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An AIDS-Ravaged Nation Turns To Circumcision

Joseph Ochieng, 18, gets circumcised at the Siaya General Hospital in western Kenya. (NPR)

The African nation of Kenya is attempting to get more than 1 million men between the ages of 15 and 49 circumcised by the end of 2013. If successful, this could be a groundbreaking effort in the fight to curb the spread of HIV.

Other African nations have also launched circumcision drives, but none have been as successful as Kenya. So far, more than 400,000 Kenyans have undergone the procedure. The Kenyan Ministry of Health is using a blitz of advertising, community organizers and mobile clinics to try to get traditionally uncircumcised men to go for what they're calling "the cut."

Studies have shown that circumcision can reduce the risk of a man's contracting the virus by as much as 60 percent.

In Kenya, the Luo tribe, which traditionally hails from the western part of the country, doesn't practice circumcision. The rate of HIV among Luo men was 13 percent in 2009, the latest year for which figures are available. This is more than three times the rate among tribes that do circumcise.

"In the province ... it is not a culture that men are circumcised," says Dr. Charles Okal, the provincial coordinator for AIDS and sexually transmitted infections at the Kisumu District Hospital.

Okal says when they launched the circumcision drive here in Kisumu in 2008, many people scoffed at it. He says friends told him he'd never be able to get Luo men to go against tradition and voluntarily be circumcised.

"We had to convince the community that this is a procedure which is proven," he says, "and that it will help us reduce the prevalence rates of HIV that we have."

The circumcision campaign in Kenya involves foot soldiers driving around neighborhoods with bullhorns, preaching the benefits of the free procedure. Peer educators canvass markets, handing out leaflets and trying to sign up men for appointments at local health facilities. Special mobile circumcision clinics are set up in gyms, churches, youth centers and even in tents in some remote villages. A program was launched to train nurses and other health care workers in how to perform the operation.

At a circumcision clinic in Kisumu, 24-year-old Mercy Aching says there has been a cultural shift in this part of Kenya; now most young men want to get the procedure. Aching has brought her two younger brothers, Lucas and Hemsted, to be circumcised.

"Now everybody's circumcised," she says. "Even these small boys, they want this thing." Aching and her brothers lost both of their parents to AIDS.

"Our dad died in 2000 and mum in 2006," she says.

She says she believes the death toll from AIDS is part of what's motivating so many teenage boys to get the procedure. At the clinic, counselors explain to the boys that circumcision isn't a magic shield and that they should also use condoms to protect against HIV.

Health officials in the region say young men have accepted circumcision, but it has been harder to convince older men.

In many parts of Africa, circumcision carries major cultural implications.

Among some tribes it serves as a right of passage into adulthood. Among others, the foreskin has been viewed as part of their cultural identity. During the deadly tribal clashes in Kenya in 2007 and 2008, there were reports of Kikuyu youth forcibly circumcising Luo men in the streets.

But some of the resistance to this public health campaign is much simpler: Many men are afraid of the procedure; others who earn just enough money each day to feed their families don't want to be off work while they heal.

At the fishing village of Osindo on Lake Victoria, Kwinta Ochola is trying to persuade a dozen highly skeptical men to sign up for circumcision appointments at the local health clinic.

The men fish here by wading through shallow parts of the lake, dragging large nets. Ochola explains that after the operation, they'll have to stay out of the water for at least three days.

The chairman of the fishermen wants to know who is going to pay these men for their lost earnings. He says they can't afford not to work for three days.

The only material compensation offered after the surgery is a bottle of warm orange soda and a pair of tight white briefs.

Nationwide, AIDS has had a deep impact in Kenya. Roughly 6 percent of adults are infected with HIV.

Benard Otieno, 20, says he had the procedure three years ago, soon after the campaign started. At that point, Otieno says, it was practically unheard of for a full-grown Luo man to go to a clinic and have his foreskin removed.

"Now, I'd say 90 percent of my friends are circumcised," he says.

Otieno is in college studying to be a teacher. He says among young Kenyans, circumcision is now viewed as a patriotic act. Otieno says he and his friends talk about wiping out AIDS in Kenya. "We want to be a generation without HIV/AIDS," he says. "Circumcision will help the future of Kenya."

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ROBERT SIEGEL, HOST:

This is ALL THINGS CONSIDERED from NPR News. I'm Robert Siegel.

MELISSA BLOCK, HOST:

And I'm Melissa Block.

Kenya is in the middle of a groundbreaking public health effort to curb the spread of HIV. It's attempting to get more than a million men circumcised by the end of 2013. Other African nations have launched circumcision drives but none has been as successful as Kenya's. So far, more than 400,000 men have undergone the procedure.

NPR's Jason Beaubien reports the Kenyan Ministry of Health is using blitz of advertising, community organizers, and mobile clinics to get uncircumcised men to go for what they're calling The Cut.

(SOUNDBITE OF MACHINERY)

JASON BEAUBIEN, BYLINE: This is Kisumu, a city of about a half a million people in western Kenya. It's on the shore of Lake Victoria near the border with Uganda. In the streets here, bicycle-taxis known as bodabodas mix with cars and three-wheeled jitneys and overcrowded matatus, the vans that serve as the main form of public transportation here.

Kisumu is home to the Luo tribe. It's also the heart of the AIDS epidemic in Kenya.

DR CHARLES OKAL: In the province where we are, it is not a culture that men are circumcised.

BEAUBIEN: Sitting in the overgrown garden of the Kisumu District Hospital, Dr. Charles Okal says when they launched the circumcision drive here in 2008, many people scoffed at it. Okal is the provincial coordinator for AIDS and sexually transmitted infections. He says friends told him he'd never be able to get Luo men to go against tradition and voluntarily be circumcised.

OKAL: We had to convince the community that this is a procedure which is proven that it will help us reduce the prevalence rates of HIV that we have.

BEAUBIEN: And those rates are high. A study by the Kenyan government in 2007 found that uncircumcised men in the country are three times more likely to be HIV-positive than their circumcised counterparts. That same year, another study showed that circumcising adults reduced their risk of contracting the virus by 60 percent.

Health officials decided to launch an all-out offensive to convince Luo men to change their customs and get The Cut.

UNIDENTIFIED MAN: ...male circumcision...

BEAUBIEN: The campaign involves foot soldiers driving around neighborhoods with bullhorns, preaching the benefits of the free procedure. They canvas markets handing out leaflets and trying to sign up men for appointments at local health facilities from. Special mobile circumcision clinics are set up in gyms, churches, youth centers, and even in tents in some remote villages. A program was launched to train nurses and other health care workers in how to perform the operation.

(SOUNDBITE OF RINGING PHONE)

BEAUBIEN: Twenty-four-year-old Mercy Aching is the only woman sitting in the waiting area of a circumcision clinic in Kisumu. Aching has brought her two younger brothers to be circumcised. Sixteen-year-old Lucas is currently in the operating room, 15-year-old Hemsted is up next.

MERCY ACHING: We've lost our mom, our mom and dad because of HIV-positive. So they don't like that disease. Yeah.

BEAUBIEN: The lanky Hemsted slouches in this chair next to his older sister. He isn't very talkative. But Mercy Aching says her brothers pleaded with her to bring them in for the procedure.

ACHING: You know, in Nyanza, many people are not circumcised but now everybody. Yeah, everybody circumcised and even these small boys, they want to this thing. And they wanted it because many of their parents are dead because of HIV. So I think they want it real so much.

BEAUBIEN: Health officials here say teenagers have accepted circumcision, but it's been much harder to sell the idea to men in their late 20's or older, even though those older men have seen more of the devastation AIDS has caused. In just about any social situation, it's difficult to discuss cutting a delicate part of someone's body. But in Africa, circumcision also carries major cultural implications.

Among many tribes it serves as a right of passage into adulthood. Among others the foreskin has been viewed as part of their cultural identity. During the deadly tribal clashes in Kenya in 2007 and 2008, there were reports of Kikuyu youth forcibly circumcising Luo men in the streets.

But some of the resistance to this public health campaign is much simpler. Men who earn just enough money each day to feed themselves and their families don't want to be off work while they heal.

(SOUNDBITE OF MUSIC)

BEAUBIEN: At the fishing village of Osindo on Lake Victoria, long, narrow, brightly-colored wooden boats are pulled up on the beach. So-called community mobilizers from the Nyanza Reproductive Health Society have set up a table with brochures under a tree where the fishermen normally weigh their catch. The health care workers brought a giant boom box to attract attention.

About a dozen highly-skeptical men crowd around Kwinta Ochola asking her why they should participate in the circumcision program.

The men fish here by wading through shallow parts of the Lake Victoria, dragging large nets. Ochola explains that after the operation they'll have to stay out of the water for at least three days.

KWINTA OCHOLA: Or maybe bed for three days. Three days (Foreign language spoken)

BEAUBIEN: The chairman of the fishermen wants to know who's going to pay these men for their lost earnings. He says they can't afford not to work for three days.

The only material compensation offered after the surgery is a bottle of warm orange soda and a pair of tight white briefs. Counselors also explain safe sex practices. The men are tested for HIV and offered access to treatment if they're positive.

(SOUNDBITE OF SINGING)

BEAUBIEN: Nationwide, AIDS has had a deep impact in Kenya. Roughly six percent of adults are infected with HIV. On this morning, an AIDS support group is convening at the Siaya District Hospital. About 60 people are sitting under the broad canopy of an acacia tree in the courtyard of the compound. A blind man complains that the generic AIDS drugs given out at the hospital all come in the same sized bottle and he can't tell them apart.

UNIDENTIFIED MAN: (Foreign language spoken)

BEAUBIEN: After him, a woman talks about how she's been so sick she can no longer work in her cornfield.

In the building just behind the AIDS support group, five young men are lined up in a clinic waiting to be circumcised. Among youth here, it's become the thing to do.

Twenty-year-old Benard Otieno had the procedure at this clinic three years ago.

BENARD OTIENO: I decided to come and to reduce the chances of me getting the killer disease.

BEAUBIEN: Otieno is in college. He's studying to be a primary school teacher. He says he'd seen the advertisements about male circumcision but it was his friends who convinced him to go get The Cut.

OTIENO: And now, I'd say 90 percent of my friends are now circumcised.

BEAUBIEN: Now he views circumcision as a patriotic act. Otieno says he and his friends talk about wiping out AIDS in Kenya.

OTIENO: We want to be a generation without HIV-AIDS. So, circumcision will help the future of Kenya.

BEAUBIEN: If Kenya can stop having to deal with HIV, he says, the country will have more money to spend on roads and schools and development.

Jason Beaubien, NPR News. Transcript provided by NPR, Copyright NPR.

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