Health personnel from government health facilities at various levels are to undergo in-service training to horn their skills on the new procedure. A Male Circumcision Task Force that will foresee and guide the circumcision of males in Kenya is going to be set-up soon.

Titled Policy on Male Circumcision in Kenya 2008, the document also wants circumcision to be promoted and delivered to males of all ages in a manner that is culturally sensitive to minimize stigma that may be associated with a circumcised person.

While some Kenyan communities invoke religious, cultural or social reasons for circumcision, others like Teso, Luo, Turkana, and few people in Coast province, undertake other rites of passage, which do not include circumcision.

Circumcision involves removal of the foreskin. Studies have shown the skin’s inner mucosal surface to be the breeding ground for the virus because it has more immune cells vulnerable to HIV infection than the external surface.

Circumcisers will therefore, among many other things, be required to counsel males and use techniques that reduce or eliminate the pain associated with such surgical procedure, to encourage more men to be circumcised.

Says the policy: “Ensure that male circumcision is performed by well-trained practitioners in antiseptic settings under conditions of informed consent, confidentiality, risk reduction counseling and safety.”

Health facilities from the dispensary to the district levels are to be strengthened to ensure they cope with the expected demand from men seeking to be circumcised.

Those implementing the policy will be required to put in place appropriate laws, regulations, and supervisory mechanisms that are going to make circumcision services accessible and provided safely without discrimination.

The adoption of the policy by the government comes at time when results HIV vaccine trials indicate that circumcised volunteers had a lower risk of HIV infection compared to their uncircumcised counterparts.

Among the results of one HIV vaccine released by in the United States, a number of the volunteers had turned HIV positive. When they were analyzed further, the researchers realized that among those who had received the vaccine and were infected; the cases were higher among the uncircumcised males compared to the circumcised ones.

The scientists are trying to investigate further this development to see if there is any correlation between HIV vaccine and circumcision. Likewise, the policy is happening at time when there are fears that the number of male being circumcised maybe reducing.

According to the 2003 Kenya Demographic and Health Survey, close 72 percent of the men aged between 15 to 19 years are circumcised compared to 84 percent who are above this age. But the survey does not analyze HIV prevalence in regions that predominantly circumcise vis a vis those which do not.

The new policy has generated excitement and disquiet among members of the public who talked to The Horizon, with some praising it, while others saying it will worsen the vulnerability of women to HIV infection as men are going to refuse to have protected sex.

“Circumcising every male is the best thing for it is going to ensure we are uniform and have reduced chance of HIV infection,” says 25-year-old Brian Okila from Westlands estate.

But Ruth Njeri, an anti-HIV/AIDS campaigner fears the idea behind the new policy may make circumcised men to engage in unprotected sex thinking they are very safe.

“Men who have been using condoms or being faithful to their spouses will discard all these once they believe that being circumcised insulates one from HIV infection.”

In Kisumu, for instance, there have been reports of circumcised male engaging unprotect sex, and then ending with HIV infection. Such tendencies are bothering the Ministry of Health as well.

In the proposed policy, the government says those promoting circumcision should ensure it does not replace known effective HIV prevention methods and should always be considered as part of a comprehensive prevention package.

It goes further to state that: “Community and individual education programs provide sufficient and correct information on the partial protection provided by male circumcision and the continuing need for other HIV and sexually transmitted infection prevention measures.”

This means circumcision will be treated as the fourth component of the popularly known ABC – Abstinence, Be Faithful, and Condoms-methods of prevention.  Health providers and communicators are going to now to adopt the ABCC slogan.

“What we are trying to pass across is a circumcised man who either uses a condom or is faithful to his partner has reduced risk of HIV infection,” says Prof Alloys Orago, the Director of National Aids Control Council.

The other issue the government has to grapple with is the cost of circumcision. While the establishment acknowledges that the intervention is expensive, it does not specify where resources for implementing it are to come from.

It just calls on the Ministry of Health to “strengthen health systems to ensure that male circumcision programmes do not interrupt or divert resources from other primary healthcare services.

To achieve this, the Ministry is required to integrate management of reproductive and sexual health and HIV prevention programs providing male circumcision services.

Strengthening the services through monitoring and evaluation to guarantee quality control and planning purposes, are other issues that are to be addressed before the program gets fully underway.

The proposed Male Circumcision Task Force is expected to help the government confront these challenges. Some of its functions will include:

• Advise Ministry of Health on plans and development programs for expanding safe, accessible, sustainable male circumcision services for the country.
• Guarantee professional, technical, and administrative excellence as male circumcision services are expanded.
• Ensure accurate and appropriate dissemination of information to individuals, communities, and the media regarding male circumcision services.
• And make certain that male circumcision is promoted within the context of the overall improvement of healthcare services.

 
The decision to adopt circumcision as one of the HIV prevention strategy is informed by research findings of three main studies done in South Africa, Uganda and Kenya, and which showed circumcision to reduce the risk of HIV infection by upto 60 percent.

World Health Organization and UNAIDS have already issued a strong recommendation calling for increased male circumcision rates in countries where the HIV infections are high.

Kim Dickson, coordinator of the joint WHO/UNAIDS working group that came up with the recommendations, is quoted in March 2007 New Scientists magazine saying, “We reviewed all the evidence, and the evidence is compelling."

In the South Africa study, circumcision was found to reduce HIV infection rates by more than 60 percent in a group of 3,000 HIV negative men

Of the 1,546 who were circumcised, 20 men became infected with HIV, while 49 of the 1,582 uncircumcised men became infected. 

Funded by the French Agence Nationale de Recherches sur le Sida (ANRS), the study sent a strong message in 2005 on the effectiveness of circumcision in HIV prevention. 

Buoyed by these results, South African scientists supported large-scale male circumcision as a possible strategy for preventing two million HIV infections and 300,000 deaths in their country during the next 10 years.

In December 2006, the Data Safety Monitoring Board that was overseeing the Kenyan and Ugandan male circumcision trials announced that the operation was a safe and effective way to reduce HIV infection among men. 

The two-year trials in Kisumu and Rakai, Uganda, involved adult, HIV-negative heterosexual male volunteers who were randomly divided into two groups – one group was circumcised and the others were not.

Findings from these trials showed medically circumcised men who practiced penile-vaginal intercourse to have more than 50 per cent less chance of acquiring HIV than non-circumcised men. 

In the Kisumu trial, circumcision reduced by 53 per cent chances of acquiring HIV among the 1, 391 men in the study, who were all between 18 and 24 years old. There were 1,393 uncircumcised men or in the placebo group.

Similar results were registered in the Rakai trial in Uganda, which involving 4,996 HIV-negative men aged between 15 and 49 years. 

Results in this study showed that the operation reduced HIV acquisition by 48 per cent among the 2,474 circumcised participants. 

The Kenyan trial began in 2002 as a collaborative venture between Universities of Nairobi, Illinois and Manitoba trial.

When the results of Kisumu and Rakai trials came out, NIH Director Elias Zerhouni praised them as a milestone in the war against HIV/AIDS.

“These findings are of great interest to public health policymakers who are developing and implementing comprehensive HIV prevention programs,” he said.

National Institute of Allergy and Infectious Diseases (NIAID) Director, Anthony S. Fauci, whose organization supported and conducted the studies, added:

“We now have confirmation—from large, carefully controlled, and randomized clinical trials— showing definitively that medically performed circumcision can significantly lower the risk of adult males contracting HIV through heterosexual intercourse.”

After impressive results, it was agreed that all men who participated in the study as a placebo group were to be offered circumcision as well. 

According to Zerhouni, male circumcision performed safely in a medical environment complements other HIV prevention strategies and is likely to lessen the spread of HIV/AIDS, especially in sub-Saharan Africa.

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