Male circumcision (MC), which can reduce HIV among men by up to 60 percent, is controversial in Malawi and government has yet to implement mass male circumcision. But a chain of private clinics has rolled out the measure with some surprising results.
Banja La Mtsogolo (BLM) - Future Family in the local Chichewa language - a private family planning organization, rolled out the procedure at its network of 31 national clinics in 2009 and is the only organization offering it as part of an HIV prevention package.
The UN World Health Organization recommends circumcision and Malawi's National HIV Prevention Strategy 2009-2013 acknowledges its role, but falls short of outlining a clear policy.
Brendan Hayes, the head of BLM's HIV project, admitted that MC has been a hard sell.
"In Malawi, you've got very big differences in the HIV epidemic from north to south and those differences don’t correlate to differences in circumcision prevalence. High prevalence rates are in the southern part of the country, which is also where we have the most circumcision ... but you're still only talking about one in three men," he told IRIN/PlusNews.
"These differences aren't totally inexplicable but I think it's made people more cautious about moving forward with male circumcision."
Confusion and controversy
Southern Malawi has a large migrant labour population and an HIV prevalence rate of about 18 percent, accounting for almost 70 percent of the country's HIV infections, according to government figures. Circumcision is culturally less prominent in northern Malawi, where prevalence rates are also lower.
The mismatch between HIV prevalence and traditional circumcision rates has raised doubts among some high-level health officials, most notably Principal Secretary for HIV and AIDS within the Presidency, Dr Mary Shawa.
Earlier this year, Shawa argued in local newspapers that she had not yet been presented with enough clinical evidence on MC, and its efficacy was questionable given high HIV prevalence rates among traditionally circumcising populations in the south.
Shawa also questioned the acceptability of the practice among ethnic groups that did not perform the procedure.
The BLM programme is small and resource-constrained, causing the organization to be wary of creating large-scale demand through social marketing campaigns that might outstrip its capacity, and create windows for unsafe back-alley procedures. Its clinic in the high-density neighbourhood of Kawale in Lilongwe, the capital, performs about 100 circumcisions a month at a cost of up to US$8 each.
"We're getting clients from all the major ethnic groups in basically representative proportions, so we're not just displacing the traditional circumcision sector or providing services just to Muslim clients," said Hayes.
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Surprisingly, traditional circumcisers - who often carry out the procedure as a right of passage for adolescent initiates - support the clinics. Arnold Kumwenda, a BLM clinical officer, said traditional circumcisers were learning to meld traditional teachings with safer clinical circumcisions.
"Some [traditional circumcisers] do the education but they come here for the procedure," Kumwenda told IRIN/PlusNews. "When the boys go home, they stay in their homes instead of maybe going to the bush and then only after [the wound has healed] do they go."
By accompanying the boys, traditional practitioners learn about after-care and receive HIV counselling from BLM. Hayes said most BLM clients heard about the services by word-of-mouth - a good indicator of latent demand.
Word on the street
About 55 percent of men undergoing MC at Kawale made use of HIV testing services as part of the counselling process. Many came because their partners had heard of the benefits of MC, and the chance of avoiding the human papillomavirus, which could lead to cervical cancer, was also a strong incentive.
"Even I believed that circumcision was only for Muslims, but now the information is getting so widespread from [former] clients, girl friends and friends that there are lots of Christians coming," said Bertha Nyirenda, an HIV counsellor and tester at Kawale.
Protecting his partner from cervical cancer as well as partial protection from HIV made health worker Lazzar Phiri* go for circumcision after talking it over with his fiancé.
He has since become a resource for interested friends. "I sometimes talk about it with work mates, and friends have been talking about it to each other," he said. "I know ... two of them that came for male circumcision just because of me."
Hayes said BLM was looking into the feasibility of partnering with private doctors to expand its MC capacity, which might become crucial in implementing a future government rollout in a country where doctors and clinical officers are in short supply.