School of Medicine and Dentistry –James Cook University Taking medical circumcision to male initiation ceremonies in Yangoru-Sausia, Papua New Guinea Clement Manineng School of Medicine and Dentistry –James Cook University

East Sepik Province –Papua New Guinea http://www.yourchildlearns.com/online-atlas/papua-map.htm

Papua New Guinea Rugged Geography 85 % of people live in rural areas Over 700 cultures and languages About 50% adults illiterate Low health indicators High Corruption Booming economy

HIV in Papua New Guinea Estimated more than 90% HIV infections in Pacific are in PNG 21,459 people living with HIV in 2013 HIV prevalence in 2013 was 0.52% 74% eligible adults on ART, 39% eligible children on ART Main route of transmission heterosexual Southern (excl NCD) 0.63% Highlands 0.60% Momase 0.25% New Guinea Islands 0.26% NCD 1.04% It is estimated that more than 90% of HIV infections in Oceania happen in PNG. In 2013, 21,459 people were living with HIV. Among adults (15 years and older), the rate of HIV in PNG was 0.47%. This is likely saying that about 1 in every 20 adults in PNG are living with the virus. The main route of the transmission of HIV is heterosexual sex. Heterosexual sex is sex between a man and a woman. NACS 2013

Male circumcision and HIV prevention 3 randomized controlled trials show HIV prevention among circumcised men WHO recommends male circumcision scale up in high HIV and low male circumcision settings. 2 studies in PNG show penile cutting practice exist in PNG and non-circumcised men were willing to be circumcised However, PNG’s challenges warrants further studies However, between 2005 and 2007, 3 randomized controlled trials in Africa found that the risk of HIV infection in circumcised men were reduced by up to 60% compared to non-circumcised men. These findings led to WHO recommending the scale up male circumcision programs in areas that had high numbers of HIV cases and whose majority of male population remain uncircumcised. In those times, Papua New Guinea was experiencing high number of new HIV infections and there was no information available on the status of circumcision among PNG men. This study was therefore conceived in line with WHO recommendation. We wanted to firstly know about the acceptability of male circumcision in the country.

The boy becomes a man from child to adult: from carefree to responsibility: from being a dependent to being independent Sourced from: http://africanart193g.blogspot.com.au/2011/11/museum-project.html and http://www.artofmanliness.com/2010/02/21/male-rites-of-passage-from-around-the-world/

Urethral Bleeding in Yangoru-Sausia, Papua New Guinea Sourced from: http://www.hamillgallery.com/OCEANIC/Daggers/Dagger03.html

Initiation ceremony outlawed Risks of permanent injury and death at initiation ceremonies Worship of ancestral spirits was against Christian teachings Stopping initiation also took away opportunity for counselling especially on sensitive issues including sex, marriage and family planning.

Initiation ceremony being revived Inclusion of; Medical Male Circumcision HIV education HIV testing

Medical Circumcision at initiation ceremony Conducted by medical team Used standard surgical MC procedure Conducted 64 circumcisions Only 2 complications –pain and bleeding

Community response to initiation ceremonies Clan elders shed tears Ceremony house is built Counsellors and Presidents voice support

Circumcision at initiation ceremonies The Challenges The enablers Insect screen Sterilization of instruments Supplies Medical team Community leaders were willing Men in medical team originate from the area Program led by provincial HIV response team

The Outcome 64 men with better chance of avoiding HIV 64 men with better chance of succeeding in life 64 men who will value and respect women Lost tradition is revived Program fits very well into local culture Provincial HIV Response team achieves community participation

Assessments of modified initiation ceremony Cultural Acceptability Feasibility –Health standards and economics Impact evaluation

Culture =Identity