South Africa is just over half-way through a massive effort by multiple stakeholders to circumcise 4.3m men which will avert 1.3m new HIV infections. Explaining what it will take to achieve the final targets, Right to Care’s medical male circumcision project director Dr Khumbulani Moyo, writes:
“Soon after the World Health Organisation recommended that voluntary medical male circumcision is offered as part of a comprehensive HIV prevention strategy, South Africa’s circumcision programme kicked off in 2010. There was tangible evidence that a large-scale circumcision programme would prevent large numbers of new HIV infections and save lives. South Africa initiated the largest circumcision programme in the world, targeting 4.3m or 80% of all men and adolescent boys between the ages of 15 to 49 in South Africa.
“To date, approximately 2.3m circumcisions have been performed in our country, and mathematical modelling shows that some 650,000 new HIV infections have been prevented. But we are only just over half way there.
“Currently, South Africa has over 7m people living with HIV. Around 300,000 new infections are occurring every year. Circumcision not only contributes to HIV reduction, there are economic gains too. A study on the cost and impact of a large-scale circumcision programme in South Africa found that if eight in ten men are circumcised, around R225bn in HIV care and treatment costs would be saved.
“From 2012, Right to Care, one of South Africa’s largest health NGOs, working as a PEPFAR funding recipient and supporting the national Department of Health (NDoH), set about expanding safe circumcision services. We focused on areas with high prevalence of heterosexually transmitted HIV and low rates of male circumcision, targeting men aged 15 to 34, given that HIV incidence in men was peaking at around 27.
“With strong coordination by the NDoH, we mobilised communities, worked with the media, identified celebrities to promote circumcision, worked with regional, local and district health teams, formed alliances with other ministries like social services, traditional affairs and education, and reached deep into the heart of peri-urban, urban and rural South Africa to achieve this.
“This enabled Right to Care to achieve over 1m circumcisions in just under five years.
“Male circumcision is one of the oldest known surgical procedures and has traditionally been performed to mark cultural identity or religious observance. Many cultures in South Africa practice circumcision as part of traditional initiation, a rite of passage from boys to men while others do it for religious reasons such as Muslims, Jews and some Christians.
“Much has been written about traditional male initiation versus medical male circumcision. We strongly believe that it is not a case of either/or – one practice as opposed to another – but rather about aligning the two practices. Despite the differences in procedures, medical and traditional circumcision can and should work together. Traditional and clinical providers need to collaborate and work together to improve the safety of male circumcision, reduce complications and improve the sexual and reproductive health of men. In this way, the socio-cultural importance of the traditional initiation can be preserved.
“Right to Care has worked with the Department of Health as well as the National and Provincial Houses of Traditional Leaders to successfully integrate medical and traditional circumcision in a culturally sensitive manner in several districts across South Africa. We are committed to apply these learnings to other areas where circumcision is a traditional rite of passage. We are cognisant that complete integration of both medical and traditional practices will be a journey that must be taken together with traditional leaders and the communities they serve.
“Never before has the need for meaningful and respectful collaboration with traditional circumcising communities been so important. The safety of our young men and their long-term health in terms of preventing HIV and other sexually transmitted infections is at the core of this collaboration.
“We will continue to work with community leaders to dispel myths around circumcision. Myths include the healing process takes too long, circumcision interferes with sexual pleasure or circumcised men don’t need to use condoms. We promote circumcision as a proactive and healthy choice for sexually active men.
“So what will it take to reach the important final mile towards achieving our national objective of circumcising an additional 2m men by 2020?
“The last mile seems difficult but through a shared vision by every stakeholder it is achievable. We live by the words of the African proverb: ‘If you want to go fast, go alone. If you want to go far, go together.’
“We at Right to Care will continue to apply the World Health Organisation’s and the South African government’s clinical guidelines in circumcision together with our deep respect for the sacred journey from boyhood to manhood.”