Circumcision reducing HIV infections but COVID-19 caused setbacks
According to a UNAIDS report released earlier this year, there have been 13 years of good progress since voluntary medical male circumcision (VMMC) was first recommended by UNAIDS and the World Health Organization in 2007. The report covers only the period until the end of 2019 and thus does not reflect the impact of the COVID-19 pandemic.
In the report, UNAIDS estimated that nearly 27 million men and boys have accessed VMMC services in high-priority countries in East and Southern Africa from 2007 to 2019. Just under 4.5 million of these were in South Africa.
UNAIDS describes VMMC as a “one-time preventive measure that reduces by 60% the risk of heterosexual transmission of HIV from women to men, in settings of high HIV prevalence among the general population”. The UNAIDS and WHO’s 2007 recommendation followed compelling clinical trial evidence showing that VMMC reduces a man’s risk of contracting HIV.
The report cites modelling estimating that by the end of 2019, the VMMC programme had averted 340 000 HIV infections in the 15 countries. Around 75 000 of these were in women, an effect driven by reduced secondary transmission from men.
Another study published earlier this year and based on three different epidemiological models estimated that the VMMC programme had averted 73 000 to 81 000 new HIV infections in South Africa from 2010 to 2017. “The future benefit of the circumcision already conducted will grow to 496 000-518 000 infections (6-7% of all new infections) by 2030,” the authors estimate.
Coverage in South Africa
In 2020, according to estimates from Thembisa, the leading mathematical model of HIV in South Africa, 59.7% of men aged 15 to 49 were circumcised. This percentage has gradually been increasing from 36% in 2010 and 46% in 2015.
“South Africa fell short of the UNAIDS/WHO ambitious target of 80% MMC coverage among men (15- to 9 years) by 2015,” says Dr Nelson Igaba, senior technical specialist for voluntary medical male circumcision at Right to Care (an NGO).
Thembisa’s estimates of circumcision coverage varied significantly between provinces. At just below 87%, Limpopo is far ahead of the other provinces. The Eastern Cape, Free State, Gauteng, and Mpumalanga are all in the sixties, KwaZulu-Natal and North West are in the fifties, with the last two places for the Western Cape at 42%, and the Northern Cape at 39%.
According to the UNAIDS report, South Africa had reported 4 460 432 VMMCs by the end of 2019 with 47% of these having been performed from 2016 to 2019. The highest annual number was reached in 2017.
Impact of COVID-19
According to Igaba, on 26 March 2021, the VMMC programme in South Africa was suspended for six months due to the COVID-19 pandemic and during this period, no VMMCs were performed. Spotlight reported in November last year how numbers had already fallen dramatically by then.
Igaba says that upon resumption of services, the VMMC programme faces significant challenges. Firstly, he says that the PEPFAR VMMC programme has instructed its implementing partners to only circumcise males 15 years and above (see page 237 of the PEPFAR 2021 Country and Regional Operational Plan). PEPFAR is the United States President’s Emergency Plan for AIDS Relief. It has been a key supporter and funder of the VMMC programme in South Africa.
The PEPFAR guidance states that boys with immature genitalia should not be circumcised and stresses the importance of informed consent. The new age-related guidance has programmatic implications since a large percentage of circumcisions in recent years were done on boys aged 11 to 14. For example, Thembisa estimates that just over 250 000 boys in this age group were medically circumcised in 2017, which works out to just over 40% of the total in that year.
Secondly, Igaba stresses that the COVID-19 pandemic has impacted the VMMC programme in multiple ways. He says several VMMC facilities were repurposed to manage COVID-19 and this has left the programme with less space to offer high-volume VMMC services.
Additionally, the COVID-19 pandemic has led to restrictions of the VMMC programme to limit crowding and congestion both in communities during demand creation and at facilities during direct service delivery. He says this has reduced the number of clients mobilised and subsequently the number of clients circumcised per day.
Mitchel Warren, Executive Director of Avac, an international non-profit organisation working on promoting HIV prevention policy, says scale-up of VMMC in most of the priority countries was steadily increasing until last year when the COVID-19 pandemic halted rollout. “As an elective medical procedure mostly conducted at clinics, the rollout was greatly impacted when countries implemented lockdowns and when medical personnel rightly shifted attention to the COVID-19 pandemic,” he says.
“Prior to the COVID-19 pandemic, South Africa had a steady rollout of VMMC, and, while all countries struggled to keep pace in the midst of the COVID-19 pandemic since early 2020, South Africa has been disproportionately impacted by this new pandemic. In 2020, South Africa conducted 452 000 procedures, representing 58% of their 2020 target,” Warren tells Spotlight.
Responding to the challenges faced by the VMMC programme in the country, the National Department of Health says it has developed a robust VMMC communication strategy and implementation guide to help provinces, districts, and other stakeholders to develop their own tailor-made demand creation strategies.
“The programme through implementing partners invests heavily in social mobilisers to generate demand on the ground,” says Foster Mohale, the department’s spokesperson. “The programme is also using behavioural economics to nudge clients for uptake of the intervention. Offering services outside normal working hours i.e. evenings, weekends, and holidays to provide for men coming from work. Mobile services to reach areas where men are, for example, hostels, prisons, military bases.”
He says that the VMMC programme in South Africa has gone close to achieving its target in some financial years, however, due to the surgical nature of the intervention and ambitious targets, it has not been easy to convince the target number of men to get medically circumcised.
Progress on both VMMC and traditional circumcision
When UNAIDS/WHO recommended male circumcision as an HIV prevention strategy, they advised that the socio-cultural context of each country/region or community should inform the implementation of male circumcision programmes. Evidence indicates that medical circumcision provides greater protection against HIV infection than traditional forms of circumcision.
According to Igaba, Right to Care has partnered with traditional leaders and other stakeholders in Mpumalanga, Free State, North West, and the Eastern Cape to support traditional/customary male initiation (T/CMI) practices without diluting the culture. He says that the partnership involves training, and mentorship of personnel involved in this practice on quality standards, infection prevention and control, wound care, early identification of adverse events, and timely referral. Further support involves providing male clinicians (nurses and doctors) access to the initiation schools to perform VMMC and follow up clients without interfering with the cultural practices.
He says that in 2013, 30 initiates died in Nkangala in Mpumalanga, but that since Right to Care’s partnership with traditional leaders in the area and with the provincial Department of Health, there have been no registered deaths related to initiation in this region in areas supported by Right to Care.
However, Igaba says, “there are still reported deaths in the Eastern Cape and regrettably the majority are from illegal initiation schools that do not follow all regulations set by the Eastern Cape House of Traditional Leaders, a body that coordinates initiation activities in the province.”
Mohale adds that from the side of the National Department of Health, the VMMC programme is working closely with the traditional sector in the Eastern Cape and Mpumalanga provinces to provide safe circumcisions as part of traditional male initiation.
“Deaths in the traditional sector due to circumcisions going wrong has significantly dwindled in the traditional sector over the past years. These challenges are mainly at illegal initiation schools. In areas where the department has intervened, the number of circumcision-related complications has drastically declined and there have been no more deaths reported due to medical circumcision. Also, other deaths have been averted through the strengthening of pre-screening, clinical assessments whilst in the mountain, and the improved availability of emergency medical care to initiates if or where absolutely necessary,” says Mohale.