EXPERTS say the UNAids Fast Track to Ending the Global Aids epidemic by 2030 circumcision programme is in trouble.
After several years of rapid increases, the annual number of circumcisions performed in eight of the 14 priority countries in southern and eastern Africa stayed level or decreased in 2015, dropping to 2.6 million in 2015, compared with 3.2 million in 2014.
In South Africa, male medical circumcisions reached a peak of 500 000 in 2013 and declined slightly in each subsequent year. This decrease comes in spite of improved surgical infrastructure and high-level marketing.
The Fast Track plan calls for an additional 25 million medical circumcisions in these high-priority countries by 2020.
In the SA Medical Journal, Norman Goldstuck of Department of the Obstetrics and Gynaecology and Faculty of Medicine and Health Sciences at Stellenbosch University and Tygerberg Hospital, and Peter Millard of the University of New England in the US, say this is an optimistic, probably unrealistic goal that would require increasing circumcisions to five million a year, nearly double the current rate.
“To reach its goals, UNAIDS is counting on programme changes and technical advances in circumcision devices, but the latest setback with PrePex is likely to further disrupt those plans,” they said. PrePex is the world’s only non-surgical male circumcision device.
After six cases of tetanus following PrePex circumcision, the World Health Organisation (WHO) recently recommended a full series of five tetanus immunisations, or two immunisations at least four weeks apart, with the second dose at least two weeks before PrePex placement.
“This will further impede acceptance and utilisation of an innovation that has shown neither safety, efficiencies, or cost-effectiveness,” Goldstuck and Millard say.
In 2007, WHO and UNAIDS proved that circumcised men reduce their risk of HIV Infection by 60% in high risk areas such as Sub-Saharan Africa.
“It is time for SA to change gears and orient marketing and programmes to males of all ages, but particularly to boys (under) 15 years of age.
‘‘Circumcising boys who have not been sexually active does not immediately affect the HIV epidemic, but will have the greatest impact on HIV incidence in the long term.”
“Let’s take a lesson from immunisation programmes and not allow for a lost opportunity at any age. Mothers are an influential but neglected target of circumcision promotion.
“Our experience is clear: mothers motivate their boys to get circumcised, come to the clinic with them, and spread the word to their friends about the availability of circumcision. The time to change course is now,” they said.
The national Health Department’s Popo Maja confirmed that there has been a slight decline in the number of males being circumcised, and said this is experienced mainly due to the department’s focus on the pivotal age of 20-35 years, an age group confirmed to provide immediacy of impact in reduction on HIV incidence.
“Our strategy is to target the most vulnerable men (20-35 years) – which also arose from a modelling exercise that has been published. This will give us the quickest impact on new HIV infections (as long as its part of a combination prevention approach). Consistent condom use remains the most effect prevention of HIV and STIs,” Maja said.
Maja said the department would move on to other groups, specifically younger men and boys.
He says strategies for the scale up of MMC services put in place by the department include: demand generation strategies targeting youth, utilising people on the ground who are MMC champions in communities, the procured services of MMC partners through tenders covering 24 districts and MMC integration into traditional circumcision practice through introduction of medical officers at initiation schools to secure MMC compliant circumcisions.