US (PEPFAR) funded anti-HIV project exposing Kenya boys to risks – study

By Gatonye Gathura

A vicious scramble for money within the US-funded anti-HIV male circumcision project in Kenya has exposed the targeted boys’ to risks.

Data collected and published on 4th November 2019 by Kenya Medical Research Institute and US researchers blame ambitious money based targets for the tragedy.

To get as much funding as possible, the report says project implementers have thrown the rule book out of the window.

Underage children

Vices being employed include recruiting underage children, bribing them, engaging unqualified circumcisers and even inadequate stitching of the boys.

The project which has circumcised about 1.6 million males since 2007 works through community mobilizers who recruit clients; boys above 10 years and present them to project clinics.

These clinics largely run by NGOs and faith groups get their funding based on steep circumcision targets set by the US President’s Emergency Plan for AIDS Relief’s (PEPFAR).

In 2016 alone, for example, the report says PEPFAR, spent over Sh1.6 billion (USD15 million) for Voluntary Medical Male Circumcision (VMMC) in Kenya.

Bribery

To get as many boys as possible and meet targets, mobilizers the report says are recruiting even underage boys, bribing, threatening, intimidating and cajoling others to join in the line.

In August another study reported about 35,000 underage boys have been circumcised without parental knowledge or consent in the ongoing HIV prevention project.

To get the numbers the new report says anything goes. “We are calling it ‘broking [brokering] system,” explained a mobilizer.

He said although they are not supposed to give children money they sometimes have to pay a boy about Sh50 for him to bring in his friends.

“So the more he brings for instance if they are four, I give 100–150 KES. At the end of the day, I will hit my target,” said the mobilizer.

But things get more interesting once the boys get to the clinic especially during the high seasons, usually during school holidays like now.

Shortcuts

The rule book says a circumcision team should incorporate one surgeon, a surgical assistant, a counselor, and an infection prevention officer all working together in each case.

Such a team should on average do no more than 12 cuts a day. On average one case, the report says should take 12 to 25 minutes.

However, during the peak season, the Kemri team says it confirmed these guidelines are not being observed with an operation sometimes taking just about six minutes.

To achieve maximum cuts, the study says the four-member teams, are against the guidelines, split up with each person working individually on their own cases.

This way, the study says one person can do as many as 25 cases in a day which involves standing up for long hours sometimes from early morning into the night.

 “So if you do 20 clients or 25 clients in a day, every day, say from Monday to Friday, it is a hell of a tiresome job,” said a clinical officer.

Adverse events

Because of resultant fatigue, the officer said there were many cases of adverse events such as bleeding, pain or swellings.

“If you look at the timings of most of the adverse events, it is usually late in the evening, after lunch, afternoon; so it has always been attributed to high volume in terms of targets, and then fatigue, and not following the protocol,” said the clinician.

Other time-saving avenues include rushing circumcisions, inadequate stitching, splitting surgical utensils and bandage packs between patients.

This mess in the project, run by the National AIDS and STIs Control Programme (NASCOP) under the Ministry of Health is blamed on the rush to secure targets based on American dollars.

To get a client to the clinic, mobilizers say is a do or die event, “. . .we are paid upon reaching the target … so we are really competing, somebody may grab your clients before you know it,”  explained a 28-year-old, male community-level mobilizer.

“. . .targets. . . are about funding, and if you don’t reach your target, you don’t get funding,” said a 49-year-old male mobilization supervisor.

Unethical conduct

This is the second time the VMMC programme in Kenya has come under fire over unethical conduct.

In December (2018) a report by NASCOP and US agencies indicated the high success rates associated with the programme may have been based on falsified data.

The study reported suspected intentional inflation of data by some implementing partners to meet targets and justify continued funding.

The current study which also involved the University of North Carolina, US, is advising the involved parties to relook at the high target numbers versus the quality of care and the rights of clients.

Some facts

19 million PEPFAR supported cuts in East and Southern Africa

27 million VMMCs targeted by 2021 in the region

1.9 million male cuts in Kenya since 2007

Sh1.6 billion spent by PEPFAR on VMMC in Kenya in 2016

240,000 PEPFAR target cuts for 2016

300,000 PEPFAR target cuts for 2019

2014, Kenya began cutting 10–14-year-old boys

500,000 cuts required to achieve 90% coverage by 2021

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