Male circumcision has been shown to reduce HIV infection risk in men. Three randomized controlled trials in Africa found that circumcision reduced HIV risk by 50-60%. Based on this evidence, the WHO and UNAIDS recommend promoting male circumcision in high HIV prevalence countries in Africa. In South Africa, male circumcision services have been piloted and national guidelines are being developed to scale up circumcision as part of HIV prevention. Challenges include addressing concerns about reducing comprehensive prevention messages, ensuring quality and safety of services, and promoting gender sensitivity.

1. Male Circumcision:
Translation of Evidence into Action
Professor Helen Rees
Co-chair of SANAC Programme Implementation Committee
Executive Director, Reproductive Health and HIV Research Unit,
University of Witwatersrand
Honorary Professor: London School of Hygiene & Tropical Medicine

2. So how’s prevention going?

3. In South Africa there
are three new
people infected
For every one
person
commencing
treatment in
2009……..
We will never overcome this epidemic if we only treat patients

4. Why did we consider male circumcision?
Source: UNAIDS 2006 Report on the Global AIDS PandemicIAS Conference Toronto 2006
Beyrer C.

5. Why did we consider male circumcision?
About 30% of males globally are circumcised mainly for
religious, cultural or social reasons

6. We already knew about some health
advantages…..
• Urinary tract infections in • Human Papilloma Virus (HPV)
infants - 63% reduction in
- 12 fold increased risk in circumcised men
uncircumcised boys
• Sexually transmitted • Cervical cancer (HPV) in
infections female partners
• Syphilis (Ulcer) - 2.0 – 5.8 times more
- 1.5-3.0 fold increased risk frequent in women with
in uncircumcised men uncircumcised partners
• Chancroid (Ulcer)
- 2.5 fold increased risk in • Penile cancer (HPV) in men
uncircumcised men - 22 times more frequent in
uncircumcised men

7. There’s been a lot of research…
• 4 ecological studies: Studies that look HIV prevalence is
at associations in large populations lower where
circumcision if
• 35 cross-sectional studies: Studies that higher
look at associations in a population at
one point in time HIV infection
reduced by
• 14 prospective studies: Studies that about 50%
follow up a group of men for a period
of time and observe what happens to HIV infection
them reduced by 50%
or more

8. And then came the Randomised
Controlled Trials

9. Randomised controlled trials of male
circumcision to reduce HIV infection
Rakai, Uganda
Gray et. al. (2007)
Lancet; 369: 657 – 66
Kisumu, Kenya
Bailey et. al. (2007)
Lancet; 369: 643 – 56
Orange Farm, South Africa
Auvert et. al. (2005)
Source: 2006 Report on the global AIDS epidemic
PLoS Med; 2 (11): e298
(UNAIDS, May 2006)

10. How were these RCTs designed?
Men are from the Select the population:
same community so Young men at risk of HIV
are likely to behave
in similar ways and
have the same Explain that they might be circumcised
environment now or after 18 months
Divide the men into two groups, half will be circumcised now and half will be
circumcised later.
The researchers and the participants are ‘told’ which group they go into.
Counsel all the men about circumcision and about safer sexual practices
Follow the group up for a year to see who gets HIV infected.
Is it the circumcised men or the uncircumcised men?

11. Results of the three MC trials (RCTs) 2007
Orange Rakai, Kisumu,
Farm Uganda Kenya
Sample size
(Number of men) 3128 4996 2784
Total sero- 69 65 69
conversions
HIV+ MC arm 20 22 22
HIV+ control arm 49 43 47
% reduction in HIV 61% 48% 53%
P < 0.001 P < 0.005 P < 0.005

12. RCT Results of three MC trials (RCTs) 2007
Orange
Farm Rakai Kisumu
Sample size
(Number of men) 3128 4996 2784
Total sero- 69 65 69
conversions
HIV+ MC arm 20 22 22
HIV+ control arm 49 43 47
% reduction in HIV 61% 48% 53%
P < 0.001 P < 0.005 P < 0.005

13. Impact on HIV incidence:
Evidence from observational studies & RCTs
Effect size
Study (95% CI)
Overall 0.42 ( 0.34, 0.52)
High-risk groups 0.29 ( 0.20, 0.42)
General Population 0.56 ( 0.44, 0.71)
South Africa 0.40 ( 0.24, 0.67)
Kenya 0.41 ( 0.24, 0.70)
Uganda 0.49 ( 0.28, 0.86)
.15 .2 .3 .4 .5 1 1.5
Effect size

14. Does it make sense biologically?

15. Does it make sense biologically?
Diagram of erect uncircumcised penis with
foreskin retracted
Inner mucosal layer of inner foreskin is exposed
McCoombe & Short, AIDS 2006 20:1491-1495

16. Acceptability in Africa?

17. Acceptable in sub-Saharan Africa ?
2006: review of 13 acceptability studies
in 9 sub-Saharan countries:
Uncircumcised men for themselves: 65% (29-87%)
Women (for their partners): 69% (47-79%)
Men for their son: 71% (50-90%)
Women for their son: 81% (70-90%)
Westercamp et al. AIDS Behav. 2006 Oct.
.

18. Acceptability of MC from 13 African studies
The percentage of men and women who agreed with the following statements:
Not surprising: Zulus, Twanas …

19. Some curved balls:
Self reported MC status
• Men asked “Are you circumcised?”
• Physical examination by a male nurse
• 45% of men who said they were circumcised had intact
foreskin
• Possible reasons:
– Confusion between MC and Initiation
– Confusion with words used, vernacular
– Lack of knowledge on what MC is
Orange Farm, Taljard et al 2008

20. HIV (%) and circumcision status
25
PRR=0.93
p=0.73
20
20.2%
18.8%
15
10
5
0
‘’Circumcised’’ Uncircumcised
with foreskin

21. HIV (%) and circumcision status
25
PRR=0.48 p=0.002
20
20.2%
18.8%
15
10
9.5%
5
0
‘’Circumcised’’ ‘’Circumcised’’ Uncircumcised
without foreskin with foreskin
Thus, self reported MC status is a VERY unreliable indicator

22. With all the available data the
scientific world needed no more
convincing

23. The Global Recommendations
WHO/UNAIDS Technical Consultation Male
Circumcision and HIV Prevention: Research
Implications for Policy and Programming, 2007

24. Global Recommendations
• Countries with high prevalence (>15%), generalized
heterosexual HIV epidemics and low rates of MC
should consider urgently scaling up access to MC
services
• 13 countries identified: Botswana, Kenya, Lesotho,
Malawi, Mozambique, Namibia, Rwanda, South
Africa, Swaziland, Tanzania, Uganda, Zambia and
Zimbabwe
• Consider ethics, communication, culture, health
systems, funding, gender, comprehensive prevention
strategies

25. UN Support Actions
The UN partners joint work plan on male circumcision
assists countries to make evidence-based policy and
programme decisions to improve the availability,
accessibility and safety of male circumcision and
reproductive health services as an integral
component of comprehensive HIV prevention
strategies.

26. UN Operational Guidance for MC Scale-up
1. Leadership and 6. Quality assurance and
partnership improvement
2. Situation analysis 7. Human resource
development
3. Advocacy
8. Commodity security
4. Enabling policy and 9. Social change
regulatory environment communication
5. Strategy and operational 10. Monitoring and evaluation
plan

27. Two years later……

28. Activities for Male Circumcision for HIV Prevention,
2009
Tanzania, Malawi
Situation analysis, pilot Kenya: national guidance &
service sites strategy, situation analysis,
guidelines, training, Quality
Rwanda advocacy Assurance guide, expanded service
campaign, situation delivery, communication & advocacy
assessment under development, M&E, research
underway, services in
military Uganda
Situation analysis, policy
Lesotho: advocacy, development, Comms draft
situation analysis, policy
development, draft Zambia: Situation analysis,
strategy & comms trainings, policy, strategy &
Implementation plan, service
Namibia: delivery
Champions visit,
advocacy, DMPPT,draft Botswana: Situation analysis,
policy, strategy, training DMPPT,policy, strategy, training,
and QA planned, M&E, communications and QA
communications plan
Swaziland
South Africa Policy approved, situation analysis,
Situation analysis strategy & Implementation plan,
underway, draft leg/regulatory assessment, trainings,
guidelines QA, M&E draft, comms draft

29. Snapshot of countries’ progress 2009
Situation Policy & Training Quality Service delivery
Leadership I II
Analysis Reg I Training II Assur M&E
Botswana
Kenya
Lesotho
Malawi
Mozambique
Namibia
Rwanda
South Africa
Swaziland
Tanzania
Uganda
Zambia
Zimbabwe

30. What is South Africa doing and
thinking?

31. What's been happening in South Africa?
Leadership and
civil society
concerns 2008
MC raised in
RCT Studies SANAC, 2008
available, 2007
Action taken
MC raised in in SANAC,
SANAC, 2007 2009
Pietermaritzburg SANAC plenary Commitment to
Orange Farm agreed to
pilot 2007 pilot 2009 public sector scale
develop public
onwards onwards up in 2010?
sector guidelines
Lack of political
support SANAC reinvigorated by SANAC
political and civil society indecisiveness
SANAC reinvigorated by about policy versus
civil society leadership leadership
guidelines

32. What's been happening in South Africa?
Leadership and
civil society
concerns 2008
MC raised in
Studies available, SANAC, 2008
2007
MC raised in Action taken
SANAC, in SANAC,
2007 2009
Orange Pietermaritzburg SANAC plenary Commitment to
Farm pilot pilot 2009 agreed to public sector scale
develop public
2007 onwards up in 2010?
onwards sector guidelines
Lack of political
support SANAC reinvigorated by SANAC
political and civil society indecisiveness
SANAC reinvigorated by about policy versus
civil society leadership leadership
guidelines

33. What's been happening in South Africa?
Leadership and
civil society
concerns 2008
MC raised in
Studies available, SANAC, 2008
2007
MC raised in Action taken
SANAC, in SANAC,
2007 2009
Orange Pietermaritzburg 2009 SANAC Commitment to
Farm pilot pilot 2009 plenary agreed public sector scale
to develop public
2007 onwards up in 2010?
onwards sector guidelines
Lack of political
support SANAC reinvigorated by SANAC
SANAC reinvigorated by civil political and civil society indecisiveness
society leadership leadership about policy versus
guidelines

34. South Africa Score Card
Leadership and partnership Quality assurance
Researchers, civil society, and now and improvement
politicians, traditional leader &
practitioners Human resource
Situation analysis development
Being completed Commodity security
Advocacy
Social change
Researchers, treatment activist
communication
Enabling policy and regulatory
environment Monitoring and
Being explored evaluation
Strategy and operational plan
Plan not policy being developed

35. Predicting the impact…Modelling

36. Modeling the Impact of MC on HIV Prevalence
& Incidence
Williams 2006
• 100% uptake of MC could avert 2.0 million new infections and
0.3 million deaths over ten years in sub-Saharan Africa
• Could avert 5.7 million new infections over 20 years
Nagelkerke 2007
• 50% uptake of circumcision over 10 years would reduce
prevalence from 18% to 8% over 30 years in Nyanza Province,
Kenya
Mesesan 2006
• 50% uptake of MC could avert 32,000 – 53,000 new infections in
Soweto, SA over 20 yrs.
• HIV Prevalence would decline from 23% to 14%

37. Questions beyond modelling…

38. How do we scale up in the public sector?
?

39. Male Circumcision Service Planning
Modelling circumcision
Services in the public
sector in Hillbrow, Inner
City Johannesburg

40. Alternative scenarios for Hillbrow
• Only 19% of the target population need to be interested to operate
one theatre at full capacity for five years
• With five theatres instead of one:
– 54,704 surgeries could be performed in the 5 years, resulting in
81% coverage
• Performing operations for 10 hours a day instead of 5 hours:
– Would achieve coverage of 37% up from 19%
• If Professional Nurses performed the surgery in lieu of doctors:
– The procedure would be 12% less costly

41. We asked who was interested
? ?
?

42. Joburg Circumcision Model Outputs
• Survey showed 80% men interested in MC
• This would mean over 67,000 males could
request MC services in Hillbrow over 5 yrs
• If there is 19% uptake of MC of those men
interested this will require one full-time
MC theatre to run at full capacity for 5
years doing 2500 surgeries per year
• The services will require 1.0 full time
equivalent doctor, 1.77 FTE staff nurses,
1.22 FTE counsellors and 0.23 non health
care workers

43. Moving onto South African policy
SOUTH AFRICA

44. Recommendations from SANAC
plenary
These recommendations were developed from
two national consultations involving all SANAC
sectors and SANAC government departments and
consultations by sectors: traditional leaders,
NGOs, PLWHA, women, children, men……..

45. Importance of male sexual health package
• MC should be introduced to adolescents and young
men as part of a comprehensive sexual health
package that could include: HCT, STI treatment, safer
sex messaging, condoms, alcohol counselling
• HIV testing should be offered prior to MC but should
not be a prerequisite for MC.

46. Communication strategy
• Community messaging outlining what MC offers,
and discouraging unsafe MC services
• Messages must be clear
– Partial efficacy (only 60% effective)
– Sustaining safer Sexual practices
– Delay sexual debut
– Alcohol abuse
– Changing gender norms
– ‘Male Morality’ e.g. respect of women
• Appropriate media for the disabled

47. MC programmes must be gender sensitive
• Messaging must target women as partners &
mothers of sons
• Messaging must explain advantages to women of MC
• MC programmes should not pull funds away from
existing programmes targeting women eg PMTCT,
Female condoms
• MC should not further stigmatise HIV+ve women by
blaming them should a circumcised male become
infected

48. MC rollout in health services
• More than 3 million young men are
uncircumcised in SA
• Design programmes with reference to
demonstration projects underway e.g. Orange
Farm 8000 MCs in 18 months
• Beware of creating demand for MC without
services being able to respond

49. Costing and Research
• Modelling and costing should be undertaken
to assess affordability, impact and cost-
effectiveness (WHO model available)
• Sustainable funding required
• Research agenda ongoing

50. Take home messages in South Africa
• Policy or guidelines?
• Address traditional male circumcision within a policy?
• Speed in implementing medical male circumcision
programme within an sexual health package as part of SRH
service provision
• Communication strategy informing communities of MC and
HIV prevention data in sexual health context and discourage
unsafe MC practices
• Ongoing consultations with Houses of Traditional Leaders and
traditional practitioners, private sector, other sectors

51. Conclusion
• We have a highly effective intervention
• We must implement this speedily with
ongoing stakeholder consultations
“If this was a pretty drug in nice packaging….”

52. Thank you
Acknowledgments
All the men and women who participated in the
many studies
Dirk Taljard, Orange Farm
Kim Dickson, WHO,
François Venter, RHRU
AND
SOUTH AFRICA