Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health; Department of Anthropology, Moi University; Brandeis University

This paper shares information and findings from a study conducted in Bungoma district, Kenya. According to the authors, over 35 observational studies and three randomised controlled trials from sub-Saharan Africa have shown that male circumcision reduces the risk of HIV incidence by approximately 60%. This paper states that male circumcision interventions in high HIV prevalence areas would be at least as cost-effective as any of the other evidence-based HIV prevention tools. It suggests that there needs to be more awareness-raising and training on male circumcision, as well as increased awareness to place it in the context of HIV prevention. It also proposes that African health workers performing male circumcision need better tools and more training to avoid high rates of complications.

The study found that there are more complications from traditional and medical circumcisions of adolescents in Bungoma than from clinical circumcisions performed on infants in developed countries. Although male circumcision is practiced universally in Bungoma, the study found many clinicians in Bungoma were not trained formally and lacked clean and sharp instruments. When practitioners were asked if they felt that they were adequately trained to perform circumcisions, only one - a medical practitioner working as a nurse in a government health facility - responded "no". Nevertheless, when asked if they would like further training, about half in each group felt that they could benefit from additional training.

Despite being a long-standing tradition in the community, fathers and older men lacked knowledge about wound care and the detection of complications. The authors suggest that raising the awareness of parents, guardians, and the initiates themselves on proper post-operative wound care and recognition of symptoms that require medical assistance could reduce the frequency and severity of adverse events significantly.

According to the paper, it became clear from both the observations of the circumcision outcomes and the interviews with medical and traditional practitioners that further training of practitioners in medical settings is required. Routine formal training in proper circumcision techniques should be integrated into the curricula of training colleges and made part of the required supervised practical for clinical officers and nurses. Roughly half of the medical practitioners who were interviewed expressed a need for training. Training should include pre-operative assessment, assessment of instruments, supplies and facilities, sterilisation techniques, patient informed consent, proper patient preparation, surgical procedures, pain management, post-operative care, counselling about wound care, recognition and treatment of adverse events, and referral to tertiary centres. Male circumcision should not be considered a stand-alone medical procedure for HIV prevention, but rather be incorporated into a full complement of HIV prevention and reproductive health services, including, but not limited to, counseling about safe sex, diagnosis and treatment of sexually transmitted infections, HIV testing, and referral to HIV treatment and care. Therefore, training should include education about these additional HIV prevention methods.

Email from Tula Michaelides on September 3 2008 and WHO Bulletin, Volume 86: 2008.