Kenya's most recent male circumcision rapid results initiative failed to meet its target, and officials are stepping up efforts to identify and fix the problems that could foil the government's campaign to circumcise more than one million men by 2013.
Conducted between November and December 2011, the initiative aimed to circumcise 70,000 men over a 30-day period, but results released in February show that only 40,000 men were circumcised. This is the first time the annual initiative - which began in 2008 - has failed to reach its target.
"We need to investigate the reasons for the inability of the programme to reach its target. Maybe we need to change our communication strategy to be able to convince those men who are still not sure about medical male circumcision," said Athanasius Ochieng, the voluntary medical male circumcision programme manager at the National AIDS and Sexually transmitted infections Control Programme.
Officials in the programme attributed the shortfall, at least in part, to heavy rains in November and December that rendered many of the roads in Nyanza, western Kenya, impassable for medical teams running mobile circumcision clinics.
Kenya has the most successful voluntary medical male circumcision campaign in eastern and southern Africa; since the campaign began in 2008, about 395,000 men have been circumcised - most of these have been performed in Nyanza Province, which has the country's highest HIV prevalence. The country aims to circumcise 1.1 million men by 2013.
While the programme has been successful in convincing younger men to volunteer for the procedure, it has been a tougher sell for older, married men. Programme implementers are looking at new ways of reaching this key demographic - many new infections are occurring within marriage.
"Involving women at the centre of men's decision-making and using already circumcised but married men as peer educators will help bring more married men to the clinics," said Ochieng.
Beyond reaching numeric targets, officials are also concerned by signs that some men are resuming sex before the designated six-week healing period, putting themselves and their partners at higher risk of contracting HIV and other sexually transmitted infections.
A November 2011 study by the University of Illinois at Chicago's School of Public Health found that 31 percent of 1,344 recently circumcised Kenyan men reported engaging in early sexual activity, usually three to four weeks after the procedure.
The research revealed that cohabiting or being in a marriage were the strongest predictors of engaging in early sexual activity.
"People's perception about male circumcision can either help achieve the reversal of HIV infections or help to accelerate [transmission]. If you have a high number of people circumcised and they believe it is some form of full protection, or they resume sex while they still have wounds, then you have problems," said Lucy Waweru, a psychology lecturer at the University of Nairobi. "Specific and targeted communication and messages must be developed to undo these dangerous thoughts. For me, these are serious challenges and could erode the gains made in reaching the set target."
Waweru said lack of adequate counselling for girls and women could also potentially scupper the programme's goals. "It is true the message is out there, but there are those women who don't have the information. This could make it very easy for a man who attends a male circumcision session alone to [tell] a woman that it offers full protection. That potential gullibility of women and girls must be dealt with," she added.
A small 2011 Kenyan study found that more women than men felt HIV was a less serious threat after their male partners were circumcised.
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According to Walter Obiero, the clinical manager at the Nyanza Reproductive Health Society, lack of information had continued to create barriers at the community level.
"Many men shy away from male circumcision - they tell you they cannot miss work for six weeks, meaning they believe that during the six-week healing period, they cannot work, yet this period only bars sexual intercourse," he said.
Under normal circumstances, a man is able to resume work three to four days after being circumcised.
Obiero said counselling women would also help to reduce cases of early resumption of sexual activity. "Men will tell you they fear losing their wives or girlfriends during the healing period, but when you talk to women, they tell you they will be ready to support their men during this time, so long as they have adequate information," he added.
Health system concerns
Experts also fear that as the programme continues to grow, the health system may not be equipped to cope with the demand for male circumcision. Today, only 200 facilities are actively offering it. Obiero noted there was a need to find a firm place for male circumcision within its healthcare priorities.
"Health workers are burdened and there are other priorities that compete. For example, a health worker will be wondering whether to circumcise a man waiting at the clinic or attend to a woman who has come for antenatal care," said Obiero. "Again, the government must create ownership of the programme at the healthcare level because you visit a facility and you ask them their target on the number of men they want to circumcise in a specific period, and they don't know."