Lesotho Taps Taxi Drivers to Fight HIV With Male Circumcision

Napo Khusu likes to think of himself as a taxi driver–educator.

Behind the wheel of his Toyota Corolla, white with a signature marigold stripe along its side, Khusu calls out for passengers in Maseru, the capital of Lesotho, in between explaining to me the benefits of voluntary medical male circumcision: better hygiene and decreased risk of contracting HIV, other sexually transmitted infections, penile cancer and cervical cancer.

Khusu is one of 15 taxi drivers in Maseru who have spent the past month educating their passengers about the methods and benefits of the procedure. The driver mobilization scheme, a pilot program that was started in April by Jhpiego, a U.S.-based health nonprofit, is part of a wider initiative called Rola Katiba, which aims to get more men circumcised and reduce HIV rates across Lesotho.

"I'm talking to them about VMMC," says Khusu, 32, employing the commonly used abbreviation for voluntary medical male circumcision. He has to speak loudly over the traditional accordion music, known as famo, that pumps from the stereo. "Some people don't understand, so I explain for them. Some of them, they are not interested. Some are interested."

Lesotho, a mountainous country of 2 million people that is entirely surrounded by South Africa, has the second-highest HIV prevalence rate in the world at 23 percent. According to the World Health Organization, VMMC reduces the risk of female-to-male HIV transmission by 60 percent. The procedure works because the foreskin, which can be torn easily, creates tiny gateways for the virus to enter the body and is a warm part of the body, meaning viruses could multiply more easily there, says Malijo Baji, a VMMC counselor at the Apex Clinic on Moshoeshoe I Road, where Khusu and others refer intrigued, uncircumcised taxi passengers.

Since the start of the Rola Katiba program in 2013, more than 108,000 men have been circumcised, around 10 percent of the country's male population, according to Jhpiego. Rola Katiba means "take off your hat" in the local Sesotho language, a gesture that is a sign of respect referring to the country's symbol, the Basotho hat. The mascot for the program, which is funded by USAID and designed to target 15- to 29-year-old men and boys, is a jovial orange penis, giving a thumbs-up while holding a yellow sun hat, that appears on VMMC pamphlets with the tagline "Be Fresh and Stylish."

We drive through Maseru, past the Ouh La La French café and dozens of fruit stands, in Khusu's "4+1" cab (four passengers, one driver) during an off-peak hour of the morning. Still, we manage to pick up two female passengers. Speaking about circumcision with women is one of the challenges of his job, Khusu says; often his lesson and gentle suggestion to pass the message on to male family members are interpreted as rude. Some women have defensively asked him how he knows their husbands aren't circumcised, says Khusu. "I'm saying to them, 'If you know someone who hasn't been circumcised, you have to tell them. Your younger brother, your husband,'" says Khusu. "You have to put it in a nice way."

When passengers are interested in VMMC, either for themselves or a family member, Khusu gives them a blue referral slip to take for a clinic consultation. In Lesotho, a VMMC procedure is available for free to anyone who wants it. There are two options: a surgical and a nonsurgical method using Prepex, a device left on the penis for seven days in order to stop blood flowing to the foreskin, which dies and is cut off. Khusu and hospital and clinics workers say Prepex is increasingly popular because it's minimally invasive, men can go back to work quickly, there are no injections and there's less pain. "Some people, they fear to cut [and] the blood" that comes with the surgical method, says Khusu. In addition, those who choose Prepex receive 50 loti (about $3.30, paid for by the clinic) for phone airtime and transportation for a checkup two days after the foreskin is removed.

The 15 taxi driver–educators are paid in fuel coupons; even if they don't refer anyone, they still receive a monthly petrol allowance of 5 liters (1.3 gallons), paid for by Jhpiego.

In the last five years, 10 million men on the African continent have undergone circumcision. But promotion of VMMC in countries near Lesotho has been a challenge. Issues around cultural and social acceptance of VMMC prevented a wide-scale rollout in nearby Swaziland, which saw just 32,000 men, a fifth of the target number, undergo the procedure between 2010 and 2012. Stephanie Reinhardt, senior programs manager at Jhpiego, says Lesotho, in contrast, is succeeding due to the Ministry of Health's efforts to engage with traditional and community leaders early on. Ministry officials visited rural areas and provided educational sessions around circumcision, while Jhpiego organized transport to take young men from villages to a nearby health center to undergo the procedure. "It wasn't seen as a foreign-led initiative," says Reinhardt. Efforts to increase uptake of male circumcision, an extremely sensitive topic in Lesotho, could have been put at risk if too much international, outsider involvement was suspected.

In the capital of Lesotho, talk of VMMC isn't confined to the backs of taxicabs. Outside the Shoprite supermarket in Maseru's main shopping stretch, many recognize and point at the smiling orange penis on the Rola Katiba T-shirts worn by Khusu's fellow drivers Tsitso Mokale and Moholi Mosebetsi. An 18-year-old at the Shoprite says he learned from a nurse that VMMC prevents HIV and other STIs. At the nearby taxi parking lot, cabdriver Letsekho Motabo says he learned about VMMC at an informational road show hosted by Jhpiego. "I know that if you are circumcised it prevents you from getting sexually transmitted infections. That includes HIV," says Motabo, who wears a yellow hoodie declaring "Las Vegas" in white letters. He's still considering getting circumcised if he can get the time off work.

One particular challenge here has been that "when VMMC came, a lot of people confused it with initiation," says Polo Motsoari, communications officer at Jhpiego. Adolescent boys in Lesotho are usually circumcised during initiation ceremonies—the details of which remain incredibly secretive—but a 2011 study published in PLOS One found that nearly a quarter of men in Lesotho who self-reported as circumcised didn't actually have evidence of any circumcision, suggesting they believed they were fully circumcised but instead underwent a ritual, and incomplete, version.

There was also confusion around language. As the PLOS One study's authors point out, "the word in Sesotho for going through the initiation process, 'lebollo,' is very similar to the word for circumcision. Thus, a male who has attended an initiation school may report that he has been circumcised even if the foreskin was only cut, or only part of the foreskin was removed."

For drivers like Khusu working to change the minds of men like Motabo, and possibly their wives, sisters or mothers, one of the biggest challenges is broaching that subject in the back of a cab. "There's not an easy way to say, 'Let me see it,'" he says.

Reporting this story was made possible by the International Reporting Project.