Male Circumcision Science
Policy Debates in South Africa
Co-chair: Prevention Technical Task Team
Declaration of Commitment on HIV&AIDS and
Political Declaration on HIV&AIDS
10-12 June 2008, United Nations, New York
“Scaling up HIV prevention in hyper-endemic countries. In
countries where HIV prevalence exceeds 15 per cent, only an
unprecedented national mobilization, involving every sector of
society and making use of every available prevention tool, will
meet the challenge posed by such catastrophic continued
spread of HIV”.
Conclusions: SADC Think Tank on
“key drivers of the epidemic in
southern Africa - multiple and
concurrent partnerships by men
and women with low consistent
condom use and in context of
low levels of male circumcision”.
– male attitudes and behaviours
– inter-generational sex
– sexual and gender based violence
– stigma, denial, lack of openness
– untreated viral STI’s, and a lack
Underlying context - gender and
mobility, and other structural
Male Circumcision is one of few HIV prevention
strategies that has strong evidence basis
Evidence basis: Orange Farm,
Rakai and Kisumu Trials
• Male circumcision has been shown to reduce men’s risk
of becoming infected by HIV through heterosexual
intercourse ranging from 38% to 66% 1
• Three randomized clinical trials (South Africa, Uganda
and Kenya) have shown that male circumcision reduces
the risk of men becoming infected with HIV by between
50 – 60%. 2
• 1. Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database of Systematic
Reviews 2009, Issue 2.
• 2 [i] Bailey, R. et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A Randomised controlled trial. Lancet Infect Dis 2007: 369:
• 2 [ii] Gray, R. et al. Male circumcision for HIV prevention in men in Rakai, Uganda : A Randomised trial. Lancet Infect Dis 2007: 369: 657-66.
• 2 [iii] Auvert, B. et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med.
2005 Nov;2(11):e298. Epub 25 October 2005.
Evidence basis: Sociological and
• This confirms findings from 40 sociological and epidemiological
studies which show a strong correlation between rates of male
circumcision and reduced HIV prevalence 3
• Biological studies of the foreskin which show a high concentration of
cells very susceptible to HIV infection 4, which is one of three
potential biological explanations as to why circumcision may reduce
• The other two being a reduction in STIs and a reduction in the
likelihood of microtears and trauma to the foreskin).
• 3[i] Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, et al. HIV and Male Circumcision – a systematic review with assessment of the quality of studies. Lancet Infect Dis 2005: 5:165-173
• [ii] Siegfried, N. et al. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2003(3):CD003362.
• [iii] Weiss, H.A., Quigley, M.A., Hayes, R.J. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000 Oct 20;14(15):2361-70.
• [iv] Nagelkerke NJD, Moses S, de Vlas SJ and Bailey RC. Modeling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa. BMC Infectious Diseases 2007, 7:16, 13 March, 2007.
4 Patterson, B.K., Landay, A., Siegel, J.N., Flener, Z., Pessis, D., Chaviano, A., et al. Susceptibility to human immunodeficiency virus-1 infection of
human foreskin and cervical tissue grown in explant culture. Am J Pathol. 2002 Sep;161(3):867-73.
Demographic and SRH Impact
• Based on the data from the clinical trials, models have estimated
that routine male circumcision across sub-Saharan Africa could
prevent up to six million new HIV infections and three million
deaths in the next two decades 5
• Male circumcision also provides other health benefits, in particular
the reduction of certain sexually transmitted diseases and cancers
• Evidence shows that male circumcision reduces some sexually
transmitted infections (STI),
• particularly ulcerative STIs including chancroid and syphilis, as well as
balanitis, phimosis, and penile cancer6
5 Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, et al. The Potential Impact of Male Circumcision on HIV in Sub-Saharan Africa. PLoS
Medicine Vol. 3, No. 7, e262. Epub 2006 July 11.
6 (1)Weiss HA, Thomas SL, Munabi SK, Hayes RJ. Male circumcision and risk of syphilis, chancroid, and genital herpes: A systematic review and
meta-analysis. Sex Transm Infect. 2006 Apr;82(2):101-9; discussion 10.
6 (2) Lavery L, Rakwar JP, Thompson ML, Jackson DJ, Mandaliya K, Chohan BH, et al. Effect of circumcision on incidence of human immunodeficiency
virus type 1 and other sexually transmitted diseases: a prospective cohort study of trucking company employees in Kenya. J Infect Dis 1999; 180:330–
6 (3) Schoen EJ; Oehrli M; Colby C; Machin G. The highly protective effect of newborn circumcision against invasive penile cancer. Pediatrics.
SRH Impact and Social
• Circumcision has also been associated with a reduction
in penile human papillomavirus (HPV), and a reduction in
cervical cancer in female partners 7.
• In South Africa approximately 45% of men report being
circumcised with circumcision rates being the highest in
the Western Cape (67.5%) and the lowest in KwaZulu-
Natal (26.8%) and Gauteng (25.2%).
• The levels of circumcision are highest amongst men over
the age of 30 (53%) 8
• 7. Castellsagué X; Bosch FX; Muñoz N; Meijer CJLM; Shah KV; de Sanjosé S; Eluf-Neto J; Ngelangel CA; Chichareon S; Smith JS; Herrero R; Moreno
V; Franceschi S; the International Agency for Research on Cancer Multicenter Cervical Cancer Study Group. Male Circumcision, Penile Human
Papillomavirus Infection, and Cervical Cancer in Female Partners. N Engl J Med 2002;346:1105-12.
• 8. Department of Health, Medical Research Council, OrcMarco. 2007. South Africa Demographic and Health Survey 2003. Pretoria:
Department of Health.
Socio Cultural Acceptability
• In certain cultures male circumcision is practiced as a rite of
passage to manhood.
• Acceptability studies conducted in 2001 and 2002 have indicated
that there are high levels of acceptability of male circumcision
amongst men and women in South Africa 9
– more than 50% of men indicating that they are willing to undergo male
– more than 50% of women indicating that they would be in favour of
• 9 Lagarde, Taljaard, Puren et al, 2003[i]; Scott, Weiss, Viljoen, 2005 [ii])
[i] Lagarde, E; Taljaard, D; Puren, A et al. 2003. Acceptability of male circumcision as a tool for preventing HIV
infection in a highly infected community in South Africa. In: AIDS 2003, 17:89 – 95.
• [ii] Scott, B.E; Weiss, H.A; Viljoen, J.I. (2006). The acceptability of male circumcision as an HIV intervention
among a rural Zulu population, KwaZulu-Natal, South Africa. In: AIDS Care, April 2005; 17(3): 304 – 313.
Accessed from: http://www.global-campaign.org/clientfiles/scott%20male%20circumcision.pdf
Issues raised by Sectors
• Women, Men, Youth, Traditional Leaders, Research,
• Acceptance of results but with general concern about non-
medicalisation of traditional practices
• Concerns about commercialization of the Medical male circumcision
• Concerns about risk compensation and potential added risk to
• HR, Financial and other health systems implementations
• PTT advocated for Circumcision policy
• Consulted with various Sectors (Communication
of the Science)
• Developed a project plan with deadlines for
policy development (June 2009)
• DOH drafted a policy concept presentation and
(Communication of Policy provisions)
• Policy option was dropped in favour of Male
Medical Circumcision guidelines and Integrated
HIV and AIDS Prevention Strategy and Policy
• MMC Guidelines based on preexisting SRH policy
developed and currently costed for implementation
• Costing using long term modeling and scenarios ongoing
• Detailed guidelines to with uniform service delivery
model and standards to guide implementation M&E.
• KYE KYR being conducted to inform new Prevention
Recommendations for the
Why the prevention gap?
Adequate and united leadership:
– sensitivities, denial, inconsistent messaging must be addressed
• Limited analysis and understanding of epidemic drivers must be addressed
• Overcome Weak planning – targets, strategies,.
• Provision of adequate costing and Resourcing for programmes
• Need to address weak or un-defined national authority & institutional
– Weak partner coordination mechanisms.
• Ensures adequate attention to implementation arrangements.
• Address Fragmented monitoring and evaluation
– Lack of results based accountability