Laying Down the Knife May Decrease Risk of HIV Transmission

By Ndiwane, Abraham

Abstract: The risk of HIV transmission may be increased by certain cultural practices. In Cameroon, these practices include group circumcision of boys using unsterile knives during rites of passage, skin cutting or tribal markings, group breast feeding practices and nose shaving rituals. Since traditional healers and circumcisers have a vital role in these practices at the village level, their collaboration is needed by government and biomedical communities to engage in health education and prevention efforts to stem HIV incidence and prevalence. Such efforts should include comprehensive education on HIV counseling, testing, condom use and male circumcision in health centers, clinics and hospitals. As more people emigrate to the U.S. from sub-Saharan countries where such cultural practices (including female circumcision) are endemic, health care providers need to identify and follow up potential health problems of these immigrants. Key Words: Circumcision, HIV transmission, Cultural practices, Cameroon

"People all over the world have always sought advice land treatment] from both biomedical doctors and traditional healers for all kinds of physical, emotional and spiritual problems. HIV is no exception. It is our responsibility that people have access to the best possible care which they need and seek" (Mane, 2007).

The above statement is particularly the case for Cameroon and most peoples of sub-Saharan Africa, where traditional healers and their practices constitute the primary and most frequently sought health care interventions (Joint United Nations [UN] Programme on HIV/AIDS, 2007). To put the situation in context, the Republic of Cameroon is an independent, democratic country on the Atlantic coast line of West Africa, with a population of 16.3 million (World Health Report, 2004). Cameroon has two official languages, French and English which are remnants of colonization, as well as rich traditions and diverse cultures. The country has about 230 tribes each with a distinct dialect (Fongwa, 2002), and predominantly of Bantu heritage (Ndiwane, 2003).

Cameroon, like many other sub-Saharan nations in the past 20 years, has been experiencing high HIV infection rates. The national HIV prevalence rates in 2004 were approximately 5% for females and 2% for males in the 15-24 year-old age range, with 1 in 10 young women aged 25-29 living with HIV (UNAIDS, 2005). These high infection rates are due to several factors notably, the rampant denial regarding the existence of the disease (Dallai et al., 2003); the stigma that is attached to the disease, essentially limiting prevention efforts such as education and / or interviewing to establish risky behavior patterns (Moore, 2004; UNAIDS 2005) and the lack of knowledge regarding modes of transmission (Joint Programme on HIV /AIDS, 2007; UNAIDS, 2005). Major determinants for the rapid progression of the AIDS epidemic in West Africa have been linked to socio-cultural attitudes and practices (UNAIDS, 2004).

RISKY TRADITIONAL PRACTICES

Old habits die hard, persisting despite the threat of disease or death. Such may be the case for Cameroon and possibly, other traditional African societies where certain commonly practiced traditions and rituals may contribute to the transmission of HIV. Awareness of these practices is necessary in order to tailor primary HIV /AIDS prevention to local realities.

Skin Cutting/Marking Practices

Skin cutting, known popularly as marking, is used by a medicine man or traditional doctor (or native healer) to treat patients or clients with illnesses ranging from stomach ache to demon possession. The practitioner uses a sharp knife or a blade to cut into the skin over the afflicted areas. Other parts of the body such as the upper chest, wrists and ankles may be cut if the traditional healer determines that the ailment is likely to migrate to those parts. Skin cutting may also serve as a source of subsidizing income for the traditional healer. The traditional doctor then applies a medicinal substance that is massaged with bare hands into the cut areas as they ooze blood; no gloves or protective devices are used. The used blade is neither disinfected nor sterilized, but can be reused multiple times on the traditional doctor’s other patients. During this skin cutting procedure, the patient and the traditional doctor might have been exposed directly to blood, thus increasing the risk of transmission of blood-borne pathogens including HIV.

Cutting the skin may also occur on occasions of non-illness particularly, during cultural rites of tribal marking to symbolize familial bonding and a sense of belonging to a particular clan. The ability to bear the pain associated with the practice of cutting symbolizes one’s sense of duty to the tribal group and ensures continuity of ancestral traditions (Bishop, 2004). In such ritualistic ceremonies, razor cuts, some as long as six inches may be made from the forehead to the side of the jaw, ending at the chin. Shorter cuts may be made on the cheeks or near the edges of the mouth. During these ceremonies, the same knife may be used on multiple persons, thus, increasing the risk of transmission of blood- borne pathogens. The healing process for these razor cuts usually eaves scars that may range from very fine lines for those who heal well to highly visible markings for those who might have been infected during the healing process.

Group Circumcision

Circumcision may be performed by a traditional healer or medicine man as a cultural rite of passage for young boys marking the transition to adulthood. Circumcision may also serve as a source of income for the traditional healer, thus, a motivation to continue its practice. A knife or blade is used for this procedure. On such ceremonial occasions, the same knife may be used on multiple boys at a time, thus increasing the risk of transmission of HIV and other blood-borne pathogens. Circumcision practices by traditional healers in many African cultures have led to high mortality rates due to hemorrhage, infections, and dehydration (CleatonJones, 2005). Young boys may also look forward to circumcision rites because the post- circumcision period is marked by ceremonial feasting, that may last from days to weeks. During this feasting, newly initiated young adults have the rare opportunity to be served with meat or poultry, delicacies usually reserved for elderly males or heads of the household.

On the other hand, male circumcision conducted with sterile equipment may have a potential health benefit. Circumcised men in South Africa were found to be at least 60% less likely to be infected with HIV through female to male transmission (Auvert et al., 2005; Nagelkerke, Moses, Vlas, & Bailey, 2007). Although circumcision does not provide 100% protection against HIV and other sexually transmitted diseases, it is still crucial to emphasize the need for primary prevention such as education on abstinence and condom use. Another public health consideration is to educate people that performing circumcision with un-sterilized knives during group circumcision of boys can increase the risk of HIV transmission.

Some women also experience ritualistic circumcision or female genital mutilation (FGM), an antiquated practice of genital cutting that is common in some parts of sub-Saharan and north-eastern Africa and other nonAfrican countries (JDhar, 2003; Morrone, Hercogova, & Lotti, 2002). From 80 to 129 million women world-wide are estimated to have undergone circumcision (Bishop, 2004). Of these women, most reside in 28 African countries where 2 million girls per year are considered to be at risk of undergoing FGM (Morrone et al., 2002). Female circumcision can lead to long-term psychological and physiological health issues including severe pain, bleeding, and infections. For women who have undergone the more extensive procedure of infibulation, serious complications can also occur during intercourse and childbirth (Bishop, 2004; Essen et al., 2002; Nour, 2003). Using the knife on multiple women can increase the risk of HIV transmission.

Despite laws against the practice of FGM in many African countries (Dhar, 2003; Morrone et al., 2002), the practice secretly continues within many family circles. A reason for the continuity of FGM is due to the governments’ inability to monitor the extent of the practice (Morrone, Hercogova, Lotti, 2002). Female circumcision is believed to "ensure marriageability, rite of passage, maintaining girls’ chastity, hygiene, preserving fertility and enhancing sexual pleasure for men" (Nour, 2003, pp. 1051).

Shaving Rituals

Shaving the fine hairs (cilia) that line the nasal passages is a common practice among middle age and elderly men in certain tribes of Cameroon. The practice is so common, it "raises no eyebrows" even when it is performed in public places (market and street corners) and in plain view of pedestrians. Those who shave their nares believe that nasal shaving is associated with hygiene or cleanliness (A. Machouda, personal communication, January 2, 2007). However, the shaver (usually an elderly male who may or may not be a traditional medicine man) uses a long, thin, sharp knife that is inserted into each nostril and rotated in semicircular motions to remove the hairs. The art of nasal shaving requires a certain dexterity of the shaver and patience of the client. The latter must sit still, usually in a squatting position on the ground facing the shaver, to avoid an accidental nip. Even then, a cut and bleeding are possible. Bleeding can be profuse because the lining of the nasal mucosa is thin and very vascular. It is not uncommon to find two or three persons waiting in line for a shave. In each case, the same knife is barely wiped with a piece of cloth and reused, thus, increasing the risk of HIV and other blood-borne pathogens. The anterior nares are a common site for Staphylococcus aureus bacteria and carriers have a higher risk of staphylococcal infection following invasive medical or surgical procedures than those who do not carry the organism (Farr, 2002; Perl et al., 2002). Staphylococcal infections also contribute to post operative complications, prolonged hospitalization, and increased hospital costs (Perl et al., 2002). Besides the risk of infection, nasal shaving also destroys the natural cilia that function as a filter for dust and fine particles which otherwise, will be inhaled into the lungs during normal respiration. Group Breast Feeding Rituals: It takes a tribe?

Breast-fed babies have several health advantages. Breast feeding has been shown to reduce infant morbidity, mortality, and infection rates, even in resource-poor settings (Fowler & Newell, 2002). However, several studies have linked mother-to-child transmission of HIV through breast milk (Coovadia, 2004; Fowler & Newell, 2002;Gaillard et al. 2004; Kourtis, Lee, Abrams, Jamieson, & Bulterys, 2006; Leroy et al. 2007; Rouseau et al., 2004). More than one-third or mother-to-child transmissions of HIV in breast-feeding populations occur through breast milk (Fowler & Newell, 2002; Rousseau et al., 2004). It is common for relatives and other lactating mothers in some closely knit tribes in Cameroon to take turns breast feeding an orphaned baby or other babies during ceremonial events. Healthy HIV-negative mothers should be strongly encouraged to breast feed only their own babies to minimize the risk of HIV transmission through breast feeding.

LIMITATIONS

Due to its secretive nature, circumcision practices, particularly FGM is a closely kept secrete within family circles, thus, laws against the practice are neither adequately enforced nor effective. Financial incentives or token gifts for circumcisers tend to reinforce and sustain the practice of skin cutting despite its disastrous consequences. Inadequate knowledge regarding the modes of transmission of HIV / AIDS (Moore, 2004; UNAIDS, 2005) also contribute to the risky cultural practice of circumcision.

IMPLICATIONS FOR PUBLIC HEALTH AND POLICY

Traditional healers and their practices in rural communities can be varied and complex. Their practices are hands on, behavioral activities that are passed down orally rather than in writing. They may also function in the roles of herbalist, spiritual healer or both. These interchangeable roles of traditional healing and biomedical health care were recognized in the early 1990s by the World Health Organization (WHO), which recommended that traditional healers be included in the national response to HIV (King, 2006). Traditional healers are not only the primary, but also the only accessible health care option for the majority of sub-Saharan Africans; they are consulted first by most patients for all types of physical, emotional, and spiritual health problems (King, 2006). Thus, a comprehensive health care delivery system in Cameroon may need to integrate two steps: (1) acknowledge the role of traditional ealers as the front-line health care providers, and (2) invite traditional healers as partners with biomedical healthcare providers to assume active collaborative roles in the national health care system.

To decrease HIV transmission through primary prevention, policy makers must note that no treatment panacea will be effective for everyone everywhere. Equally important, all interventions to prevent HIV transmission should be designed to fit local realities and should include local participants for whom the program is intended. To suggest that traditional healers and circumcisers lay down their knives may seem too easy a proposition, as it is; it will require tradeoffs from the biomedical community, governmental organizations and the traditional healers. The following recommendations are offered:

1. The important role of traditional healers needs to be recognized and acknowledged by the biomedical community, particularly in rural communities where 80-85%> of the population utilizes their services because the healers are easily accessible, use culturally accepted treatments, are credible, and are accepted and respected (King, 2006).

2. Governmental agencies can work together with the assistance of local and traditional healers to enforce existing laws in countries where the practices of female circumcision are endemic, thus, protecting and promoting the integrity of young girls and women. Enforcement of such circumcision laws need to emphasize components of openness and dialogue versus the use of force, threats or punishment, which otherwise can drive the perpetrators underground. Given that more than two-thirds of women in Cameroon, aged 1524 years old, lack a comprehensive knowledge of HIV transmission (UNAIDS, 2005), young adults, traditional healers and others who use knives or blades to cut the skin need to be educated regarding the modes of HIV/ AIDS and other infectious disease transmission and prevention.

3. Male circumcision at health care centers and health clinics should be endorsed and promoted by the WHO, respective Ministries of Public Health of African countries, and other donor NGOs as culturally appropriate and as part of an AIDS prevention initiative. Promising preliminary results indicate that male circumcision can decrease the rate of HIV transmission (Nagelkerke, Moses, Vlas, Bailey, (2007). To prevent complications and risk of HIV transmission, male circumcision should be performed in health settings by health professionals rather than in home settings by traditional healers and circumcisers. Finally, male circumcision should be part of a comprehensive HIV prevention strategy that includes counseling, AIDS testing, condom use and AIDS treatment and management.

4. Gender equality and empowerment should be promoted by African governments through mass media campaigns and state agency such as the Ministry of Women’s Affairs. Such efforts need to address cultural norms and beliefs that tend to increase women’s vulnerability to practices such as female circumcision.

5. Pregnant women in Cameroon need to be encouraged by biomedical communities (hospitals, local health centers officials) to deliver their babies at health facilities. If mothers deliver at home, they should be encouraged to bring their babies into the health centers for check ups or circumcisions for male babies. Involving traditional healers in this effort can serve to establish trust, a necessary requirement for collaboration between the biomedical and traditional healthcare systems, which has been lacking (King, 2006).

6. Research is needed to document the nature and effectiveness of traditional medical practice. This effort can increase trust and collaboration between traditional healers and the biomedical community by recognizing the important role of traditional healers in the local culture.

7. Openness is needed between the biomedical health care community and the traditional healers to assure continuity of beneficial healing practices. Everyone benefits when each others’ needs and expertise are openly communicated. Each community of health care providers seeks to improve their clients’ health but based on the nature of their expertise, uses different approaches toward meeting that goal.

8. Formula-feeding of orphaned babies should be the last alternative, if there is no HIV negative woman available. However, this approach may be the lesser of two evils because in most resource-poor settings, basic resources such as clean water may either be lacking or inadequate. Formula that is poorly prepared due to dilution and /or contaminated bottle or water may lead to diarrhea and secondary dehydration and deaths. Mothers in more affluent communities can be educated and trained regarding formula feeding. In a structured setting where abundant, free formula and clean water were available over a sustained period, approximately 94% of HIVinfected mothers chose formula feeding over breast feeding to reduce post natal HIV transmission (Levoy et al., 2007). However, the authors suggested that antenatal counseling and long term health outcomes of mother-child need to be considered, prior to making recommendations on infant feeding practices among HIV-infected women in African settings.

9. Financial investments in African health care systems should be considered by donor agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria to support AIDS prevention efforts (including expansion of circumcision services), particularly, in rural health centers. Most health care systems are poorly funded, staffed and stretched beyond capacity to meet even basic human needs. There needs to be proper follow up evaluations to ensure that the funds are reaching the intended audience and the goals are being met.

10. Immigrants to the United States from sub-Saharan countries bring with them the health effects of their native cultural practices, including female circumcision. The health needs of these immigrants require close attention of U.S. health care practitioners to identify and follow up potential physical, biological and psychological health problems.

CONCLUSIONS

Traditional cutting practices such as circumcision, endemic in regions of Africa and other parts of the world may lead to transmission of infectious diseases, particularly, HIV/ AIDS. To decrease the risk of HIV is a major concern not only in Cameroon but all over the world. These cultural practices are identified in order to engage the biomedical healthcare community, traditional healers, and health organizations in a collaborative commitment to stem HIV incidence and prevalence. Such efforts can begin with a comprehensive education on certain cultural practices that may increase the risk of HIV transmission, so that circumcisers and others may realize the essence in laying down the knife. REFERENCES

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ABRAHAM NDIWANE, PHD, RN

Abraham Ndiwane is an Assistant Professor in the Graduate School of Nursing & Community Outreach Coordinator; University of Massachusetts Worcester, 55 Lake Avenue North, Worcester, MA 01655. Dr. Ndiwane may be reached at: Abraham.Ndiwane@umassmed.edu

Copyright Tucker Publications, Inc. Summer 2008

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