic, conciding with the third term holiday when initiation camps, which involve cutting of the foreskin for males to mark their transition to adulthood, are common.

To reach out to many, they developed a relationship with traditional initiators (angaliba), traditional and religious leaders who are helping mobilise boys and men in their communities to embrace VMMC services which, according to the World Health Organisation (WHO), reduces HIV acquisition among heterosexual men by approximately 60 percent.

Doing it against the traditional way, the angaliba take their clients to VMMC centres for circumcision in the first week of their initiation camps instead of doing it themselves.

After the circumcision, the clients are ferried back to the camps where they spend a week or two to go through healing and other rites.

Ibrahima Majawa accompanied 22 of his clients aged 10 to 15 to the hospital on this day.

Listening to Majawa testifying about benefits of medical circumcision, one would think he or she has approached a wrong person and not a ngaliba, considering the traditional and cultural myths associated with circumcision and Jando.

He states that apart from reducing the spread of  cervical cancer, tetanus and HIV, medical circumcision has eased their work and made the process simple and less painful.

“In the past, we were using rough tools to cut the foreskin. The process was very painful to our clients. We had no proper medication to ease the pain. We could spend more than a month in the camp to give more time for the healing, but now we spend less than three weeks because the wounds heal quickly,” he says.

Traditional initiators are influential advocates for VMMC particularly in  Zomba, Thyolo and Mulanje where Jhpiego has been running the Smart Choice (Sankhani Moyenera) Project since 2013. Jhipego targets 25 000 clients at the end of this year’s campaign period.

In Zomba, Cobra Wilson challenges fellow ngalibas that in this age of HIV and Aids, it is not proper to continue with the traditional way of using one instrument on all clients in their camps.

“Traditionally, one instrument is used on all clients without even doing sterilisation. Besides, proper hygienic measures are not followed, a situation which at times leads to complications,” he states.

Patrick Baluwa, Chikwawa District nursing officer who is also VMMC coordinator in the district says the excercise has helped to increase the number of men seeking public health services including uptake of ARVs by men.

“When clients come, they undergo counselling, treatment of sexually transmitted infections [STIs] and HIV testing. This has helped them access health services,” he says.

According to Baluwa, even men who have undergone traditional circumcision are coming forward for check-ups and circumcision redone by medical experts.

VMMC technical specialist for Jhpiego Malawi, Whyson Mkandawire, hints that, initially, they were facing resistance as communities in areas that practise traditional male circumcision—especially the Yao, Mang’anja and Muslims—were reluctant to embrace VMMC. They thought it might erode their culture while the uncircumcised societies among the Chewa, Lhomwe, Ngoni, Tumbuka and most Christians believed they had nothing to do with it.

However, the figures have been improving since they started incorporating traditional initiators.

Currently, Jhpiego has circumcised over 100 000 males aged between 10 to 45 since 2013, contributing to almost 41 percent of the circumcised population of that age group as of December 2016.

Malawi wants to circumcise 1.3 million sexually active males by 2020. n