I wish I could remember where I read this, but a thought came into my mind over and over again as I researched two stories on voluntary medical male circumcision in the lake-side region of Kenya, near Lake Victoria: Science does not progress in a neat straight line.
I kept thinking this because nothing was clearer than that with each step forward a different challenge has presented itself. The country is hailed for its success in promoting Voluntary Medical Male Circumcision as part of a comprehensive HIV prevention package. But it seems every time you solve one problem a new one crops up. In fact, this is especially true for a health issue like circumcision, which requires behavioral change to work. So now we have to address new challenges.
This story, in a two part series, explains what I learned on my trip, and what may lie in store as the hard work of fighting HIV continues. It’s a sobering story, but not a sad one. After all, it has also been said that you know you are making progress if you find yourself tackling a different problem as you move along.
The Campaign Begins
In the mid-2000s, randomized controlled trials in Kisumu, Kenya; Rakai District, Uganda and Orange Farm, South Africa, all showed that male circumcision reduces the risk of female-to-male sexual transmission of HIV by approximately 60%. There hadn’t been such good news since the development of anti-retrovirals, which don’t prevent spread of the virus but rather enable patients to survive – and at a much greater cost.
The World Health Organization and UNAIDS reacted quickly to the results of the trials, recommending voluntary medical male circumcision as a strategy for reducing risk of transmission of the virus, particularly in settings where HIV is prevalent and circumcision rate is low.
In Kenya, attention immediately turned to the Luo community on the shores of Lake Victoria in Nyanza, a non-circumcising community with some of Kenya’s highest HIV infection rates. Almost every Luo knows of a relative or neighbour who died of AIDS during the HIV/AIDS epidemic of 1990s and early 2000s. According to the National AIDS Control Council’s, AIDS Epidemic Update 2011, Nyanza Province alone accounted for one in four HIV infected people in Kenya.
HIV Prevalence in Kenya according to the Kenya AIDS Indicator Survey 2012
Persuading the Luo to accept circumcision wouldn’t be easy. Traditionally, a circumcised Luo boy wouldn’t want to join his friends bathing in the river because they most certainly would consider him an outsider who didn’t belong. This was the reverse of most other communities in Kenya, where circumcision is common and few, if any, uncircumcised boys or men would even dare shower or use a urinal in public places for fear of being considered ‘less of a man.’
But public health advocates went to work to change public opinion in Kenya using some tools never previously tried. They mounted a very intensive campaign involving the media, community health workers and special mobilizers. Recognizing that radio reaches far more people than television, newspapers or web-based services, they also used vernacular radio stations, popular among the Luo community.
Perhaps most importantly, they actively courted political leaders, including Raila Oding’a, the Luo’s unquestioned leader for the past fifteen years. While he didn’t say whether he himself had undergone the procedure, Raila supported it fully, and his brother, Oburu, openly agreed to undergo it. That was enough. Beginning in Kisumu and subsequently in other parts of Luo Nyanza, men started getting circumcised.
Nyanza region registered an increase in male circumcision prevalence from 45% in 2007 to 66% in 2012 according to the Kenya AIDS Indicator Survey.
Based on these figures, Kenya built a reputation as a public-health success – one that other countries have sought to emulate. But the story does not end there. The battle over scientific evidence had been won, and advocates had proven they could sway a resistant population group, but circumcision is not yet a permanent part of Kenya’s health system, and long-term public support for it remains uncertain.
From the outset, the push for voluntary medical male circumcision has been a free standing, donor-funded project. It is run parallel to services offered by the Ministry of Health, but isn’t part of them. While the funding has been good, dependence on donors has brought some problems; in fact, some strategies that contributed to early successes now complicate the achievement of long-term goals.
One issue is the use of mobilizers to persuade men to undergo the procedure. Chosen because they have undergone the procedure themselves, mobilizers are thought better placed to explain the importance of undergoing the procedure, allay any fears, debunk any myths and refer community members to facilities where they can be circumcised themselves. In the beginning, mobilizers were assigned to specific areas ranging from individual homes to schools, ensuring that their work would be well targeted. They were reimbursed according to the number of people they persuaded to visit clinics that perform circumcisions.
A group of students mobilized at the beginning of school holidays
This was a powerful strategy, but it set circumcision apart from other health care services. There aren’t special, paid mobilizers for pregnant women to attend antenatal care clinics, and certainly no one needs to persuade a person to visit a health centre if he has a bout of diarrhea or simply isn’t feeling well. Today, that distinctive status for circumcision complicates possible efforts to integrate it into mainstream health programs.
The ‘NGO’ Perception Challenge
A second complication arises from the fact that the circumcision services have been run mostly by non-governmental organizations. Rarely short of funds, they generally pay better salaries than government institutions, and often have better facilities and their employees enjoy better working conditions. While good for the circumcision project in the short-run, this disparity works against the goal of making circumcision an ongoing, routine health priority.
The problem becomes especially clear during ‘peak VMMC season,’ school holidays when more students are able to undergo the procedure, and also following ‘Rapid Results Initiative (RRI)’ periods; a structured process that mobilizes teams to achieve tangible results over a rapid time frame. Suba District Comprehensive Care Clinic Centre, one of two facilities offering medical male circumcision in its area, often is forced to convert additional rooms into makeshift theatres during holiday season so its staff can treat more than 150 circumcision clients in a day. The facility, which is run by Family AIDS Care and Education Services (FACES), also needs help from technical staff working in the nearby government facilities to handle the extra workload.
Increase in clients during holiday season necessitating conversion of rooms to minor theatres in Suba
Government workers are more than willing to take on this temporary work, since it presents an extra source of revenue. In fact, even though they are fully trained to perform circumcisions, the extra income makes them prefer to help the NGO-run facility rather than take referrals at their own facilities. At another private circumcision facility, a staff member who asked to remain anonymous reported that government workers even ask for payments to refer men for circumcision when the issue arises during other routine clinic visits at government facilities.
It’s unclear how widespread such behavior is, but the use of ‘NGO branding’ as leverage for higher pay may distort priority setting in health facilities. While it may promote the procedure during special drives, it may inadvertently discourage men from undergoing it at other times, either by raising its cost or by subtly conveying that it is less of a priority than other services that are routinely available at all times.
The patient’s role
Donor funding also may undermine the long-term goal of convincing men that circumcision is something they should want on their own. The case of a so-called ‘hard to reach group’ illustrates this issue. These are men above the age of 25 who work as casual laborers and rely on their daily earnings to provide for their families. A prime example is men who drive ‘boda bodas’ which are the main form of public transport in most rural settings.
Most community members utilize ‘boda bodas’ to access services
Across the board, mobilizers as well as technical advisors say it has been especially difficult to persuade this group to undergo medical circumcision. The men complain that they would lose income on the days spent recuperating, which would be especially difficult considering the nature of their work. They often flatly say that they will only undergo the procedure if they are paid for the days that they would miss work.
Such requests evidently stemmed from earlier days, when researchers in Kisumu were first studying whether medical male circumcision would work as part of a HIV-prevention strategy. To persuade men to participate in the trial, the researchers reimbursed participants for their transport costs to go to earmarked facilities and undergo the procedure. Once the trial was completed, the facilities kept offering to perform circumcisions, but stopped reimbursing their patients. Many men declined to seek the service, saying they would only participate if offered compensation. Now, some even say their families should be supported while they, the breadwinners, are at home healing.
So far, it’s unclear how the public health system will deal with this difficult problem. Health experts themselves are divided on the issue.
How do we afford it?
The biggest stumbling block to scaling up and sustaining voluntary medical male circumcision in Kenya might be money. Up to now, the costs of voluntary medical male circumcision are 100% met by the donors. For all that has been achieved, it has also enabled the government of Kenya to avoid having to decide whether it believes circumcision belongs in the country’s overall priorities. It can’t avoid the issue forever, though: donor support cannot and will not be sustained indefinitely.
The issue may not be easy to resolve. Should the government take funds from malaria, immunization and other programs, in the process stretching already thin budgets and less than motivated staff members for a voluntary procedure that wasn’t even considered important barely a decade ago? And if spending on other programs can’t be cut, where will additional funds be found?
Stakeholder forums held in 2013 produced suggestions that at least some policy-makers and health providers consider medical male circumcision less of a priority than other competing health services – even though data prove that it would be an effective and low cost addition to a comprehensive HIV prevention package.
Until the debate is resolved, Kenya’s HIV-prevention success story is incomplete. In the second part, I’ll look more closely at the issues that will arise as the country tries to figure out how to bring what it has accomplished to scale.
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