Mission impossible: The journey to a million circumcisions

“Despite there being enough evidence that male circumcision reduces chances of contracting HIV, it just won’t be accepted in Zimbabwe!”

“1,3 million men by 2017! It’s a mere dream and might not be worthwhile investing in such a futile mission in Zimbabwe.”

Well, these were but some of the many views that some stakeholders and individuals had in 2009 when the Ministry of Health and Child Care (MoHCC) was seriously considering adopting a new effective way of preventing HIV in Zimbabwe.

Some were outrightly convinced that it just would not be possible.

As the naysayers rumbled on, the MoHCC and its partners decided to embark on one of the most ambitious public health initiatives ever undertaken in the history of the fight against HIV in Zimbabwe. New HIV infections were still high amongst the different population groups, and without a doubt, this had to be done.

So what was the mission?

The mission was to begin a comprehensive consultation process of how to circumcise adolescent and adult males at a rapid scale as the impact modelling that had been carried out showed that if 80 percent of the male population aged between 10 to 29 years were circumcised by 2017, then the following results would be achieved: 212, 000 new HIV infections would be avoided by 2025. US$1,13 billion would be saved from medical bills that would have been incurred from people who would otherwise get infected if they were not circumcised.

With such evidence, ‘mission impossible’ began. And truly, what was ‘mission impossible’ in most people’s eyes soon was to become one of the most successful public health interventions.

Setting the pace

Traditional chiefs, religious leaders, parliamentarians, researchers, civil society, human rights activists, people living with HIV and many more constituted the key groups who were consulted extensively before the voluntary medical male (VMMC) program began.

Their invaluable input constituted what was to be the National MC Policy to provide the overall framework of how circumcision was to be provided in Zimbabwe, upholding the safety and rights of every client who went through the program.

Starting with a few pilot sites, men started trickling in slowly at sites such as Spilhaus in Southerton, Harare, their motivation and convictions being different.

Some had desperately wanted to get circumcised, but the cost before this program was introduced was the prohibiting factor. Some, despite having been sexually active for years, were silently agonising from congenital problems such as ‘phimosis’, hypo or hypospadias, and many other related problems.

Some just saw the golden opportunity of enhancing their chances of reducing HIV, especially after seeing the gory years before the introduction of antiretroviral medicines, where almost every Zimbabwean could literally see the effects of HIV right in their face. Some were just motivated by the fact that it would help them maintain better hygiene for their ‘prized possession’. Whatever your motivations were (for those reading this and have been circumcised through this program), you made that bold decision to be in charge of your own sexual health. Well done!

Gaining momentum

As the years went on, the program started achieving its annual targets. At some point, the demand outweighed the supply. Queues started being very visible at the circumcision centres across the country. A few innovative changes were then introduced in VMMC in Zimbabwe.

A rapid introduction of new circumcision sites across the country was done. What was initially reserved for medical doctors, was now also opened up for nurses as evidence showed that upon appropriate training, nurses could also competently provide the circumcision services.

New innovative ways of circumcising were also introduced, like the PrePex Ring, which became quite popular with the adult male population.

Now, every district in Zimbabwe offers safe voluntary medical male circumcision services and with this drive, we can put a smile on our faces as we have managed to circumcise over 1,2 million men in Zimbabwe so far! We haven’t yet reached 1,3 million, but at the current rate of circumcisions per month, we will hit this mark in only a few months to come.

2017 saw the highest number of MCs being done in the country as the program in August achieved 10 000 circumcisions in just one week across the country. This was a true sign of how Zimbabwean men have gone against the tide and proven that their health is their responsibility and they will make wise decisions for it.

With the popular mantra, ‘Pinda muSmart/Ngena kuSmart, Get Circumcised Today’, Zimbabwean men have listened to the clarion call to get circumcised for the health benefits.

Let me hasten to say that circumcised men are still counseled and encouraged to continue abstaining from sex if they are not yet sexually active and for those that are sexually active, they are encouraged to be faithful to one sexual partner and to also use condoms correctly and consistently.

Growing pains

Well, this is not to say it has been a smooth sail all the way. Despite all these successes in policy shifts, service delivery and demand creation innovations, the program has witnessed a fair share of challenges.

Zimbabwe has faced the challenge of losing human resources and this did not spare the health sector, let alone the VMMC program as many doctors and nurses have left the program after being trained and mentored on how to provide safe circumcision services.

Whilst most communities have seen a sustained high demand for the service over the years, some few communities have seen low numbers of men coming in and this is in spite of the fact that new HIV infections are high in those areas.

In this regard, the MoHCC and its partners, the Population Services International and the ZAZIC consortium, have continued to explore more innovative approaches in creating demand in such communities.

Sustain the gains, increase the pace

We are proud to say that Zimbabwe has received numerous accolades for this program, including being recognised by a team of external assessors for having one of the safest programs scoring above 90 percent. The external audit assessments looked at the quality of circumcision procedures being done; the quality and depth of the counselling; adherence to national policy and international guidelines on safe circumcision services, amongst other things. As we rapidly move closer to circumcising the initial 1,3 million men, the VMMC program will, from 2018 going forward, begin the process of making this service one of the routine services offered in health facilities across the country, which is called the sustainability phase. While the targets remain high, the benefits will continue to be enjoyed as the country seeks to end Aids by 2030. A big thank you to the stern leadership that has been shown in this programme as what was initially thought of as ‘mission impossible’ has truly and clearly proven to be ‘mission very possible’ as more than one million men, including this writer, are truly enjoying improved health.

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  • Claiming that circumcision prevents a health problem is a compulsion of circumcised men to have done to others what was done to them. Historically, this compulsion has led to over 200 potential health claims for circumcision. All have been refuted. Thirteen national and international organizations recommend against circumcision. Search “circumcision information summary” to learn why.

    The foreskin has various functions that contribute to sexual experience for both partners. It contains thousands of nerves and expands sensitivity. Cutting it off is like cutting off a thumb believing the hand will work better. Search “functions of the foreskin.”

    Many professionals have criticized the studies claiming that circumcision reduces HIV transmission. The investigators did not seek to determine the source of the HIV infections during their studies. They assumed all infections were heterosexually transmitted.

    Many HIV infections in Africa are transmitted by contaminated injections and surgical procedures. The absolute rate of HIV transmission reduction is only 1.3%, not the claimed 60%. Even if the claim were true, based on the studies, about 60 men had to be circumcised to prevent one HIV infection.

    Authorities that cite the studies have other agendas including political and financial. Research shows that circumcision causes physical, sexual, and psychological harm. This harm is ignored by circumcision advocates. Other methods to prevent HIV transmission (e.g., condoms and sterilizing medical instruments) are much more effective, much cheaper, and much less invasive. Even HIV/circumcision studies advise using condoms. With condoms circumcision adds no benefit to HIV prevention.

  • Paul Mason

    Was never going to work and was always cultural colonialism by a bunch of American circumcised men and their financial backers who needed to persuade “backward” Africans to look like them. Racist assumptions that Africans un-educatable and driven by dark and uncontrollable forces. Prevent HIV = safe sex or PReP.

  • Michael Butscher

    Among the other problems with circumcision there is also the possibility of risk compensation, meaning that feeling safer leads to riskier behavior up to the point that the risk is higher than without the safety measures.

  • Kiwi

    Studies have found that African men pressure women not to use condoms because they falsely believe circumcision acts as a “vaccine” against diseases.