Roll-out of Medical Male circumcision (MMC) for HIV prevention in non-circumcising communities of Northern Uganda

Introduction Recent studies have shown that circumcision reduces HIV/AIDS infection rates by 60% among heterosexual African men. Public health officials are arguing that circumcision of men should be a key weapon in the fight of HIV/AIDS in Africa. Experts estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. Some communities in Uganda have misconceptions to MMC and resist the practice. Methods To roll out MMC to a non-circumcising population of Northern Uganda from June 2011 as a strategy to increase access and prevent the spread of HIV/AIDS. Results Circumcision in a non-circumcising communities of Lango and Acholi sub-regions with a population of about 0.5 million mature males 15-49 years. Enrolment was voluntary, clinical officers, nurses carried out MMC after training in the surgical procedure. Mass sensitization and mobilization was conducted through radios, community leaderships and spouses. Cervical cancer screening was incorporated at circumcision sites and used as incentive for the women. Circumcisions were conducted at static sites, camps and outreach services where VCT and adverse events (AEs) were recorded and managed. All clients assented/or consented. Conclusion A total of 26, 150 males were circumcised in eight months. The AEs rate was 1.2% and was mild. 2,650 women were screened for cervical cancer and positive test rate was 1.7%. Mobilization and sensitization were by radios and spouses’ involvement in cervical cancer screening exercise.


Introduction
Male circumcision is the surgical removal of some or all of the foreskin (or prepuce) from the penis [1]. Several types of researches have documented that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex.
Compared with the dry external skin surface, the inner mucosa of the foreskin has less keratinization (deposition of fibrous protein), a higher density of target cells for HIV infection (Langerhans cells), and is more susceptible to HIV infection than other penile tissue in laboratory studies [2]. The foreskin may also have greater susceptibility to traumatic epithelial disruptions (tears) during intercourse, providing a portal of entry for pathogens, including HIV/AIDS [3]. In addition, the microenvironment in the preputial sac between the un-retracted foreskin and the glans penis may be conducive to viral survival [1][2][3]. Finally, the higher rates of sexually transmitted genital ulcerative disease, such as syphilis, observed in uncircumcised men may also increase susceptibility to HIV infection [4,[5][6][7].
Three randomized controlled clinical trials were conducted in Africa to determine whether circumcision of adult males would reduce their risk for HIV infection [8]. The study conducted in South Africa [9] was stopped in 2005, and those in Kenya [10] and Uganda [11] were stopped in 2006 after interim analyses found a statistically significant reduction in male participants' risk for HIV infection from medical circumcision [8,[9][10][11][12][13].
In these studies, men who had been randomly assigned to the circumcision group had a 60% (South Africa), 53% (Kenya), and 51% (Uganda) lower incidence of HIV infection compared with men assigned to the wait-list group to be circumcised at the end of the study [8,9,10,11]. In all three studies, a few men who had been assigned to be circumcised did not undergo the procedure, and vice versa. When the data were reanalyzed to account for these occurrences, men who had been circumcised had a 76% (South Africa), 60% (Kenya), and 55% (Uganda) reduction in risk for HIV infection compared with those who were not circumcised [8][9][10].
Lack of male circumcision has also been associated with sexually transmitted genital ulcer disease and chlamydia, infant urinary tract infections, penile cancer, and cervical cancer in female partners of uncircumcised men [1,8,12,13]. The latter two conditions are related to human papilloma-virus (HPV) infection. Transmission of this virus is also associated with lack of male circumcision which was observed in a recent meta-analysis including 26 studies that assessed the association between male circumcision and risk for genital ulcer disease [8,12,13]. The analysis concluded that there was a significantly lower risk for syphilis and chancroid among circumcised men, whereas the reduced risk of herpes simplex virus type 2 infections had a borderline statistical significance [4,8,12].
Reported complication rates depend on the type of study (e.g., chart review vs. prospective study), setting (medical vs. non-medical facility), person operating (traditional vs. medical practitioner), patient age (infant vs. adult), and surgical technique or instrument used [1,8,12]. In large studies of infant circumcision in the United States, reported inpatient complication rates range from 0.2% to 2.0% [1,8,12,14,15]. The most common complications in the United States were minor bleeding and local infection. Similarly, in the recently completed African trials of adult circumcision, the rates of adverse events possibly, probably, or definitely attributable to circumcision ranged from 2% to 8% [8,12]. The most commonly reported complications were pain or mild bleeding. There were no reported deaths or long-term sequelae documented [9,10,11,16]. This community where this research was being implemented is a Luo community which is a non-circumcising community. A recent survey in Uganda indicated that northern region had the lowest prevalence of circumcised person of all regions with a rate of only 2.4% [17,18]. This community resists circumcision and has a derogative local name, "Layom" which literally means "glans exposed like a penis of monkey/baboon". Traditionally in the Acholi and Lango community, a man known to have no foreskin would be denied courtship/married to the village/community because it was considered an abomination/curse and thus would transfer unfavourable/unwanted genes to the population if allowed to marry a woman. Local songs would be composed about such individuals so that no woman would even attempt to court him. The person would be stigmatized in public and kept out as an outcast of the community. He would not be allowed to participate in community activities such as group hunting, bathing, farming, politics and community leadership because he would be considered a bad omen to the community. Similarly, a study conducted among the Luo of Kenya indicated that some members of the community were in fear of a possibility of discrimination and would shun recently circumcised men, especially when community members were older and/or less educated [19].    it exposes the glands penis making one appear like a baboon; it makes one unable to conduct routine work; circumcision makes a man to wear a skirt or wrap up in a towel; circumcision converts a Christian to Islam and many other issues that have tended to give a negative publicity to circumcision among the community [19]. A study conducted in western Kenya among the Luo population indicated that the commonest identified barriers to MMC were pain, culture and religion, cost, possible adverse events (AEs), and the potential for risk compensation (i.e., an increase in risky sexual behavior following MC) [19,20].
Traditionally in some of communities in this region, a male born without/retracted foreskin would be stigmatized [19]. Local songs would be composed in their names describing how their glans penises were exposed like that of a baboon. Every effort would be made by the community to prevent such a male from courting/marrying any female in the neighbor-hood/community. promoting MMC in a country [19]. This similarly became an important recommendation in scaling-up of MMC services in this region.
The introduction of cervical cancer screening services for the women brought women to participate in the project. They in turn encouraged their husbands to accept circumcision and adhere to the postoperative guidelines. Majority of married clients who turned up indicated that they were encouraged by their wives who had undertaken cervical cancer screening at the circumcision sites.
Previous studies had observed that females had the best response to ill-health and the best health seeking behaviours in Uganda more especially among the Acholi people [21-23]. A satisfied client brought in the next client and thus the whole community became involved in the campaign. A pain free postoperative period because of the eutectic local anesthetic used was crucial for the propagation and promotion of circumcision project in this community.
VCT and HIV prevalence: Participants were young men mostly in their late teens. The HIV prevalence was 5.7%, which was much lower than the 8.2% for the general population of Northern Uganda [17,18]. This could have been because of the age bracket, young single adolescents and mostly in secondary schools were the majority. However, this rate was relatively higher than the rates in

Lessons Learned
In order to improve access to MMC activities in a traditionally noncircumcising community, the following could be the most effective way to achieve it:   PubMed | Google Scholar