Traditional leaders in Zimbabwe are championing the push for medical supervision when it comes to circumcision ceremonies.
Every August, hundreds of Shangaan people in the rural areas of Chiredzi and Mwenezi districts in the southeastern part of Zimbabwe gather to celebrate hoko, which means "male circumcision" in Shangaan.
The traditional ceremonies that accompany it mark the graduation of boys into men, much like ulwaluko in South Africa.
For the past three years, initiation ceremonies have been performed with a marked difference: chiefs have allowed doctors and nurses from the government's medical male circumcision programme to remove the foreskins of initiates' penises surgically. Previously, only traditional circumcisers without medical training were permitted to do so.
There have been several initiation-related injuries and deaths in the past, but this year more than 1 000 adolescents were circumcised safely in five circumcision camps. The initiates also received health information on sexual and reproductive health and HIV.
These services were offered alongside the traditional initiation education conducted by the traditional leaders during the three-week-long rituals that prepare adolescent Shangaans for their passage into adulthood.
Engagement with the traditional leaders was based on mutual respect, and an appreciation of the importance of keeping cultural practices intact, while improving the safety of the male circumcision procedure.
"I am filled with joy [that] we no longer have to fear that our sons do not return from the camps," says an elderly woman while applauding the procession of returning boys and men from the initiation camps. "Circumcision is now safe for our children."
The day-long graduation ceremony was attended by local government leaders, health department officials, Shangaan chiefs, traditional leaders from other communities and workers from the health organisation Population Services International (PSI), which is the Zimbabwean government's technical partner in the implementation of medical male circumcision.
Medical male circumcision has not only made traditional circumcision among the Shangaan people safer, it is also helping to protect them against HIV infection, among other health benefits.
In 2007, the World Health Organisation (WHO) and the United Nations Programme on HIV/Aids recommended medical male circumcision as an HIV prevention method for countries with high HIV infection rates, but low male circumcision rates.
This was after several clinical trials demonstrated that medical male circumcision, during which a doctor removes the entire foreskin of a man's penis, can reduce a man's risk of acquiring HIV through heterosexual intercourse by up to 60%.
Studies have shown that traditional circumcisers sometimes remove only part of the foreskin – only the complete removal of the foreskin has been proven to help to prevent HIV. Scaling up medical male circumcision services could therefore substantially alter the trajectory of the HIV epidemic.
Determined to introduce medical male circumcision in Zimbabwe, the country's National Aids Council together with the department of health and PSI started talks with Shangaan chiefs in 2009 to encourage them to incorporate modern, safer methods of circumcision into their traditional practices.
The chiefs agreed that professionals from the country's medical male circumcision programme should offer the whole package of services, including HIV testing and counselling, screening for sexually transmitted infections, preventative HIV counselling, condom promotion for those who are sexually active, health information as well as the surgical male circumcision procedure itself, at traditional initiation camps.
The conditions were that only male doctors and nurses were allowed near the camps and that male circumcision surgery was to be conducted near the traditional settings and not at healthcare facilities – a logistical and infection prevention challenge that had to be mastered.
PSI and the health department's medical male circumcision teams pitched several tents in the designated areas close to the initiation camps to provide confidential testing and counselling, as well as the surgical procedures.
Clean water had to be transported to the tents from as far as 150km away in large containers, and diesel-powered generators provided electricity for lights and for electrocautery, which is used to stop bleeding during the operations.
The success of this collaboration between traditional and conventional medical providers has encouraged other traditionally circumcising communities to follow the example of the Shangaan people.
Similar collaboration between the traditional ceremony and modern methods has, for instance, taken place with the Varemba and the Venda people in other districts in Zimbabwe.
Now nontraditionally circumcising populations are also heeding the call to take up medical male circumcision, and the number of men and adolescents volunteering for circumcision continues to increase. Nearly 200 000 men have been circumcised since the programme began in late 2009.
Dr Karin Hatzold is a public health specialist, the deputy country director of Population Services International (PSI) Zimbabwe and the director of the regional Gates male circumcision partnership project for South Africa, Mozambique, Zambia and Zimbabwe. Dr Ngonidzashe Madidi is a medical doctor and the director of PSI's voluntary medical male circumcision programme in Zimbabwe.
For a clear summary of medical evidence which shows medical male circumcision reduces the risk of HIV infection, and analysis thereof, click here