HIV activists from Africa and the US have called for a rapid increase in voluntary medical male circumcision in Africa to reduce new infections.
They want 14 “priority countries”, including South Africa, to “move with speed” to formulate “a detailed, costed, timeline-driven operational plan” by the end of the year.
In a report, A Call to Action on VMMC: Implementing a Key Component of Combination Prevention, issued a week before the start of the 19th International Aids conference in Washington DC on Sunday, activists say the implementation of voluntary circumcision has been limited, which is having devastating consequences. HIV treatment and male circumcision will top the agenda at the biannual conference, which is the world’s largest gathering of HIV scientists and activists.
The report was written by the US-based Global Advocacy for HIV Prevention and several African organisations, including South Africa’s Sonke Gender Justice Network.
Several long-term studies have shown that voluntary medical circumcision, in which the entire foreskin is removed, can reduce men’s risk of acquiring HIV from female partners by up to 76%.
The inside of the foreskin is soft and moist and more likely to develop tiny lacerations or sores during sex, which allows the HIV to enter a man’s body more easily. The foreskin also contains many “HIV target cells” to which the virus can attach itself. After circumcision, the skin on the head of the penis becomes thicker and is less likely to tear.
Five years ago the World Health Organisation and joint United Nations programme on HIV and Aids identified South Africa and 12 other Southern and Eastern African countries that could benefit “immensely” from voluntary circumcision. The US government, the largest donor to the programme, has since added a 14th country, Ethiopia.
Mathematical modelling has shown that 3.36-million new HIV infections, or more than 20%, could be averted by 2025 if 80% of men between the ages of 15 and 49 in these countries are circumcised by 2015. It is estimated that, of all the countries, South Africa would be able to prevent the largest number of infections - one million by 2025. According to projections, about five medical male circumcisions are needed to avert a single case of HIV infection.
The modelling studies, which were published in the peer-reviewed medical journal PLos Med last year, also reveal that an investment of $1.5-billion between 2011 and 2015 in these countries would result in net savings of $16.5-billion, taking into account the cost of treating those who became HIV infected with antiretroviral drugs. This means that 20.3-million circumcisions would have to be carried out by 2015 and an additional 8.4-million between 2016 and 2025 to reach the goal.
The report states that Africa is lagging far behind the goals. By March this year, countries were only “8% of the way to reaching the target of circumcising at least 80% of adult males” by 2015.
The only country that seems to be making significant progress is Kenya, where 50% of eligible men have been circumcised. Most of them are in the country’s western Nyanza province where the Luo, an ethnic group that does not traditionally circumcise their men, live.
South Africa has reached only 8%, or 303534, of the just more than 4.3-million circumcisions needed. Lesotho, Malawi and Rwanda have barely started with the process and only 0.7% or less of their targets has been met (see graphic).
Factors that have contributed to slow progress include the initial cost of increasing efforts, despite the huge investments made by international donors such as the US government and the Bill and Melinda Gates Foundation, and a lack of political leadership.
Another factor is that communities that practise traditional circumcision have not accepted the medical procedure. A study in last month’s South African Medical Journal states that 66% of Xhosa men from Nyanga in Cape Town, who participated in a trial, refused to undergo medical circumcision or permit their sons to do so, despite knowing about the preventive benefit of the procedure. They gave “religion and culture, notions of manhood and social disapproval” as their reasons.
In the case of traditional circumcision, often very little of the foreskin is removed. In the study, carried out by the Desmond Tutu HIV Centre at the University of Cape Town, almost a third of the men who reported that they had been traditionally circumcised had some or all of their foreskin remaining, and 86% of study participants who learned that their circumcisions were incomplete were unwilling to undergo medical circumcision.
In all the studies that have shown voluntary medical circumcision can be effective for preventing, at least to some extent, HIV infection, the entire foreskin of study participants was removed. The effect of partial foreskin removal has not been researched sufficiently to make a finding.
Moreover, the South African Medical Journal study found that the median age at which participants underwent traditional circumcision was 21, although the average age of sexual debut was 14.6 years, and 14% of those younger than 20 years were already infected with HIV.
“To realise the full benefit of circumcision in reducing HIV acquisition, it would be optimal to ensure that the procedure be carried out before any sexual risk exposure,” the researchers state.
Mia Malan works for the Discovery Health Journalism Centre at Rhodes University.