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Siyayinqoba Beat It! Episode 14 –

Circumcision

In this episode of Siyayinqoba Beat It! the team looked at the findings of the Orange Farm study that found that male circumcision substantially reduces the risk of HIV infection for the circumcised male. What implications should these results have on prevention strategies in South Africa? How can the benefits of circumcision be introduced to men without compromising or undermining other prevention strategies? The support group discussed these questions and also discussed what other benefits can and should be derived from traditional Xhosa circumcision.

Shalom Ncala: Molweni siyani amukela kusiyayinqoba Beat it! Igama lami ngu Shalom Ncalo. Ku Beat It Support Group sonke siphila negciwane ne HIV.Njalo ngeviki siyahlangane sixoxe ngezinkinga ezithinta ukuphila kwethu,kungaba yikunciphisa ukuncindezela ingqondo noma ukukhuluma ngezocansi. uSiyayinqoba nguhlelo lwakho loku phila kangcono ne HIV. Uma uphila negciwane leHIV, noma unesithandwa, yilunga lomundeni noma umungani ophila negciwane le-HIV uSiyayinqoba ungowakho. Intlololovo yamuva eyenziwe e-Orange Farm nase Uganda isikisela kakhulu ukuthi ukusoka kunengxenye ekhulu ekuvimbeleni ukusakazeka kwegciwane le-HIV. Namuhla sixoxa ngalokho okutholakele futhi sibheke ukuthi ukusoka kuyawanciphisa na yini amathuba wokhuba amadoda athole leligciwane. {isiZulu} [Hello and welcome to the Siyayinqoba Beat It! Support Group. My name is Shalom Ncala. In the Beat It! Support Group, we are all living positively with HIV. Each week, we get together to discuss issues that affect our lives, form stress reduction to talking openly about sexuality. Siyayinqoba is your guide to better living with HIV. If you are living with HIV, or you have a partner, a family member or a friend who is living with HIV, Siyayinqoba is for you! Recent surveys in Orange Farm and in Uganda strongly suggest that circumcision has a big part to play in preventing the spread of HIV. Today we discuss these findings, and explore whether being circumcised reduces the risk of infection in men.]

Question: Ulwaluko lwani lungandinceda njani ndinga tholwa yintsholongwana kagawulayo? {IsiZulu} [Does circumcision reduce the risk of HIV infection in men?]

Shalom Ncala: kuningi okushiwo ngokusoka. Ukuze s’sizakale sikuqonde si amukela udokotela Trevor Majoro, udokotela osebeze kakhulu ngengciwane le-HIV osenisikathi isinde asoka abantu. Makesibone abantu base Orange Farm bazizwa kanjani ngokusoka. {IsiZulu} [There are many issues around circumcision. To help us understand, we welcome Dr Trevor Majoro, an HIV doctor who is experienced in doing circumcisions. Let’s check out the research trial in Orange Farm.]

Orange Farm- Gauteng: Male circumcision

Question: Do you and your partner enjoy sex more?

Dirk Taljaard (Social Research, Progressus): For a very long time there has been indications that circumcision might be protective against HIV; safe male circumcision; and so we have tried for a long time to raise money to do a trial to do an experiment to see whether it is in fact so. We started in 2002, basically we recruited 3500 men who first of all were not circumcised, second of all wanted to be circumsed. We did not exclude people who are HIV positive although we tested people form the beginning for HIV, we did not exclude those who were HIV positive.

Counsellor: Have you been tested for HIV.

Dirk Taljaard:But after we recruited 3500 we divided them into two groups, one group was sent for circumcision straight away and the other group we offered circumcision free of change but wanted them to delay that for two years then there is two groups, compare the groups on all sort of things like the sexually behaviour, their ethnic group where they are from, their religious groups that they are from, all sort of, all things you can think of.

Counsellor: I’m going to ask you a question about your sexual behaviour, is that okay with you?

Young man: It’s fine.

Dirk Taljaard: We find that the two groups were identical, at the beginning of the trial. Then we followed them for two years and after two years we compared again the group that was circumcised right at the beginning and the group that was circumcised right at the end. Of the almost 70 people that became HIV positive during the trial, 20, they were from intervention group in other word they were from the group which was circumcised right from the beginning. Well 50 was from the group which was uncircumcised. So you can see circumcision has a quite dramatic protective effect. As far as the setting of circumcision in our trial all circumcision they are circumcised by general practitioners in the surgeries, so it was done in our clinically sterile environment.

Auvert Bertans (Researcher): The main objective of this study is very simple, we have said in average circumcised males were less infected by HIV than uncircumcised males. But its just an observation, we were not sure, so we had to do the medical experiment.

Dirk Taljaard: Because it was successful, very successful, then it was no longer ethical to delay some people from getting circumsed. We have to let people understand circumcision is not 100% effective. So this is not a permanent condom; it’s not going to make sure that100%, that you don’t get HIV. So that is the very important part of implementing circumcision on the community level that people have to understand circumcision is not hundred percent. I think other than that circumcision can only work if its part of all the other interventions strategies running at the moment. In other words its got to be of the overall global approach on prevention.

Support group

Shalom Ncala: [How is the infection rate between male and female affected if the male is HIV positive and circumcised?] {Sesotho} In a situation where a condom breaks because those are the ultimately situations were it happens.

Dr Trevor Majoro, HIV/AIDS Specialist: The reason why it is not easy for somebody who is circumcised to be HIV infected is because in a person who is not circumcised the foreskin has been found to have cells that receive the virus. They’re cells called the Langerhans cells, there are cells called dendritic cells and there are cells called macrophages, so what happens is these cells receive HIV from a female partner or male partner into this person who’s got a foreskin. Now what we are saying is if the foreskin is removed you decrease the rate of infection of acquiring HIV into your self if your circumcised because you are then removing a greater portion of the foreskin which harbors these cells that receive the virus. But in the same value we are saying you are not preventing HIV you are only reducing the risk of getting HIV.

Lihle Dlamini: Amathuba omuntu osoke entabeni, ayalingana yini nomuntu osokwe esibhedlela ukuthi angayi tholi iHIV? {IsiZulu} [Are the chances of not getting HIV similar when circumcised in the hospital to in the bush? ]

Dr Trevor Majoro: Alright umasikhuluma nge training ne skill ezibhedlela nase makliniki nasena surgery almost kweziwa ngokufana. Kusho ukuthi usoswa ujwabi oliningi and siyazi ukuthi bakhona abayile entabeni ukuthi ngedlela ujwabi lususe ngakhona alwususanga ngobuningi. So umehlukho ukuthi labantu abase maclinic or lapha entabeni basusa ujwabi ongakanani na? The smaller the portion lwojwabi olususayo the more the risk of umuntu oyithole iHIV ngoba ushiya iforeskin le ekwiyona enamacells amukela igciwane. So si encourage abantu mangabe bacircumcisor bafunde the right technique ukuthi the greater portion lwejwabu yihambe ngoba kula singathi iminyango iyamukela igciwane itholakala khona. {Isizulu} [It all depends on the training and skills. In hospitals, clinics and surgeries it is done the same way. We remove the same amount of foreskin and traditionalists may differ. The difference will depend on the amount of the foreskin removed. The smaller the portion of foreskin removed the more the risk of getting HIV. This is because you have left a piece of skin containing these cells. So we encourage people to learn the right technique because they must cut out the greater portion of the foreskin, so as to get rid of the part that contains these cells.] Now with regards with sexually transmitted infection and circumcision I want to relate to the fact that when you have a foreskin, it is very easy to have problems with that foreskin. Number one you can have cracks on your foreskin and when these cracks heal they can cause your foreskin to be tighter and next time when you want to engage in sexually intercourse the head of the penis finds it very difficult to move out from the skin, so you further cause more cracks and with open wound in the foreskin you can easily get any organisim into your foreskin. Secondly in those people who force them self upon a tight virginal opening their foreskin is pulled over to the neck of the penis and the head is left outside, by the head of this orifice or the opening of the vigina and sometimes it swells and it swells so much that the foreskin finds it very difficult to go back and when that happens you compromise your blood supply to your foreskin it will also crack as well further opening itself up to germs that easily enter the body because one of the way the body protects itself from foreign bodies is threw the skin. Once that barrier has been bridged anything can come in including sexual transmitted infections.

Shalom Ncala: Umasibuya emakhethe sizokhuluma futhi ngokusoka futhi negciwane leHIV. Unganyakazi. {IsiZulu} [We talk more about circumcision and HIV after the break. Don’t go away.]

Shalom Ncala: Reya ho amuhela mona ho Siyayinqoba Beat It Support Group. {Sesotho} [Welcome back to the Siyayinqoba Beat It! Support Group] – uhlelo lwabo bonke abanegciwane leHIV nabanezihlobo ezinalo. Bakesibone ukuthi abantu base Orange Farm bazizwa kanjani ngokusoka. (IsiZulu) [the programme for everyone infected and affected by HIV. Let’s see how the people of Orange Farm feel about circumcision.]

Orange Farm – Gauteng: The Link between circumcision and HIV infection.

Counsellor: Do you think circumcision will protect you from getting HIV?

Young man: Not 100% it’s just that there are slim chances that you will get infected. The best way is for you to use a condom when you are having sex.

Counsellor: Why did you participate in the study?

Young man: The reason is I was having problems with my foreskin. My foreskin was too large and then that is why I wanted to participate.

Young man: I think as you know there are less chances for you to get STDs and stuff so I always wanted to get circumcised. So I thought this was a chance for me to do.

Counsellor: Do you use condoms?

Young man: Ja, I’m still using condom, {Sesotho} [because these people didn’t say that I would not get AIDS if I am circumcised. So I have to still use a condom.]

Young man: Yes, I’m continuing using condoms.

Young man: Yes I was still using condoms.

Young woman: Ja, yena i-condom uyayi user. Ngigazi ke ukuthi utshintshile ama-partners but mina angikamuboni. {IsiZulu} [He uses a condom. Yes he uses it. I don’t know if he’s got other partners but I haven’t noticed anything.]

Interviewer: Even noma a-circumcizile? {IsiZulu} [Even now that he’s circumcised?]

Interviewer: Wakhe wamubona namanye ama-partners or wezwa? {IsiZulu} [You have not seen him with other partners or heard of it?]

Young Woman: No.

Counsellor: Have you tested for HIV?

Young man: No I have not tested for HIV.

Young man: Yes I have. About three months I have to go back next month.

Young woman: {Sesotho} [No, I haven’t tested.]

Interviewer: {Sesotho} [Could you tell us why?]

Young woman: {Sesotho} [He has tested, but I haven’t.]

Counsellor: Do you and your partner enjoy sex more?

Young man: I think women feel great with a man, who is circumcised, they like men who are circumcised.

Young woman: {Sesotho} [I could say that now we enjoy it more than before, because it lasts longer.]

Young woman: Nomasiqala uku-heva makathi uyayifaka like i-gripe something like that, so njengoba a circumcizile ikahle ingena kahle. {IsiZulu} [Sometimes the condom would grip when he tried to put it on. So now that he is circumcised it just slides nicely in.]

Support group

Shalom Ncala: And doctor considering i-study esiyenziwe e-Orange Farm nama results azo, and futhi uthathe ukuthi culturally si-different and siphuma kuma backgrounds a-different abanye abentu they don’t consider uku-circumcisor as part of ihlanzeko let put it that way, ukungaba ukuthi sibheke ukuthi it was successful in a sense yokuthi abantu aba-high baye ne-chance a less bathole i-HIV through circumcision.{IsiZulu} [If you take the results of this study and consider different backgrounds, some of us don’t consider circumcision as part of their culture. When we see that it was successful and more people had less chances of contracting HIV through circumcision,] how difficult or easy will it be for a doctor to influence or to tell abantu abanga believe kwi circumcision to for circumcision. {IsiZulu} [convince those who don’t believe in circumcision to go for circumcision?]

Dr Trevor Majoro: I think i-question oyi buzayo ibalulekile i-answer enginayo for yona i-short ukuthi it’s about people’s choices but those choices zibazihle if baziyenza ba-informed. [That’s a good question and it has a short answer. It’s about choices and those choices are made easier if they are informed.] So it is important first to inform people the benefits of doing circumsion and the risks as well involved, so that when people make a choice, they know what to except and also make known to them the results, like the out come yase [study of] Orange Farm. {IsiZulu}

Shalom Ncala: Into engiyi nothayo kuna this thing yokuthi bakungabe i-partner eyi one itestile eyi one ingayi ukuyo testa? Angazi why indaba ye couple testing inga pusheki, abantu bahambe boyi-two as a couple bayo testa because kunalento yokuthi hayi mina ngi-sharp ngi-grand because umntanami, i-cherie yami icenda ukuthola icosi moos, ngiphethe icosi ngi-sharp ngi-grand futhi untanami u-fresh mawungamubona, akutshengise isithombeni athi nagu umntanami anga-consider ukuthi angizange ngisazi i-status sami before ngiza get into the act ukuthi ngenze naloyomuntwana loyo. {IsiZulu} [Another thing is why does one partner test and not the other? There must be couples testing. Guys often think they are fine if their girlfriend has just given birth. They never consider that they could not have known their status before that.]

Busisiwe Maqungo: And beside that even if umama womtana uphume esharp naye uwazelaphi intobana ndiyile ekliniki ngexesha ndikulwele ndatestwa ndafuminiswa ndi positive ndathula ndacwaka ndaphiwa i-Nevirapine umuye azoqhayisa athindi sharp. {IsiXhosa} [Besides, how does he know if the mother tested positive during pregnancy, and was given Nevirapine while he’s bragging that his baby is fine?] .

Lihle Dlamini: Does it really make a difference ukwenza isex [to have sex] if you are circumcised or not? Is there really a difference because sizwile ku-insert loya athi since wa-circumcisor we don’t use i-condom anymore and] {IsiZulu} [the lady in the insert said that they don’t use a condom since he got circumcised and] it lasts longer. What’s that? Is there really a difference or is it a state of mind?

Busisiwe Maqungo: I want to say I don’t think the question is only for the doc, it’s for all the men here.

Lihle Dlamini: I’m sure Vuyani can tell us more.

Dr Trevor Majoro: I think leyo question is subjective, kukhona abantu abathi bazwa umehluko. Mhalmbe {IsiZulu} [I think that question is subjective, there are people who say yes it does. Maybe] we should ask the people who where never circumcised before and now are circumcised to tell us what is the difference.

Vuyani Jacobs: The difference to circumcised and not circumcised. It’s like driving a bicycle to a Rolls Royce, which means that a boy really cannot enjoy sex, because just imagine, your foreskin will have to go up before you are inside, and stuff like that, but now it’s just like there because it’s beautiful. Because most of the sexual nice part is when it’s here intamo uyabona [in the neck you see.] Ja, that’s the nice part I’m sure uThambo uyasho naye [says the same thing] but anyway but for me the issue, the issue of culture. The issue of people getting a bigger cut is based on the mere understanding that it’s not the removal of foreskin, it forms part of that. Circumcision has got a whole programme that goes within it which we call manhood. And I think that we should then say that maybe that men who are doing circumcision must include education around HIV, must include testing, must include promotion of condoms. Circumcision must now include responsibility as a man, which means that men who don’t rape, men who don’t abuse, that should be part of the ukwaluka part; circumcision. {IsiXhosa}

Shalom Ncala: Umasibuya emakhethe sizokhuluma futhi ngokusoka futhi negciwane le-HIV. Unganyakazi. {IsiZulu} [We talk more about circumcision and HIV after the break. Don’t go away.]

Shalom Ncala: Reya ho amuhela mona hoSiyayinqoba Beat It Support Group. {SeSotho} [Welcome back to the Siyayinqoba Beat It! support group] – uhlelo lwabo bonke abanegciwane le-HIV nabanezihlobo ezinalo. Namuhla sixoxa ngedima yekusoka ekuvibheleni ukusakazeka kwe-HIV. {IsiZulu} [the programme for everyone infected and affected by HIV. We are talking about circumcision and its role in lowering the risk of HIV infection.]

Thami Mthembu: Udokotela bekhathi clinically izinto ezi-traditional bezilokwe zibukelwa as izinto ezi-behind. [The doctor was saying that traditional methods have always been seen outdated.] And here we are we have always been step ahead and I think ukuthi [that] like uVuyani was saying, circumcision is a forum to take a boy towards manhood. If I understand you correctly Vuyani that when they are in the entabeni [mountain] bush, the cutting of the ijwaba [foreskin] is only part of the process there is more to it, there is the training eyenzakayo entabeni [happening at the mountain] and I think what he’s pointing out is very important. Abantu bakwazi uku counseliswa, uyabona ke ubudoda kusho ukuthi you take responsibility kuzinto uziyenzayo, kusho ukuthi ufanele usebenzise i-condom ungabe uyenza X, Y and Z. [People should be counselled about manhood and taking responsibility, which means you should use a condom when doing X,Y and Z.] And I think if we start using cultural forums like that when we start to take away things young boys has been socialised to believe like boys because when you are telling them in a forum lapha entabeni [at the mountain] when they are in the process of circumcision because that is something they respect and are proud of into [something] that is part of their culture. So if the message comes from people who they respect they are more likely to hear the messages than to read it from the billboard per say. {IsiZulu}

Nokubonga Yawa: Mna I think kwinto beyigqiba ukuthethwa ngubhuti Vuyani I think mna ngokhomuva kwami uVuyani kunindeka ukubana nina eningo tata nebe ne mea;s forum ukuhlaleni kwenu ne. Apho nizabe nifundisane khona like ukuqala kubatwana abana 12 years because kwezinye izindawo kolusa abatwana abana13 years. Then from iage ya12 ukubheka phezulu kulapho nibafundisa khona hayi ukuthi ifundise otata cibi bondwa nabo babekhona kwi workshops aniziyenzayo, because abatwana, otata babo abakhula noba emakhayeni abo abakwazi ukuthi bahlale nabo babe ncancisele ukuba mntanami ngoku kuzati kuthi kuthi omunye uvelo athathwe axelelwe ukuba lifikele ixesha yokuba ahambe ayokho koluka akayazi kufaneka atheni ixelelwa namhlanje ukuba nge cawe funeka ahambile. Then acayazi noma uqheleli ukuyiva I information ekliniki uqhele ukuyiva isikholweni but akakwazi ukuthi ayoyiyenza leyento ngoba uxelelwe ngexesha lokhu gqibela. {IsiXhosa} [What I understood from Vuyani is that there should be men’s forum where education starts from at the age of 12, as some boys are circumcised at 13. The boys should attend these workshops from an early age. Most fathers are unable to prepare their sons for circumcision. Some are just told to leave for the bush and are not mentally prepared. They may have heard about it at clinics or at schools, but that’s not enough.]

Nokhwezi Hoboyi: Mna ke ndingene kulomubandela yokuthi amadodo afanele ukuthi afundisiwe, ngaledlela ayi chaza ngayo uVuyani wena uthi ukucircumcisor makuhambisane noku ne issues zokhuthi abantu bafundiswe nge condo usage, safer sex methods, ngokuphata abantu besifazane, ngedaba zekuthi bangahlukumezi abatntu bango mama nabatwana . Lonto uVuyayi akathethi ngokwehlanga ukuthi lento izoyenzakala etabeni kuphela. Ngedlala mina endimuva ngayo yikuthi nanxa madoda nxa uzayeza imen’s forums ilokhishini not wonke amadodo azo attender aphayana akhona amadoda angazu athenda kodwa umuntu athathe umntwanake amuse esibhedlela ayomolusa. Udlela lula into azama ukuyiveza ukuthi ogqirha makhafika esibhedlela idoda bayifikele ithi ndize ukuzoluka bathi ke njengecounselling ndoda njengoba uzakweluka nje asisho ukuthi yekha ukusebenzisa icondom, isisho ukuthi iwusoze uyifumane igculaza, asisho futhi sithi hamba ulala nabaninabani yiba faithful, zenze zonke ubudoda bunje. {IsiXhosa} [I also agree on the educating of men, as Vuyani was saying, the circumcision lessons should come with other educational issues like, condom usage, safer sex methods, and how to treat women and children. Vuyani is saying that it shouldn’t happen only during initiation. The truth is if there is a men’s forum, not every man is going to attend. Someone might not attend and yet take their son to hospital for circumsion. Doctors should also emphasise these issues during counselling. Circumcision does not mean you have a shield against HIV. It doesn’t mean you should be unfaithful.]

Nokubonga Yawa: Abafhowethu kubanzima ukuba nxasine workshop bona baze bazomamela thina ukuthi sithini ngeHIV sithini nge STIs. Ingaba niyalibona itshentsho olukhoyo or kusafana nakuqala if ikhona I change ngaba nxa wuqikelele bangaki ngexesha lwelwaluko abantu abasiwa elkiniki for ukuyo testwa for HIV ne- STIs before baluswe because ndi-believer ukuba ubhuti babantu abamunyama abanoyenza ukuba bayoluswa usibhedlele ba-believer ngokuya ehlathini. {Isixhosa} [It’s difficult for most of our brothers to attend local HIV/AIDS workshops, because they don’t want to hear about HIV and STIs. Have you, as doctors noticed any change, how many guys go to clinics to test for HIV and STIs before circumcision, because a lot of these guys refuse to go to any hospital before circumcision?] .

Dr Trevor Majoro: Kubantu abasebenza ngesintu asiye siba treyine. Siyesithole ukuthi abaningi bayakujabulela lokho futhi abanye babo bebavele ba encourage amaclients wabo ukuthi baqale emakliniki athole ukuthi amakanjani na? Whether HIV positive or not. Kuhle manje ngoba even though it’s a huge challenge abantu sebayaqala manje ukuthi baye emakliniki ukuthi bayo testa. Sizaba encourage nabo ukuthi batester ngoba asifuni especially if uzoya entabeni, uye entabeni ungasazi istaus sakho ufikelena ubenamanye ima opportunistic infection I mean ukugula okufana njengabo pneumonia ngoba icircumcision iyenza asekuphande then sekulula ukuthi use ungene yikugula okukhulu ngoba amasotsha wakho sewayeha yale gciwane.lile ngenda, so kunga kuhle if abantu baya test before baye entabeni.{IsiZulu} [Many traditionalists like getting advice from us about STIs. They encourage their clients to go for HIV test before going to the bush. Even though it’s a huge challenge, more people are going for tests. We will keep on encouraging this. It’s very dangerous to go to the bush without knowing your status. You get there and have opportunistic infections like pneumonia. Circumcision is done when it’s cold and you get sick if your system is low. So it’s very important to test before going to the bush.]

Shalom Ncala: Namhalnje sifunde ukuthi umuntu wesilisa osokile unamathuba abancane okuthola igciwane leHIV. Wonke amadoda kufanele ukucabangisisa kahle ukusoka ukuzu ijazi lumukwenyana liqhuma abenamancane amathuba wokuthola igciwane leHIV. Hambe uyosokwa yisisebenzi kwezephilo emutholaphilo, ngaphuzu kwakonke kusafanele usebenzise ijazi laka mukwenyana njalo lapho uya encansini.Ukusoka ngeke kukuvibhele ukuthi ungatholi igciwane kumane nje kincibisa ubungozi. Kufanele usebenzise ijazi likamukwenyana njalo. Ukusoka akuthathi nezi indawo lejazi likamukwenyana. Siyabonga ngezi ncwadi zenu, sicela niqubekhe ngonisibhalela, siyayazisa imibono yenu nemibuzo. Sithemba ukuthi siyijabulele leshow futhi niyawuzwa umoya lesiyayinqoba, sisonke singayinqoba. Yibanathi futhi ngeviki elizayo, kuSiyayinqoba Beat It! support group. Kuze kube yileso sikhathi, hlala unephilo, hlala unumubono umuhle. Bye bye {IsiZulu} [Today we have learnt that a circumcised man is less likely to contract HIV. Men should consider circumcision as it reduces the chances of getting the virus. Get circumcised at a clinic by a health worker. Most importantly, always use a condom when engaging in sex. Circumcision will not prevent you becoming infected; it will merely lower the risk. Always use a condom. Circumcision does not take the place of the condom. Thank you for the letters, please carry on writing to us. We welcome your comments and suggestion. We hope you enjoyed the show and are feeling the Siyayinqoba spirit – together we can beat it! Join us again next week on the Siyayinqoba Beat It! Support Group. Until then stay healthy, stay positive.]

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