The traditional practice of cutting a girl's genitalia still marks the transition to womanhood among the Pokot in the northeastern Ugandan region of Karamoja, despite growing fears that the ritual is fuelling the spread of HIV/AIDS.
"It is a very crude operation - there's no sterilisation of equipment and one knife will be used to cut the genitalia of up to 30 girls at a time," said Sister Jane Atai, the nurse in charge of community health at Amudat Hospital in Uganda's Nakapiripirit District.
Female circumcision - commonly referred to as female genital mutilation (FGM) - has been internationally condemned as a violation of a woman's rights. The long-term physiological effects include septicaemia, genital malformation and even death.
It is performed by women elders, who are 'specialists' in the community but rarely have any medical training and little or no knowledge of the risks of HIV infection. The Ugandan government publicly condemns the ritual, although it is not specifically outlawed.
The Pokot, who straddle the Uganda-Kenya border, are one of just two groups known to carry out female circumcision in Uganda, the other being the Sabiny in the east. Among the Pokot, the most prevalent form of FGM is 'infibulation', which involves the removal of all or part of the external genitalia and stitching up the vaginal opening, leaving a very small passage.
According to the United Nations Children's Fund, the main link between FGM, HIV and heightened vulnerability to infection comes from the increased likelihood of infections in the reproductive tract that provide a "doorway for HIV to enter the body".
"When the vagina is stitched up to leave a small orifice, the result is much more friction during sex and childbirth, which leads to a greater risk of infection either from a sexual partner or through mother-to-child transmission," explained Dr Patrick Sagaki, medical superintendent at Amudat Hospital.
The International Rescue Committee (IRC) has been promoting "one girl, one blade" to prevent HIV infection from spreading, while the Church of Uganda has focused on changing attitudes to phase out the practice, starting with the women elders who perform FGM and are its strongest proponents. "We are trying to change a culture and that takes time," said Reverend Michael Chorey from Amudat Parish.
Local Health authorities estimate HIV prevalence in Karamoja at three percent; just 10 years ago the virus was unheard of among the isolated tribes of Uganda's least developed region. "We need to put an end to FGM to help fight HIV/AIDS in Karamoja," Atai said.
HIV/AIDS prevention in the region is more than a decade behind the rest of the Uganda, levels of HIV awareness are extremely low and literacy rates are among the lowest in the country.