Voluntary medical male circumcision is one of the most important ways to reduce new HIV infections. The foreskin contains receptors that the HIV virus can attach to, and removing it reduces HIV transmission from women to men by about 60% – but cost and access issues have been barriers for many men and boys in southern Africa.
Adjunct Professor Peter Millard from the University of New England, United States, writes in The Conversation:
With US funding being cut for HIV programmes, it is increasingly important to scale up voluntary circumcision programmes using local resources.
With Bonginkosi Eugene Khumalo, head of circumcision programme at Northdale Hospital, KwaZulu-Natal, we did a study to evaluate the training of primary care providers to use Unicirc, a novel surgical instrument designed in South Africa according to World Health Organisation (WHO) specifications.
Our study describes an ongoing training programme being run by the Centre for Excellence (a long-standing circumcision training programme) at Northdale Hospital, in a province where traditional circumcision is not practised and which has the highest HIV prevalence in South Africa.
Unicirc is a simple, single-use circumcision tool made of metal and plastic. It’s pre-sterilised, disposable and designed for use by general healthcare workers, not just specialists. This makes it safe and practical for use in local clinics.
The study demonstrated the practicality of training primary care doctors, nurses and clinical associates in Unicirc male circumcision.
Circumcision is an important HIV prevention method, and vital for countries to scale up services in a cost-effective way and to make them widely available in local areas.
How it’s done
Currently, almost all circumcisions are done by surgical cut-and-stitch techniques, where specially trained surgeons cut off the foreskin with scissors, then sew up the open wound. It can be done in a surgery under local anaesthesia, but men and boys need to be monitored closely afterwards to make sure all bleeding is stopped.
It can cost anywhere between R1 000 and R4 000 in the private sector in South Africa.
Doctor Cyril Parker and Doctor Elisabeth Parker developed the method at their general practice in Cape Town in 2012. This new tool greatly simplifies circumcision so that it can be performed by medical personnel with basic training.
It takes only 10 minutes, causes no bleeding, needs no injections or stitches. It results in a rapidly healing, cosmetically pleasing circumcision.
Thousands of these circumcisions have been performed at clinics in Cape Town and in Mitchell’s Plain, and nurses and clinical associates have been trained in the technique. Unicirc circumcisions are now being offered at nurse-run Unjani clinics in South Africa.
In the Northdale programme, Dr Cyril Parker and his colleagues trained 67 providers, most of whom were nurses and clinical associates – mid-level healthcare professionals working under the supervision of a medical doctor to provide primary medical care.
They performed these circumcisions on 1 240 men and boys with no serious complications. Trainees found it faster, simpler and with better results than other methods. The programme is ongoing, with trainees continuing to perform circumcisions safely.
Initially, none of the trainees had used Unicirc. Around 61% of them were men and 39% were women, showing a need to encourage more women to join. Nurses (46%) and doctors (45%) made up most trainees, and clinical associates the rest (9%). About 38% had no prior circumcision experience, while 33% were highly experienced in surgical circumcision.
This shows the programme can train complete beginners as well as experienced providers.
Nurses and clinical associates are key to expanding cost-effective circumcision access, freeing up medical doctors for other tasks. A disposable, single-use tool reduces infection risks and is well-suited to clinics with limited resources.
What next?
The programme is moving into a phase focused on mentoring, quality checks and further expansion. If widely adopted, Unicirc could greatly improve access to safe, simple and rapid circumcision across resource-limited settings. It is simple enough to be used in traditional circumcision schools.
Along with effective treatment, prevention of mother-to-child transmission, and medication to prevent HIV infection, circumcision plays a critical role in HIV prevention efforts in Africa. Unlike traditional circumcision, voluntary medical circumcision is done under sterile conditions by trained providers with few complications and the ability to deal with any that do occur.
Several southern African countries started their national circumcisions programmes to prevent HIV in 2010. As of 2023, 37m voluntary medical male circumcisions had been performed in 15 high priority African countries.
Estimates are that 1m HIV infections have been prevented, saving the cost of treating and monitoring those cases, and avoiding transmission to partners. Circumcision actually saves money in many countries.
Peter S Millard – Adjunct professor, University of New England, United States
Study details
Cohort study of the implementation of a Unicirc circumcision training programme in KZN SA
Peter S. Millard & Bonginkosi Eugene Khumalo
Published in African Journal of Urology on 26 August 2025
Abstract
Background
Voluntary medical male circumcision (VMMC) is a key intervention to prevent HIV transmission, but open surgical circumcision requires extensive training and lacks the capacity for further upscaling. The objective of this study was to evaluate the results of a simplified device-based circumcision training program among primary care doctors, nurses, and clinical associates.
Methods
This was a prospective cohort study of a training program in KwaZulu-Natal, South Africa, which evaluated the training of primary care doctors and mid-level providers, and subsequent surgical outcomes.
Results
A total of 67 providers were successfully trained in the Unicirc method, among which 37 (55%) were nurses and clinical associates. A total of 1,240 men and boys were circumcised with a low rate (2.4%) of mild or moderate adverse events. There were no serious adverse events.
Conclusions
Instrument-based circumcision with Unicirc simplifies the procedure to make it amenable to training of mid-level providers in rural settings with a low rate of adverse events. Widespread adoption of this method may result in improved access to safe circumcision services for men and boys.
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