Aaron Lubega rides his motorcycle into the Bbali Health Centre IV, in Kayunga district, Uganda. Clad in blue jeans, the 30-year-old walks quickly into the counseling tent.
Aaron was circumcised a week ago. He is here at the mobile clinic for follow up.
“Even after the cut I was wearing jeans but inside I had tight underwear to keep the penis in one position. I rode to town an hour after the surgery,” said Aaron, who has two sons, aged six and nine.
Aaron is a police officer who decided to have the ‘cut’ to prevent sexually transmitted diseases and to keep good hygiene when in the field, saying that he spends many days without bathing when on duty and his colleagues who are ‘cut’ are cleaner.
Uganda is aiming to circumcise 4.2 million men in five years aided by new technologies that reduce circumcision surgery time. A mobile clinic to reach remote areas and most at risk populations like fishermen has now been launched to make this goal a reality.
Public health experts say it is important to reach a critical mass of people to create an impact. The more people circumcised, the more HIV infections averted,” said Mark Breda, program manager Makerere University Walter Reed Project (MUWRP).
Already, World Health Organization has endorsed safe medical male circumcision (MMC) as an effective HIV prevention strategy, based on research findings that it reduces the risk of HIV acquisition of circumcised men by 60 percent.
The MMC mobile clinic, the only safe MMC mobile clinic in East Africa, was custom built in South Africa and funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Makerere University Walter Reed Project (MUWRP).
“The mobile clinic can provide circumcision services to the hardest to reach, most at risk populations in Uganda safely and at a cost saving. We can circumcise more people per day at a fraction of the cost,” said Breda.
Since it was started in November 2010 about 7,000 men have been circumcised. At its first location, a remote fishing village in Northern Kayunga District, more than 300 men were circumcised in three months.
Inside the MMC mobile clinic is a self contained surgical unit and two surgical beds. The smell of Jik, a disinfectant, hangs heavily in the air outside.
In a day, 35 to 40 circumcisions are carried out using technologies that are safe and cheap, said Dr. Peter Masaba the prevention coordinator at MUWRP.
The MMC mobile clinic uses a new technology, MOVE, which combines task shifting to optimize staff and space. Proficiency is important for the approach, with a nurse doing more of the mundane tasks than a doctor.
“You divide labor. Everyone is on the move all the time. When you stand you break the move,” explains Masaba, who is also a surgeon at the mobile clinic.
Dr Masaba added that procedures will not take more than 15 minutes unless the client has a problem. A total of 99. 5 percent of all clients are discharged after an hour, having undergone a procedure lasting between 8 to 20 minutes, half the time of a normal medical facility.
There is hope by MUWRP that other partners will replicate this new delivery method.
At the MMC mobile clinic, circumcision is free due to PEPFAR’s support while at national referral hospitals it costs up to 80,000 to 140,000 shillings, rising to 400,000 shillings in private hospitals.
Counseling services;
Student Godfrey Aganza is one of the clients about to undergo the ‘cut’ at Bbale health Centre IV where the mobile clinic is parked. But first, the 18-year-old will undergo counseling in a tent adjacent to the clinic.
In here, Godfrey will discuss sexually transmitted infections (STIs), HIV/AIDS, family planning and general health education. He will also undergo a series of counseling sessions about the risks and benefits of medical male circumcision.
The commonest question among clients is whether erections become painful after being circumcised, says Isaac Kasozi a counselor at the site. The myth most widely held by clients is that circumcision is a family planning method.
The men hoping to be circumcised must also pass a basic physical and written test examination to test their understanding on the issues raised during the counseling sessions and in the education materials.
One of the questions asked is how long a man needs to abstain after circumcision. There are multiple choices but the right answer is 42 days, even after the wound heals. Those who fail this pre-service test are put on one-to-one training until they pass. Success in the test is a prerequisite as it helps them understand what circumcision means.
The men also have to undergo an HIV test but picking the results up is optional. Fortunately, said Masaba, all of them want to know their results and most of them are negative.
The few who do not qualify may have a heart problem, an allergy to the medicines used at the clinic, be on drugs or have congenital abnormalities on the penis such as the position of the urethra. These cases are referred to a specialist, said Masaba.
After counseling, Godfrey moves with his file to the next tent where they take his records and he consents to the surgery. Consenting age is 18, below that (up to 15 years) clients must assent with parent attending to give consent on their behalf. The average age for the procedure is 15 to 35.
Godfrey later emerges from a tent in a green theatre gown. He joins other men waiting to enter the mobile clinic, which takes two at ago.
The mood is jovial with jokes and laughter. But some are visibly frightened. Asked why they have chosen to be circumcised, replies include:to reduce STIs, to have better sex, my wife demanded it, my penis is too big, you become efficient, it is easier and faster to put on a condom.
Most of the men heard about the free service from a friend. MUWRP also conducts community sensitizations on circumcision with local political, religious and opinion leaders for each site. In addition, they advertise the service via loud speakers at market places, on community radio stations and on centrally located billboards.
The mobile clinic is parked at a central referral and the patients receive a follow up after surgery. They come back for these follow up visits on day 7 and day 30 to ensure their wound has healed completely.
“When we leave a place there should be referral. MMC is not an isolated programme it is the activity of the Ministry of Health,” said Masaba.
“I was pricked (for sterilized) then felt nothing. They just told me they had finished. Cutting took only about five minutes,” said Godfrey ready to go home.
