HIV/Aids has ravaged Uganda to devastating lows. The fight back that has taken the country through a journey of ignorance and fear at one time saw a self-proclaimed spiritual healer Yowanina Nanyonga even feed multitudes on her miracle mud.
The death toll, especially in the 90s when stigma was at its peak was immense. But government sustained efforts have been revered in equal measure. In a bid to stop new infections, the ABC campaign prominent for abstinence, being faithful and use of condoms, took a front seat. It was later inherited by a new fashionable agenda of circumcision as an HIV prevention option.
Through the Safe Male Circumcision (SMC), President Yoweri Museveni unveiled a road map of ending HIV by 2030.
Circumcision is a traditional ritual performed in some communities in Uganda, especially among the Bagisu, Bakonjo and Sabiny to initiate boys into manhood. However, medical circumcision performed by surgeons has even been embraced by some ‘cowardly’ Bagisu who evade the knife which critics consider brutal and unhealthy.
Free circumcision has been offered to boys and men above the age of 10 to offer them protection. Seventeen-year-old Trevor Mwesigwa was circumcised at 11 years and his mother Winnie Mutesi says it is the greatest gift she could give him.
“It is important for my boys to be circumcised so that they avoid some of the common infections that come when you are not circumcised,” Mutesi says.
Removing the foreskin is one of the oldest rituals recognised in both the Bible and the Quran. Around the world, one out of three men are circumcised. It is performed as a custom for the Muslims and the Jews. But the mass medical circumcision which started in the middle 2000s aims to reduce HIV infections by 60 per cent and 14 countries in east and southern Africa are encouraging their men to lose their foreskins.
Also, 10 million men have been circumcised so far in the world. The World Health Organisation (WHO) wants to circumcise another 25 million by 2020 with an aim of preventing up to 5.7 million new infections and three million deaths.
“If somebody is not circumcised, it presents a bigger surface area for exposure to HIV. But also that cover of the penis has a big number of cells that are targeted by the virus for entry. So by removing it, you reduce the chances of getting infected and bruising during sex which also contributes to the reduction of chances of getting HIV infection,” Dr Peter Kyambadde of Mulago’s Most at Risk Population Initiative (MARPI) told the BBC in a recent interview.
Clinical trials were conducted in 2005 but real work started in 2010 through the funding of PEPFAR. But mass circumcision has been a hit. A 2017 UNAIDS Global Review Mission to Uganda; found that young people, especially girls aged between 15 and 24 are excessively affected by HIV infection.
Among adolescent girls; every single hour, two young women are getting infected with HIV. The prevalence of HIV among adolescent girls stands at 9.1 per cent, compared to the national prevalence rate of 7.3 per cent.
Uganda registers 230 HIV new infections a day. Despite widely available anti-retroviral therapy, 76 people die of AIDS-related causes every single day. According to Sylvia Nakasi, a policy and advocacy officer at the Uganda Network of Aids Service Organisations (Unaso), Uganda has seen a significant reduction in new HIV infections from 135,000 in 2010, to approximately 60,000 in 2016. New infections among children dropped from 26,000 in 2010 to 4,000 in 2016.
“We need to set ambitious targets… with more emphasis on prevention using proven options such as voluntary medical male circumcision,” Nakasi says.
Is circumcision deceptive?
Circumcision does not offer protection to the woman directly but the thinking is that if a man has reduced his chances of getting HIV through circumcision, his partner cannot get infected either. Circumcision among other benefits reduces (Human papillomavirus) HPV infections which can reduce chances of getting cervical cancer among the women.
The SMC programme aims at getting 80 per cent of men circumcised. The success of the campaign so far has been through the peer push through television, radio billboard ads, social media, celebrity endorsements and peer recommendation.
The sensitisation campaign is managed by the Uganda Health Marketing Group (UHMG). But the message in the public health ads is less about HIV and more about sex, lifestyle and cleanliness. It is more about the desire.“Most women prefer circumcised men for fear of diseases,” says Paul Ssennungi in an interview on why he got circumcised.
Other sexually transmitted diseases such as syphilis and gonorrhea cannot be prevented through circumcision. Therefore, responsible sexual behaviour remains the best option. Talk of reducing the risk of infection by 60 per cent is not what it seems because the risk only drops but it does not go away. To the critics, the angling of the message is misleading as it may lead people into risky sex without a condom or with sex workers because they think they are 60 per cent safe.
According to Dr Barbrah Nanteza, the coordinator of the National Safe Male Circumcision, Uganda has made tremendous progress in its SMC programme scale-up with more than 1.7 million men circumcised in 2013 and 2014 alone. “We try to keep it simple but we know it is a partial risk reduction. You should continue using condoms, be faithful or abstain,” she cautions. The new normal is now infant circumcision which proponents argue that the earlier it is done, the easier it will be for the child.
Why not cut?
But a one Charles Tabu, who does not approve of circumcision, says it is about the culture. “In West Nile we believe a man should be buried whole. Where do they take the foreskin after cutting it off? It is irrational,” he says. To him, this is like male genital mutilation which should not be encouraged.