The Kenyan government has embarked on an ambitious national programme to fast track the national rollout of male circumcision as a means of preventing HIV.
Results from three randomised controlled trials in South Africa, Kenya and Uganda, in 2006 showed that following circumcision, the incidence of HIV infection was reduced in men by more than half.
According to the new policy document, circumcision will be rolled out for males of all ages in a culturally sensitive way and in a clinically safe setting.
The programme will involve some strengthening of the health infrastructure, but according to Peter Mutie, head of communications at the National AIDS Control Council (NACC), the existing health centres are sufficiently equipped for the rollout.
"We are trying to fast track it so that by mid-2008 we can start rolling it out," Mutie told IRIN/PlusNews.
Although a handful of ethnic communities in Kenya - including the Luo, Suba and Teso in western Kenya and the Turkana in northwestern Kenya - do not practice circumcision culturally, Mutie said the government's programme would focus on the whole country.
"Most of our tribes practice circumcision as a rite of passage, but many do it traditionally, using the same blade for several boys, a practice we would like to eradicate; others don't remove the entire foreskin, which is the medical way to do it - they just cut off a bit of it," he said.
Mutie added that in order to limit resistance to the programme, social mobilisation exercises would precede the rollout, with community members being trained to educate their peers on the benefits of male circumcision.
"This is a programme that needs very careful implementation, and education is key - for instance, people need to know that it is not in any way a guarantee of protection from HIV," Mutie said. "
He stressed that traditional circumcisers would play a key role in re-educating their communities. "We cannot totally remove their role - they are useful advisers whom people look up to, so they can be taught to advise the young initiates on safe sex and other healthy practices," he added.
The news about a national policy will be good news for many NGOs and medical practitioners who have been awaiting guidance on male circumcision. Among these is Marie Stopes Kenya, which started a pilot project on male circumcision in western Kenya a year ago using World Health Organization guidelines. The organisation is part of the national male circumcision task force.
Testing the waters
"Our pilot is a free mobile outreach, where a team of five members - a doctor, clinical officer, care assistant, nurse and driver - goes into various communities and sets up camp in a room at a local medical centre or in a tent, and invites people to come or bring their children for circumcision," said George Obhai, monitoring and evaluation manager at Marie Stopes Kenya.
Before the mobile team arrives, the local hospital or clinic is contacted to conduct community mobilisation, and on the day every man getting circumcised receives counselling from a trained member of staff before the procedure is carried out.
"Interestingly, many of the ideas people have about male circumcision work in our favour, even among the Luo; for example, people believe that it improves the sexual experience and that ladies prefer circumcised men," he added.
For the more culturally fastidious Turkana, the idea of circumcision will need more time and energy
Obhai noted that male circumcision has not been a hard sell in western Kenya because the Luo, Teso and Suba are surrounded by circumcising communities, and many of them know people who have been circumcised. The HIV prevention benefits it offers also made the practice popular in the region.
In four districts of Nyanza Province, more than 2,700 men have volunteered for circumcision through Marie Stopes since April 2007, and the numbers are increasing every month; 80 percent of the men and boys being circumcised are from traditionally non-circumcising communities.
But this success is not uniform; among the Turkana of northwestern Kenya, an isolated and very traditional society, it has been much harder to push the circumcision agenda.
"When we took the mobile team to Turkana last year, we got two cases on one outreach day, on another day we got three cases," Obhai said. "We pulled out because we simply didn't have the financial resources to justify continuing at the time, but once we are able to set up some more mobile teams we will go back to the region."
Marie Stopes also uses people from within the community as peer educators, and hopes to incorporate the traditional circumcisers into their programmes.
"In the past we have experienced resistance from them [traditional circumcisers], as we are perceived as trying to take away their source of income or their role in society," Obhai said. "For instance, in many areas, this coming August is a circumcising period, so we'd like to encourage them to maintain their role as counsellors and even pay them an allowance for that, but to bring the boys to the clinic for circumcision."
The pilot has been particularly successful in reaching rural populations with little access to modern medical facilities, and prisoners, who also lack access to healthcare. The social mobilisation is also being used as an entry point for education about the traditional ABC - Abstinence, Be faithful and use a Condom - prevention strategy, as well as as an avenue for promoting voluntary counselling and testing.
Marie Stopes' outreach has recorded five complications with the procedure in the year it has been operational - two adverse reactions to the anaesthetic and three post-op infections.
The organisation intends to replicate its mobile outreach across the country following the success of the Nyanza experience.