|The national policy will be launched in July 2010|
"We now have a national vision on how to move forward, and a government policy and communication strategy will be launched in July," said Dr Alex Opio, assistant commissioner for health services in the Ministry of Health.
"Circumcision will be carried out in national referral hospitals, district hospitals and health centre IVs [county level health centres] which have the capacity to conduct minor surgeries."
Why the delay?
The government began drafting the policy in 2008 and there has been criticism of the delay in launching the circumcision programme. In terms of the National AIDS Strategic Plan 2007/8-2011/12, at least 160,000 men should have been circumcised by the end of 2010.
It had taken time to get all the government's ducks in a row. "We needed funding; PEPFAR [the United States President's Emergency Plan for AIDS Relief] has stepped in to give the ministry and its partners US$5 million for male circumcision over the next year," Opio said.
Unlike neighbouring Kenya, whose programme has already circumcised more than 100,000 men, medical male circumcision was relatively new to Uganda, where only 25 percent of the adult men are circumcised.
"Starting prematurely can do more harm than good; we needed to be sure we were truly ready to deliver safe medical circumcision before we launched," Opio commented.
The Rakai Health Sciences Programme (RHSP), a medical research facility in central Uganda - one of three sites where research confirmed the protective effect of male circumcision against HIV - has circumcised more than 5,000 men, and is expanding its services to local district hospitals.
|Starting prematurely can do more harm than good; we needed to be sure we were truly ready to deliver safe medical circumcision before we launched|
Their figures match those of a 2008 study by Uganda's Makerere University and Family Health International, a reproductive health NGO, which found that 62 percent of men in four districts would consider being circumcised.
"It seems quite fashionable now, like somehow men who are circumcised are more civilised, more educated," said David Sembatya, a motorcycle taxi rider, or 'boda boda', in the neighbouring district of Lyantonde, where RHSP provides male circumcision at the district hospital. "I will definitely do it."
James Nkale, a clinical officer at RHSP, said prevention of HIV and other sexually transmitted infections, hygiene, and social status were among the reasons men were so keen to be circumcised. "Men also listen to women, who have better health seeking behaviour and are advising their partners to go for the service."
Circumcision is a new concept to much of the population and there are some misconceptions. "Of course, the most common fear is pain - people associate circumcision with men wearing skirts and walking with a staggering gait," Nkale said.
"There are also some cultural practices that may be harmful ... some believe it is a curse to have sex with your official wife after circumcision, so the first sexual encounter after the procedure should be with another partner; others believe vaginal fluids are good for healing wounds, so they may have sex before they are properly healed. This is all anecdotal - we don't know how deep-seated these misconceptions are, so we need more studies."
Kakaire said another common perception was that male circumcision was a way of "Islamising" the population; in some ethnic communities the word for male circumcision is "okusilamula", which translates as "to make Muslim". "We discourage the use of that word, instead we use the word "okukomola", which means to trim," he noted.
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The Ministry of Health's Opio said the message that male circumcision was not a "magic bullet" against HIV was central to the communication strategy. "It is just an additional tool in our prevention arsenal - it becomes part of the 'plus' in our ABC [Abstinence, Be faithful and Condomise]-plus strategy," he said.
Getting it right
Kakaire noted that good medical care and counselling were also critical to promoting circumcision, and RHSP has been training nurses, counsellors, and clinical and medical officers for more than two years. In the past year it has trained more than 170 health workers from across the country and is planning to double its training programmes to cope with demand.
One of the reasons this [RHSP] programme has been successful is that the clients get a complete service - from pre-op counselling to the procedure and post-op follow-up," he said. "Clients need to trust the programme for it to succeed."
"We are drawing up a roadmap that will guide the [national] programme," Opio said. "Training is ongoing and we are being careful to ensure that all practitioners of male circumcision follow standards set by our technical guidelines."