The Kindest Cut: Male Circumcision and New Directions in HIV Prevention in Africa

Timecode

Transcript

10:00:03:00 –  10:00:11:00

VO: This is Ben, and in three day’s time, at the age of 19, he will be circumcised as part of a public ceremony to turn the boy into a man.

10:00:46:00 –  10:00:52:00

VO: In Uganda, age old cultural practices are joining modern medicine in the fight against HIV.

10:00:53:00 –  10:01:04:00

Watibini Ben Nicholas I/V and Subtitles: In Bagisu, if you are circumcised, people don’t minimize you as those who are not circumcised. People tend to respect you.

10:00:58:00 –  10:01:02:00

Super: Watibini Ben Nicholas

10:1:05:00 – 

10:01:22:00

VO: Ben is from the Bagisu tribe, in Eastern Uganda, which has one of the lowest rates of HIV infection in the country. With a rate of 5.3 per cent or over one in 20, it is considered low for Uganda, where regional levels can be almost double that. 

10:01:24:00 - 10:01:34:00

VO: It has long been suspected, but only recently proven, that a large contributing factor to keeping the HIV rate down is that nearly all Bagisu men are circumcised.

10:01:33:00 –10:01:45:00

Watibini Ben Nicholas I/V and Subtitles: Yes, I am proud. Actually I heard that the government was encouraging it because it minimizes some diseases, such as AIDS.

10:01:47:00 –10:01:50:00

VO: But tomorrow, Ben’s priorities are with his own reputation.

10:01:53:00 –10:02:03:00

VO: A goat is slaughtered on his grandfather’s grave and the strength of its heart assessed. If the blood flows quickly, Ben will stay strong and not shame his family. 

10:02:05:00 –10:02:10:00

VO: The goat’s heart has foretold that Ben will make it, and his family will be proud. 

10:02:11:00 –10:02:17:00

Wafula Christopher I/V and Subtitles: So I’m one hundred per cent sure that the boy will make it, my son.

10:02:13:00 –10:02:16:00

Super: Wafula Christopher, Ben’s Father

10:02:26:00 –10:02:33:00

VO: A special alcoholic brew is prepared to track Ben’s progress and identify him as the candidate for circumcision.

10:02:34:00 –10:02:45:00

Dr Mulongo Muhamed I/V: To get fully fermented into a brew, it takes three days, so it starts today, he’s going to dance today, tomorrow and then the third day. So on the third day, when it’s full brew, he will be circumcised.

10:02:36:00 –10:02:40:00

Super: Dr Mulongo Muhamed, Program Officer, Medical Services, TASO

10:02:46:00 –10:02:53:00

VO: The exhausting three days of dancing and receiving of gifts is a critical part of ensuring Ben is ready for the big moment.

10:02:56:00 –10:03:15:00

Watibini Ben Nicholas I/V:  If you are alone, or if you don’t get friends or relatives you cannot gain the confidence. Because I fear to be ashamed if I fear. So now I have the confidence in me that I’ll finish well.

10:03:17:00 –10:03:30:00

VO: The actual circumcision used to be carried out by a cultural surgeon using a single knife for multiple young men, without pausing for even a quick wipe of the blade. This effectively cancelled out any potential health benefits.

10:03:33:00 –10:03:38:00

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VO: Now, the cultural surgeons spend three weeks receiving training in modern sterilization and wound management.

10:03:39:00 –10:03:55:00

Master of Ceremonies I/V and Subtitles: At least to boil the knife for at least … not less than 20 minutes. That is when we will begin the surgery. And then later, after cutting, we insert the knife inside the spirit, to clean the germs.

10:03:56:00 –10:04:08:00

VO: This is one of just many HIV reduction strategies fought for by The Aids Support Organisation or TASO, the leading assistance and campaigning group for people living with HIV/AIDS in Uganda.

10:04:10:00 –10:04:28:00.

VO: Dr Mulongo Muhamed is Ben’s first cousin, a Bagisu man and a project officer with TASO. TASO recently had a major win, with the introduction of a nationwide policy of medical male circumcision. This is the first significant change to HIV/AIDS prevention policy in more than a decade.

10:04:29:00 -10:04:49:00

Dr Mulongo Muhamed I/V: Yes, medical male circumcision helps prevent HIV because we are preventing … by circumcising we are preventing the abrasions, the injuries we get on the foreskin of the penis through which the virus passes.

10:04:50:00 –  10:04:55:00

VO: But TASO is wary of the circumcision message encouraging people to have unsafe sex.

10:04:56:00 –  10:05:35:00

Dr Mulongo Muhamed I/V: If the message doesn’t go out so well, people are going to get even more risk sex. First of all we say, after circumcision, delay … no, first of all we say circumcise early … the youths, the young people, for older people, yes circumcise, but also delay sex after circumcision. We need up to six months to allow the period of healing and the changes in the foreskin to take place. Then two, we would say, after circumcision, don’t have multiple sex relationships just because you are circumcised. No.

10:05:36:00 –  10:05:47:00

VO: The six months of healing and the Bagisu cultural choice to take several wives still lies ahead for Ben. For now, it’s show time, and he needs to get through the next ten minutes.

10:05:49:00 –  10:06:08:00

Dr Mulongo Muhamed I/V: We are waiting for Ben to come, to be brought for circumcision.  The relatives here, the father and the uncles they have gathered around and they are taking beer, while they wait for him. In the meantime, they have prepared the ground where he is going to be circumcised from and the surgeons have also prepared.

10:06:09:00 –  10:06:23:00

Dr Mulongo Muhamed I/V: There is already anxiety among relatives, friends. If it all goes well, there’s going to be a lot of jubilation, if he shows any signs of fear, there will be a lot of disappointment among the relatives.

10:06:24:00 –  10:06:32:00

VO: The goat heart hangs from a stake, reminding Ben to stay strong while the spear is a warning of what his father will do to him if he buckles.

10:06:34:00 -10:06:47:00

VO: Nearly the entire district has gathered to see what will happen. If Ben flinches, the damage could be more than his family’s dignity. Candidates have been known to lose part of their penis or suffer serious nerve damage in botched circumcisions.

10:07:47:00 –  10:07:53:00

Wafula Christopher I/V: I am so happy! For my boy to stand courageously.

10:07:55:00 –  10:08:05:00

VO: Ben has come through with pride, maintaining the family’s dignity. But his cousin, Dr Mulongo, doesn’t intend for his own son to go through the same public challenge.

10:08:07:00 –  10:08:19:00

Dr Mulongo Muhamed I/V:  Actually, my son is already circumcised, he was circumcised at 2 and a half years. So I would encourage people to circumcise at an immature age, the medical way, rather than wait for the cultural aspect.

10:08:20:00 –  10:08:36:00

Dr Mulongo Muhamed I/V:  We want it to be part of the strategy for HIV prevention. We would like it to go together with counseling and testing. We want it to go together with abstinence, with faithfulness, with condom use. We want to take it as a package.

10:08:37:00 –  10:08:54:00

VO: A B C, Abstinence, Be Faithful, Use a Condom, is the cornerstone of HIV prevention in Africa. But in countries like Uganda, the numbers haven’t changed and the proportion of people with HIV has remained steady, at around 6.3 per cent. More needs to happen.

10:08:55:00 –  10:09:16:00

VO: The next front on the war against HIV in Uganda is people like John and Rachael. Apparently healthy, middle aged and …. Married. One of the highest risk groups in Africa for contracting the HIV virus is heterosexual couples, because of what is known as discordance, where one partner is positive and the other negative.

10:09:18:00 –  10:09:27:00

Namugowa John Andrewson I/V and Subtitles: We found it out when we went for an HIV test. In fact, I was sick then and it was found out that I tested positive and she tested negative.

10:09:18:00 –  10:09:22:00

Super: Namugowa John Andrewson

10:09:28:00 –  10:09:32:00

VO: Six years on, and John has become a public advocate for HIV prevention.

10:09:34:00 –  10:10:08:00

Namugowa John Andrewson I/V and Subtitles: I never hid myself. First and foremost, we went together for the HIV test. Then after which, we received our results together and from that day on, I think she was counselled, I was counselled how to keep me and how to maintain my life. I was also counselled to maintain her serostatus and up to now, she still remains negative. And the relationship remains more strong than ever it was because she loves me more than ever she used to love me.

10:10:09:00 –  10:10:17:00

VO: Couples like John and Rachael are now in the sights of TASO, as part of an international study into Pre-Exposure Prophylaxis, or PREP.

10:10:18:00 –  10:10:46:00

Dr Akasiima Mucunguzi I/V and Subtitles: PREP is a research that is going on and it targets couples who will be given anti-retroviral drugs to establish whether they can help prevent the one who is HIV negative from acquiring HIV. We are looking at two main objectives, whether PREP works, that is, efficacy, and if it works, is it safe.

10:10:18:00 –  10:10:21:00

Super: Dr Akasiima Mucunguzi, Co-ord, PREP study

10:10:22:00 -10:10:56:00

VO: Despite up to 50 per cent of couples in East Africa being in a discordant relationship, it’s still not easy finding the 4000 couples needed to validate the study.

10:10:58:00 –  10:11:08:00

Dr Akasiima Mucunguzi I/V and Subtitles: Of course, we are dealing with a rural community. So there is a challenge. We find we have to venture so much into making people understand the value of research.

10:11:09:00 –10:11:29:00

VO: And sometimes would-be enthusiastic couples, such as John and Rachael, cannot be part of the study. John’s condition has deteriorated and he needs to be on anti-retroviral therapy, or ART, disqualifying them from the trial. But John has chosen to be involved in another way, by convincing other discordant couples to sign up.

10:11:30:00 –  10:11:58:00

Namugowa John Andrewson I/V: I was selected on our committee which takes in about ten districts on the eastern side of Uganda to be the representative of discordant couples. I have a very big role to play, very big indeed, because if I don’t convince the discordant couples, they might not come up but my work, of course, is to talk to them.

10:11:59:00 –  10:12:08:00

VO: There is no magic bullet to stop HIV spreading in Uganda, but the work of individuals like John and the people at TASO give hope for the future.

10:12:19:00 –  10:12:26:00

Namugowa John Andrewson I/V: There’s a very nice mango this way, but I think I’m very very short!

10:12:30:00

ENDS