At 19 years old, Otto is at a crossroads deciding whether or not to get circumcised. His culture prohibits the practice; but what he has learned at Jhpiego’s (Johns Hopkins Program for International Education in Gynecology and Obstetrics) male circumcision (MC) promotion event on July 20, 2010 has made him feel otherwise. He is conflicted since for Otto and most of the Nuer and Anuak men, MC is a culture of the Highlanders (people who are not originally from Gambela). Getting circumcised would mean risking acceptance by his community.
A 2005 Demographic and Health Survey of Ethiopia (DHSE) indicates a 93% male circumcision rate in Ethiopia, and a 46% circumcision rate in Gambella, while the national HIV AIDS prevention and control office (HAPCO’s) 2010 single point estimate data indicates a 2.4 percent HIV prevalence rate in the region. Findings from the South Africa Orange Farm Intervention trial stated a 60% reduction in HIV infection among men who were circumcised. This finding is in line with the announcement made by the United States of America National Institutes of Health based on two trials conducted in Kisumu, Kenya, and Rakai District, Uganda which revealed a 53% and 51% reduction in risk of acquiring HIV infection respectively. The link between un-circumcised men and HIV infection can be explained biologically since the tissue of the internal foreskin absorbs HIV up to nine times more efficiently than female cervical tissue through Langerhans and other HIV “target cells”. The internal foreskin also has a mucosal surface, which is particularly susceptible to tears and abrasions, consequently increasing exposure to sexually transmitted infections and HIV.
These findings of MC studies along with the high rate of un-circumcision and HIV prevalence rate in Gambella have called for a rapid intervention like the one undertaken by JHPIEGO, to increase male circumcision rate through education and provision of free circumcision service.
ARC has also provided technical support in developing strategic communication messages (billboard, poster and brochure) by identifying communication objectives, primary and secondary audience as well as key constraints and benefits of male circumcision for the two tribes. The messages were pretested with two groups of Anuaks and Nuers, where the results were found to be vital in producing tailored messages for the target audience.
On July 20th and 22nd of 2010 Jhpiego, in collaboration with the Gambella regional Health Bureau, SSE and JHUCCP/ARC’s outreach program held MC promotional event in Gambella and Itang towns. JHUCCP/ARC’s outreach program mobilized the public to attend the event and organized activities which include: poem competition, question and answer session about MC, music performances, testimonials of circumcised men, and some brief presentation about MC.
The events were attended by more than 500 people as well as local government officials. . I met Otto at the event held in Gambella town on July 20th 2010. You could easily sense his concern about getting circumcised. Otto is worried because circumcision is not his culture and he has seen circumcised men from his tribe being ostracized by his community members as they were considered to have abandoned their culture to embrace that of the Highlanders’. Otto is also uncomfortable with the circumcision procedure since he has heard that it causes pain during sex. He is also conflicted since he has heard that not getting circumcised has a protective effect against HIV since the foreskin traps and decomposes the viruses. These myths about circumcision are pervasive in Otto’s culture which makes men like Otto from the Nuer and Anuak communities reluctant to get circumcised.
To address the low rates MC and high HIV prevalence in Gambella, Jhpiego has been providing free MC services at the Gambella hospital; Itang and Metti Health Centers. The service is provided by nurses and local health practitioners who were trained at the Black Lion Hospital in partnership with Surgical Society of Ethiopia (SSE). According to Dr. Negash Seyoum, Infection Prevention Advisor at Jhpiego, the circumcision procedure only takes about 10 minutes, during which clients are given local anesthesia. Reproductive Health and HIV Counseling and Testing (HCT) services are also provided to clients before the procedure.
At a recent meeting organized by UNAIDS-PEPFAR held in Durban, South Africa from September 22-24, it was indicated that the MC activity so far has mainly focused on service delivery and techniques to improve efficiency in the clinical context without integrating MC communication as a strategy. Health professionals from 16 different countries met to discuss how to improve the efficiency and effectiveness of the male circumcision scale-up.
Ato Suleiman Shifaw, art director at JHU-CCP/ARC has attended this event and shared JUC-CCP/ARC’s experience in pretesting for MC communication material development. Ato Suleiman explained that pretesting is an essential component of communications development work as it ensures that the target audience understands the messages presented in the materials, while also assessing receptivity to the messages. “Pretesting is a safeguard against the development of culturally inappropriate materials, unnecessary cost, and ineffective work, as these problems will be identified during pretesting”, added Ato Suleiman. JHU-CCP/ARC’s experience with pretesting was taken as a model to be adopted by the countries represented at the conference who are implementing MC scale-up. During this meeting, the needs for normative guidance and technical guidelines on how to develop, implement and evaluate MC communication programs was also brought forth by a number of East and South African countries.
In Ethiopia, Jhpiego has taken the first step in providing the needed MC intervention in Gambela region with a two pronged MC program which includes MC promotion alongside MC services. Jhpiego disseminates MC communication materials to educate members of Nuer and Anuak tribes about the benefits of MC. The materials explain that MC reduces female to male HIV transmission and lowers the risk of STIs such as syphilis, herpes simplex, urinary tract infections; and cervical and penile cancer. Mobile public announcements, banners and billboards in Amharic, Nuer and Anuak languages are also used by Jhpiego to mobilize the public and provide information about MC services locations.
Mr. Ujulu Omed, head of the Gambella HIV/AIDS Prevention and Control Office explained that there is a gradual change in the perception of MC among the Nuer and Anuak communities. “In addition to the successful turn out at the event, people are now open to the idea of circumcision,” said Ato Ujulu. Ato Gezahene Gessesse, Operation Room Nurse at the Gambela Hospital also said that the number of people, especially youth, seeking MC services has increased after the event. Ato Gezahene stated that up to 4-5 men get circumcised each day at the Gambela hospital.
Although there are encouraging results from the MC activities undertaken by Jhpiego, providing the services at a satisfactory level is still a challenge due to lack of access to remote areas, shortage of trained health care providers and equipment, as well as language barriers. Additional strategic communication is needed to dispel misconceptions that those like Otto have about MC. At the local level, NGOs, governmental organizations and community groups working in the region can reinforce Jhpiego’s MC interventions by implementing MC as part of a comprehensive package for HIV prevention. Since MC only provides partial protection against HIV, WHO and UNAIDS recommend that MC interventions should be offered in conjunction with provision of HIV testing and counseling services; promotion of male and female condoms; promotion of correct and consistent condom use; treatment for sexually transmitted infections; and promotion of safer sex practices to deliver a comprehensive HIV prevention program.
