The World Health Organization recommends voluntary medical male circumcision (VMMC) as a medical procedure for reducing the risk of heterosexual HIV transmission by up to 60 per cent. Free voluntary medical male circumcision (VMMC) has been free in Uganda since 2010. The USAID Local Partner Health Services in Eastern Uganda (LPHS-E) partners with district and facility teams to offer VMMC services in 21 health sites in Bukedi, Bugisu and Sebei sub-regions in Eastern Uganda.
In 2021 USAID Regional Health Integration to Enhance Services in Eastern Uganda (RHITES-E) halted VMMC activities in Nabiganda Health Center IV in Butaleja District, following an audit. The audit discovered irregularities in VMMC activities such as poor logistical and supply management, tracking of stock and requisition and circumcision of non-eligible males who were less than 14 years old. The auditors also discovered non-uniformity in the documentation process.
“We felt cheated when they closed us down. But this was due to internal wrangles we had with some district officials,” recalls Peter James Esodoit, a Surgeon at Nabiganda HC IV.
The supplies, guidelines and standard operating procedures (SOPs) were withdrawn from the site. After the closure of Nabiganda, only one site, Busolwe Hospital was authorized to offer VMMC services in Butaleja District.
In addition, the region lacked sufficient skilled personnel to conduct VMC services, “recalls Allan Musitwa, a Quality Assurance Officer for USAID Local Partner Health Services in Eastern Uganda (LPHS-E).
In October 2021, Nabiganda was assigned a target of 516 VMMC clients. “When I heard that the site had a target, I was anxious. How would I overcome the challenges the site was facing,” says Musitwa.
At first, Musitwa assigned the target to another site that was excelling. But the HIV Prevention Manager advised him to engage Nabiganda health workers. The target could not be reallocated.
In February 2022, Musitwa made an appointment with the District Health Educator of Nabiganda HC IV to discuss the reopening of the site. “The team was not new to me. I had worked with them before in a different capacity. For me it was personal. I didn’t want them to fail,” says Musitwa.
An entry meeting for all Safe Medical Circumcision (SMC) service providers discussed what happened before the closure of the site. The meeting discovered that the site lacked the capacity in offering VMMC services because the previous team had transferred out after the closure. A VMMC team comprises of a surgeon, an assistant surgeon and a counsellor.
USAID LPHS-E scheduled a backup team for the site to attend a training organised by Rakai Health Sciences Program in April 2022. During eight days, the team was trained on different surgical skills. To obtain a certificate, a surgeon needed to operate on ten successful cases.
The team learnt mobilisation and demand creation skills such as door-to-door mobilization, using women to mobilize for eligible men, entry points at facilities, and satisfied clients among others. It learnt how to manage adverse events of a circumcised case and follow up of clients. LPHS-E took the team through stock management, filling stock cards and ensuring that the site had a designated store for keeping the supplies.
After the training, the facility team re-organised itself and bridged the gap that existed between it and the district. It started engaging the sub-district and assigned roles amongst themselves. The District HIV Focal Person was co-opted to supervise SMC services at the site.
Following the training, LPHS-E and the facility team re-engaged the community mobilisers to conduct outreaches. Abdul Zacharia Gesa, a Counsellor at Nabiganda was among the mobilizers whom the Activity took through a one-day orientation to counter myths such as VMMC causing impotence.
“The people believed that if a surgeon stops bleeding the skin will peel off making the penis crooked during the healing process. The other myth was that the penis’ shape would be lost if the threads are not removed.
“We considered Village Health Team (VHTs) members who are closer to the cultural institutions. The link to the cultural institutions helped break barriers,” says Esodoit, the Lead VMMC Surgeon at Nabiganda HC IV.
The cultural leaders (Batusa) are very influential in each of the 239 clans they lead including non-Banyole in Bunyole area.
The team co-opted VHTs from other departments like ANC to talk about circumcision. The mobilizers used megaphones in trading centres, drinking joints and religious institutions to rally people for the VMMC outreaches. LPHS facilitated each VHT for each client that was circumcised. The VHTs also conduct home visits where one family member convinces others to undertake VMMC services.
LPHS-E continues to facilitate the facility and VHTs to mobilise in schools and tertiary institutions through headteachers. The Activity has mentored the facility team to do full documentation of clients circumcised including properly seeking consent from the clients during the outreaches. LPHS mentored the team on weekly data reporting on numbers circumcised. It advised the team on filling out consent forms on-site.
To date, the team holds regular meetings to discuss any adverse event and strategize for quality improvement. If a client has suffered an adverse event, his history of counselling, assessment, operation and the post-surgery period.
“Follow up of clients in their homes is another mobilisation strategy. When neighbours see us visiting the client, they envy him. Because they too desire to have high profile people visit their homes, they come for VMMC,” says Esodoit.
The site received 25 circumcisions on February 21, 2022, after the entry meeting. The numbers kept rising and by May 2022, the site had attained its annual target. In FY22 when the USAID LPHS-E assessed the site and found a few gaps such as health education materials missing in the facility. It had no minutes during the facility meetings. The team attained 85 per cent. It engaged a senior surgeon from Busolwe Hospital and gained learnings that enabled them to fill the identified gaps.
In October 2022, the Ministry of Health assessed the facility again. It scored 100 per cent. For COP 2022, Nabiganda’s target was doubled from 516 to 1360 clients. By December 2022, the site had achieved 48 per cent of its COP 22 target. Since the re-opening, a total of 1,281 circumcisions have occurred at Nabiganda HCIV.
The success of the VMMC services in the area has attracted VHTs like Paul Were, a VHT in Luheje village, Luheje Ward, Butaleja Town Council to join the team. Were, form er Counsellor saw VMMC posters in the facility and approached the VMMC focal person at the facility to become a mobiliser. The facility team welcomed him. To date, Were has successfully mobilised approximately 180 clients for circumcision. Among them is Joseph Olota aged 42 years.
For a long time, Olota a private security guard at a hotel and confectionary establishment near Nabiganda desired to be circumcised but because of the nature of his job, he always missed out. “Every time I wanted to get circumcised I was transferred to another location. I kept suffering STDs [sexually transmitted diseases] like gonorrhoea and syphilis,” says Olota.
On December 8, 2023, Olata overheard Were interacting with adolescents nearby, he asked them what they were discussing. When he heard that it was circumcision, he left his workplace that day in search of Were. He counselled Olota about the merits of circumcision.
“This was the chance I had been praying for. The surgeon asked me twice if I was sure I wanted the operation and I said yes,” says Olota.
He got circumcised that afternoon. “At first I feared but I knew it was good for my health. And it was painless,” he says.
A few days later, he broke the news about his situation to his colleagues. A few days, three of them walked into Nabiganda HCIV for circumcision.
Commitment from facilities, VHTs with support from USAID LPHS-E coupled with different strategies enabled Nabiganda HC IV to change its negative picture to a successful site from which others can learn.