Creating demand for medical circumcision

 

It is around 9am at Chipini Health Centre in Zomba District. On our arrival, village head Mzazira has just emerged from a session where health workers briefed him on the procedure to follow. He says nothing—and it seems he will not say anything soon.

The traditional leader is waiting outside the rural health centre in Chingale.

“Once I get circumcised, my subjects will follow suit,” he says.

The country has embraced voluntary medical male circumcision (VMMC) as one of the strategies to turn back HIV infections. Studies show the procedure reduces the likelihood of HIV infection by 60 percent.

This could be a game for Zomba residents. Out of nearly 600 000 people in the district, almost 90 000 are living with the virus which causes Aids. This means 15 in 100 people are infected, a higher prevalence rate than the national average estimated at 10 percent.

Music star Nepman is one of influential voices backing the VMMC campaign

This is alarming. Medical officer Dr Vanessa Kandole once described the situation as “pathetic.”

“VMMC is important in Zomba as one way of reducing the prevalence rate which currently is on the higher side,” she told Malawi News Agency.

According to Kandole, at least 18 000 boys and men have been circumcised since VMMC campaign began in 2013.

The results emanates from collaborative efforts led by the Ministry of Health. Jhpiego is one of the players.

At Chipini, men and adolescent boys are waiting anxiously. When we arrive, there are 11 of them queuing for the procedure.

When his turn comes, Mzazira will undergo HIV testing and counselling as well as screening for chronic diseases before he gets circumcised.

“Being a village headman, I want to lead by example. I want my people to appreciate and understand that this is life,” he tells us.

Chipini is one of the areas where Jhpiego is carrying out the intervention. The organisation has been in Malawi since 1999. From 2010, it was part of the development of national standard operating procedures for VMMC.

At that time, Jhpiego implemented Malawi’s first pilot initiative on VMMC for HIV prevention in Mulanje, circumcising up to 4 348 men and boys.

In 2012, Jhpiego received additional funding through Maternal and Child Health Integrated Programme (MCHIP) to provide VMMC services to more than 8 000 males in Thyolo.

As Jhpiego expands its footprints, it is estimated that 115 647 males have undergone voluntary medical circumcision since 2011.

The involvement of chiefs is just one of the advocacy approaches Jhpiego uses. After conducting advocacy meetings with chiefs in the target districts, the Ministry of Health requested MCHIP to offer VMMC services in vulnerable and hard-to-reach health centres to ensure medical circumcision is not confused with traditional rites of initiation.

“The approach has yielded enormous success,” says community mobilisation assistant Samson Jali.

The VMMC project called Sankhani has spread from Chikwawa, Zomba to Thyolo.

Why these districts?

“Ministry of Health and United States Agency for International Development (USAid), following recommendations from the World Health Organisation (WHO), identified some districts due to high HIV prevalence. The three are among the priority districts,” says communications and demand creation manager Lionel Chipeta,.

When it comes to demand creation, the intervention mostly uses interpersonal communication which triggers honest discussions with individuals and groups.

“We also have events like pool tournament, bawo tournament, football bonanzas which are simply crowd-pullers. Then, we engage them into discussions using community mobilisers,” he explains.

In the three districts, those aged above 15 have not been forthcoming.

At national level, Malawi has only reached out to seven percent of targeted number while the neighbouring Tanzania has attained about 90 percent. Zambia has achieved nearly53 percent.

As a nation, we are still very low in reaching our expected target to halt more HIV cases as desired,” adds Chipeta.

Jhpiego has embraced the involvement of community leaders to close the gap.

Jhpiego is implementing the VMMC campaign with funding from Presidents Emergency Plan for Aids Relief (Pepfar) and USAid. n

 

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  • The evidence that male genital cutting has any effect on HIV is sketchy at best. The claim is mainly based on three clinical trials by genital-cutting advocates on paid volunteers for genital cutting (that is, men who did not value their foreskins).
    They cut a total of 5,400 men and made another 5,400 (the control group) wait.
    The cut men were warned not to have sex for six weeks after being cut, or to use condoms if they did. The control group was not given that advice. Of course the cut men were not told to stop using condoms after six weeks.
    After less than two years, the trials were cut short prematurely. Trials cut short are known to give more positive results.
    64 of the cut men had HIV. 137 of the control group had HIV.
    327 of the cut men and 376 of the control group dropped out, their HIV status unknown. Thus the real numbers of men with HIV could be very different. Cut men might drop out when they learnt they had HIV after a painful and marking operation they thought would protect them. Control group men might simply change their minds about getting cut, especially after friends told them what it was like. (Men were recruited by a “snowball” method, which increased the chance of them knowing each other.)
    So the 73 cut men who didn’t get HIV when they might have, are the whole of the case that cutting has any effect on HIV. In 10 out of 18 countries for which USAID has figures, more of the cut men have HIV than the whole men. Even if there is some protective effect, men must wear condoms for strong protection, and when they do, genital cutting can make very little difference.