• November 13th, 2018
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Knives out: A day at the recently opened VMMC clinic



WINDHOEK – It was on a sunny Monday afternoon at around 14h00 when this reporter walked into the waiting area of the Voluntary Medical Male Circumcision (VMMC) clinic at the Katutura Health Centre.
There, 21-year-old David Nehale anxiously awaited his turn to be seen by a nurse. 

While fiddling with his hands and promptly responding to questions by this reporter, Nehale said he had for a long time contemplated getting the “smart cut”. 

But on 6 August he visited a clinic in Windhoek for a HIV test. There, the nurse encouraged him to consider circumcision “because it reduces the risk of contracting HIV by 60 percent”. 

The VMMC clinic at the Katutura Health Centre, which  officially opened in September, has the capacity for 20 circumcisions per day and 400 per month. By Saturday (13 October) 140 men had been circumcised at the facility. 
During New Era’s visit to the facility, the chairs were empty with only Nehale present who was later joined by 26-year-old Temani Andrew Kock who had also agreed to share his “smart cut” journey with the newspaper. Kock walked into the clinic in a rather cheerful mood, introducing himself to this reporter. Minutes later, Kock’s cheerfulness was replaced by silence.  “Are you nervous?” I asked him. “I hate needles. I don’t like needles at all,” he laughed, as he fiddled with his sunglasses. Not long after that, the nurse called Kock into the examination room where he would be prepared for what awaited him.  In the examination room, clients are given information on general hygiene and other health information, including the benefits of circumcision, and asked their medical history and if they are willing to take a HIV test. This lasts about 15-25 minutes depending on the patient’s medical history. 

This is important because there are some medical conditions that may make a client ineligible for circumcision, explained the nurse surgeon at the VMMC clinic, Jona Johannes. 

Meanwhile, Nehale too admits that he is nervous. “I’m a little bit nervous but I have to go for it because I’m doing this for myself,” Nehale said. 

In fact, he has done a little reading on circumcision and knows that the partner of a man who is circumcised is less likely to get cervical cancer, he shares. 

Not so long after that, Nehale was also called to the examination room, where he too would go for eligibility tests and the health information session. 

Both were cleared and were told that they were eligible for the “smart cut” and the moment of truth had finally arrived for the two men, who said they were more anxious about the pain they would experience than anything else. 
Dr Lawrence Kahindi, a general practitioner who is also contracted by AIDSFree Namibia to conduct circumcisions under their project, was present to attend to one of the two men. 

Kock was the lucky one, or maybe not. The thought of being attended to by a doctor didn’t make him less nervous and as he was told to undress and lie on the bed, the doctor tried as much as possible to make him comfortable by diverting his mind from the procedure that was to take place. 

Dr Kahindi spoke to Kock throughout the procedure and at one point the patient shared why he dreaded the cut.  A colleague who had undergone the cut had told him that he was injected 12 times during procedure.  “When I came here I contemplated going back home several times but then I told myself that I can’t keep delaying this,” Kock later told New Era. He said the procedure was not what he expected. “I had a strange sensation because the foreskin was removed,” said Kock. The two were required to return to the clinic two days later for a post-procedure assessment.

Kahindi said there are many myths associated with medical male circumcision. “The men come here expecting a lot of pain but they are surprised that is not the case,” Kahindi said. 

There is also a myth that it is better to get circumcised during the winter, for the wound to heal faster, added the doctor. As a result, not many men show up for circumcision during summer.  

“That is why the clinic is so empty,” Johannes elaborated on why the clinic was practically empty.  VMMC is a biomedical intervention in HIV prevention and is part of the Ministry of Health and Social Services’ combination prevention strategy. 
The national strategy is to reach 80 percent (or 300 000) men and boys between the ages of 10-49 with VMMC services by 2021.

Private patients who want to get the smart cut are not excluded from the VMMC services. Since October 2014, these services have been availed to the general public in the Khomas region. 

Currently, 16 private health facilities offer VMMC services to the public and those without medical aid can also get a smart cut at these facilities.  This is possible because of the United States Agency for International Development (USAID) support through AIDSFree. 

AIDSFree Namibia is leveraging and engaging private sector resources to achieve HIV epidemic control. AIDSFree provides targeted assistance to private healthcare providers to increase access to affordability and quality of HIV services, in particular VMMC. 

This partnership has allowed 35 000 men and boys to access medical circumcision in a private clinic, the Governor of the Khomas region, Laura McLeod-Katjirua, said at the opening of the VMMC clinic at the Katutura Health Centre in September. 

The U.S. Ambassador to Namibia, Lisa Johnson, explained at the same event that circumcision under the AIDSFree programme is paid for by medical aid, from which private providers claim directly. 

“But, the programme equally welcomes clients who do not have medical aid. Their circumcisions are covered by a subsidy that PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) provides to the private providers,” said Johnson. 
Through this approach, the programme has successfully reached men who otherwise would not have benefitted from this public health intervention, the U.S. ambassador explained.  But Kahindi said they are not getting the numbers they want in terms of men seeking VMMC services. However, men are not necessarily against circumcision, stated Kahindi. 

They are just procrastinating. “When we tell them to consider circumcision now they will tell us that they will come in the winter and when it’s winter they come up with another reason why not to get the smart cut,” he said. 

The numbers vary, he added. For example, during the April-May school holidays, the men circumcised under the AIDSFree Namibia project varied between 350-400 in a week. 
In September, they circumcised about 100 per week. “The capacity to offer more is there. 

The men need to make the decision and come,” said Kahindi. Eric Atkins, the Public Affairs Officer at the U.S. Embassy, said PEPFAR Namibia works with the Ministry of Health and Social Services to address some of the challenges to men being medically circumcised. “One of the challenges faced in Namibia is the distance to healthcare services,” Atkins said.  
PEPFAR has supported the expansion, renovation or building of VMMC clinics, added Atkins. 
Likewise, PEPFAR has provided funding to support the use of mobile clinics that are able to bring services directly to communities. 

The health ministry has also been educating communities using innovative approaches such as inviting artists such as The DOGG, real name, Martin Morocky, who appeals directly to young men, to be the VMMC ambassador.

Morocky said he has been educating the public on circumcision for the past two years and has seen a change in men’s attitude towards circumcision. “In the beginning, it was difficult to get men to listen to the message on circumcision but now they are coming, the hospitals are full. People call me all the time wanting to get more information on circumcision,” said Morocky.  

Medical male circumcision is crucial because it is one of the interventions in addressing the problem of HIV, said Morocky.  According to the NAMPHIA results released this year, HIV prevalence in adults aged 15-64 is at 12.6 percent. This is a further decrease from the 2013 Demographic and Health Survey (DHIS), which reported a 14 percent HIV prevalence for ages 15-49 and 16.4 percent for ages 50-64. 
 “People shouldn’t be shy. Men are getting cut, their health should be more important than anything else,” said Morocky. 

The benefits
There is a 60 percent reduction in the risk of HIV infection, commented Atkins.  “Through high-quality care, and the provision of clear and simple information, the public is increasingly being informed about the benefits of VMMC,” said Atkins. 

Asked about the benefits circumcision has for women, Kahindi jokingly responded: “The women should tell us what their preference is. It’s at a personal level. I believe there are unrevealed benefits.” 
Some men walk into the facilities for circumcision because their partners have insisted they get the “smart cut”, said Kahindi. 

“You’d be amazed at the influence of a woman on a man,” the soft-spoken doctor added. Circumcision goes beyond medical reasons, commented Kahindi. “It’s (the penis) much cleaner and it looks better.”  

Complications
The wound takes one week to heal, and, sexual intercourse is “highly” discouraged until after six weeks after the procedure, to reduce the risk of infection. 
“This is because the skin is not fully recovered and engaging in sexual intercourse during this period might rupture the wound,” the doctor explained. 

The Health Communities website reports that as with all surgical procedures, with circumcision, there is a risk of bleeding and infection. 

Other risks include severe bruising (hematoma), poor cosmetic result, and a change in sensation during sex.
Because men who want to be circumcised are required to undergo a medical examination, their eligibility for circumcision is determined, and as a result, complications during the procedure are rare, said Kahindi. 

Kahindi stressed that hygiene cannot be underestimated before and after the medical circumcision procedure. 
“They should shower or bath before they come for the procedure and they should put on clean underwear,” the doctor advised.  

After the procedure, they should equally maintain good hygiene to decrease the risk of infection, he stressed. For some men, circumcision is an old cultural practice. New Era spoke to Rapanda Adam Uarukuijani who has been circumcising boys and in some instances men for the past 22 years.  Among others, the Ovaherero and Ovazemba communities have been practising circumcision under their culture for many years, he said. “The Ovaherero have been practising circumcision for hygiene purposes but these days there are also medical benefits,” he said. Circumcision among traditionalists has now become a business, said Uarukuijani.  

“There are more people practising circumcision in the community now. It is really more like a business. I charge N$250 to circumcise a child and if it’s outside Okakakara and transport is required I can charge N$300 depending on the distance,” he said. 

Uarukuijani’s clients have to bring their own gloves and a razor blade, which he discards immediately after use. The healing process takes up to two weeks, depending on how fast the person recovers, said Uarukuijani. 

“I always encourage my clients to keep the wound clean to reduce the chances of infection,” he said. He warned others practising circumcision the traditional way to maintain hygiene to reduce the chances of spreading diseases. 
Atkins, who stressed the importance of medical circumcision, said it is vital when undergoing circumcision that the equipment used is sterile and the patient is clearly informed about how to care for the wound after the procedure.

“Healthcare providers who perform medical circumcision are highly trained and their performance is closely monitored,” said Atkins. 


Alvine Kapitako
2018-10-15 10:12:10 29 days ago

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