Mail & Guardian | 6-12 Nov 2009

By Kristin Palitza

Medical experts and AIDS activists have welcomed the South African health department’s long-awaited move to offer male circumcision free of charge as part of its HIV prevention policy. But to be successful, they caution, the service needs to come with a massive education campaign.

According to Department of Health (DoH) deputy director general Yogan Pillay, the policy will be implemented by the end of March next year. Insiders say the department plans to start service provision in KwaZulu-Natal, South Africa’s province with the highest rate of HIV infection and the lowest number of circumcised men.

According to a UNAIDS report, only about 35 percent of South African men are circumcised, despite the fact that male circumcision can lower the risk of HIV transmission for heterosexual men by 60 percent.

After health experts lamented government's lack of urgency in introducing male circumcision as a HIV prevention method for the past couple of years, the DoH, together with the South African National AIDS Council (SANAC), finally began extensive consultations on the matter with medical experts and civil society organisations earlier this year.

After the consultation process, DoH spokesperson Fidel Hadebe promised that “male circumcision is going to form part and parcel of HIV prevention in this country." The procedure was recommended by the World Health Organisation (WHO) as an HIV prevention method already in 2007.

“It’s a delayed move from the DoH, but we are happy they are now taking male circumcision seriously. The DoH seems really committed to making male circumcision work,” says Dirk Taljaard, project manager at the Bophelo Pele circumcision centre in Orange Farm near Johannesburg, currently the only facility that offers the procedure free of charge in South Africa.

“Once we have the policy, which should be fairly soon, we are likely to make rapid progress,” he hopes.

According to UNAIDS, the benefits of male circumcision are huge, with one HIV infection averted for every five to 15 male circumcisions performed on heterosexual men.

“If we roll out male circumcision widely and effectively, we will be able to prevent one HIV infection for every two circumcisions performed within the next twenty years,” reckons Taljaard.

Francois Venter, clinical director of the Reproductive Health Research Unit (RHRU) of the University of the Witwatersrand in Johannesburg, agrees with Taljaard: “Male circumcision is one of the most effective biological interventions for HIV prevention, and it’s permanent. It’s very exciting that the health department is looking at including it in its HIV policy.” 

The DoH will have to set aside a considerable amount of money in its health budget to ensure that facilities and staff are available to meet the demand for the service. “To provide male circumcision safely and at a mass scale, it needs to be well planned and well resourced,” notes Venter.

“Although health services are grossly under-funded in South Africa, if they want to, government can make the funds available to roll out male circumcision,” he says. “It’s not going to be easy, but it’s doable and it needs to be done.”

A measure to avoid staff shortages would be training non-physician clinicians, like nurses, to perform circumcision – as it is already done as part of the Bophelo Phele project. “It’s a procedure a professional nurse can do under supervision of a doctor. So, for example, if one doctor is present, about ten nurses can operate,” Taljaard says.

“It’s not a difficult surgery, and complication rates are very low,” he further explains. “It’s just a matter of training. It takes only about three weeks to get nurses confident and to do it well.”

Venter believes it will be worth the investment: “The more men we can circumcise, HIV-positive or HIV-negative, the better. It will cost money to set it up, but we will see cost savings in the long-term,” he predicts. “Compared to what it costs to have a patient on ARVs [antiretrovirals] for a life-time, male circumcision is good value for money.”

According to the London School of Hygiene and Tropical Medicine, countries will be able to reduce the cost of health services by three percent per annum if they offer free male circumcision services.

Moreover, new findings by the UNAIDS, WHO and the South African Centre for Epidemiological Modelling and Analysis (SACEMA) show that male circumcision will bring down the cost of preventing HIV infections in high prevalence areas to between $150 and $900 within ten years.

In contrast, first-line ARV treatment usually costs more than $7,000 during a patient’s lifetime, and costs double if a patient develops resistance to first-line drugs, needing the more expensive second-line therapies, the report states.

“Male circumcision is one simple, 20-minute procedure. You do it once and that’s it. It’s a no-brainer in terms of cost,” confirms Taljaard.

However, health experts warn that male circumcision is not a magic bullet for HIV prevention. To be a successful prevention practice, it needs to be tightly linked to a massive education campaign that promotes safe sex. 

“Offering a clinical intervention to solve a social-behavioural issue, like sexual risk-takin, is difficult,” warns Tim Quinlan, research director of the Health Economics HIV/AIDS Research Division (HEARD) of the University of KwaZulu-Natal in Durban.

“It will only work if it’s tightly integrated with educational campaigns and sufficient financial and human resources to make sure the service is sustainable. Otherwise it’s not likely to have a big impact,” he explains. “We will need training, education and counselling similar to what is provided when putting a patient onto ARVs.”

On the flipside, rolling out widespread male circumcision services at public health facilities can provide health practitioners with a rare opportunity to target men, the majority of whom hardly access health services, with HIV education and counselling. 

“Male circumcision provides a great entry point to speak to men, the majority of whom hardly seek health services, about masculinities, reproductive health, sexual risk taking behaviour and condom use,” says EngenderHealth communications officer Mogomotsi Supreme Mafalpitsa. “In that case, male circumcision can play a crucial role in HIV prevention.”