Ethiopia has one
of the highest circumcised male populations in Africa – 93 percent, according to a 2005 survey by the Ethiopia Demographic and Health Survey. But the dominant ethnic groups of the Nuer and the Anuak in Gambella have until recently regarded the procedure with suspicion and as an instrument of “imperious foreigners”, disliked because of their historic attempts to change the Nuer culture. They also feared that it could cause impotency.
“The people in our culture are in doubt and believe that others want to change our culture. But those of us who have thought about the benefits, see it as only positive,” Both told IPS, explaining that hygiene and HIV prevention were two important benefits of circumcision.
Kelly Curran, director of HIV/AIDS and Infectious Diseases at international health non-profit, Jhpiego, told IPS: “The vast majority of men in Ethiopia are circumcised for religious or cultural reasons, usually in infancy. Gambella region is the exception.”
However, attitudes in the region are changing. It started in 2009 with a voluntary medical male circumcision (VMMC) campaign, which set out to increase circumcision prevalence to 80 percent by circumcising more than 40,000 men.
“When the VMMC programme started, Gambella was the only region in Ethiopia where less than half the men were circumcised, and it had an HIV prevalence three times the national average,” Curran said. Gambella has an HIV prevalence rate of 6.5 percent and a male circumcision rate of only 46.8 percent.
Randomised controlled medical trials in Kenya, Uganda and South Africa carried out by the French National Agency for AIDS Research and the United States National Institutes of Health successfully demonstrated that VMMC reduces the risk of female-to-male sexual HIV transmission by roughly 60 percent.
Based on the success of the trials, in 2007 the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation identified 13 countries with high HIV prevalence and low circumcision rates, all of which were in East and Southern Africa.
There are now 14 countries implementing VMMC programmes, in which males receive a package of HIV prevention services including education and risk-reduction counselling, HIV testing, screening for sexually transmitted infections and condoms.
HIV transmission in Gambella is high due to a low level of awareness, a high influx of itinerant farm workers, and a high number of refugees from neighbouring South Sudan said Ajim Othow, the Gambella regional HIV/AIDS prevention and control officer.
“HIV awareness is low especially among the local population. Many still believe that condoms carry viruses. They understand that HIV exists, but do not take it seriously,” Ajim told IPS.
In 2009, Jhpiego, with support from the U.S. Centres for Disease Control and Prevention, partnered with the Gambella regional health bureau to target adult males here. Gambella had only one surgeon prior to the medical alliance.
To date, the programme has circumcised over 32,000 males, trained 71 healthcare providers as male circumcision surgeons, and trained 26 educators and counsellors as well as 129 health extension workers.
“This programme is really trying to create a new norm in Gambella, it also has worked hard to respect the diverse ethnic groups living in Gambella,” said Curran.
VMMC is cost effective as it saves on antiretroviral therapy costs, which are expected to exceed 5.8 million dollars between 2009 and 2025 in Ethiopia. Modelling shows that every five to 15 circumcisions avert one HIV infection in a high HIV-prevalence environment.
In Gambella town, outreach campaigns have targeted at-risk populations such as high school students and the city’s prison population. The programme has also sponsored educational broadcasts in the local ethnic language on local radio. All of which have helped to raise awareness of the benefits of male circumcision.
Bang Chut, a 32-year-old water supply worker, attended the programme’s Lare health centre in Gambella with his wife. On the basis of an educational campaign, they both decided he should take advantage of the free surgery and be circumcised.
“We read the leaflet together. It was written in our language and easy to understand. We both see the obvious benefits. Now that it’s free, there’s no reason not to do it,” he told IPS.