Voluntary Medical Male Circumcision (VMMC) has been shown to reduce the risk of female-to-male HIV transmission by 60%. Studies have also shown that by reducing infections in men and boys, the intervention in turn also reduces HIV infections in women and girls, although to a lesser degree.
But with the COVID-19 pandemic and the associated lockdown, health authorities and organisations conducting VMMC in South Africa say the numbers of men and boys being medically circumcised have dropped dramatically.
According to recently released estimates from the Thembisa model, the leading mathematical model of HIV in South Africa, over half a million medical circumcisions were conducted in South Africa in 2019, with just under half of these in boys aged 10 to 14.
"There have been very high rates of medical male circumcision uptake since 2011, especially in the 10-14 age group," says Dr Leigh Johnson of the Centre for Infectious Disease Epidemiology and Research, at the University of Cape Town. "Medical male circumcision reduces men's rate of HIV acquisition by about 60%, so we think this is one of the significant factors leading to HIV incidence declines in young men in recent years."
"Medical Male Circumcision is an elective surgery and to prevent the risk of COVID infection to MMC clients and health professionals, all activities [under the programme were suspended] in March in line with the President's call for a level 5 lockdown," says Popo Maja, spokesperson for the National Department of Health. "However, with the easing of the lockdown as per presidential announcements, the suspension was lifted in late June 2020, to allow for low-volume circumcisions in non-hot spot districts/provinces in line with the integrated COVID-19 risk reduction strategy developed by the National MMC programme."
Figures shared by Maja show that in the first three quarters of 2020, 111 766 medical circumcisions were conducted in South Africa, compared to 411 063 in the first three quarters of 2019. This amounts to a drop of around 73%.
As Maja explains from the graph below, "it is clear that COVID has severely affected and has negatively impacted on the routine performance of high-volume medical circumcisions nationally".
Spokesperson for the Western Cape Department of Health, Mark Van der Heever says that due to the lockdown, which resulted in the restriction of movement of people and the subsequent de-escalation of non-emergency medical care, the province's medical male circumcision target of 15 000 - 16 000 for the 2020/21 financial year will not be achieved.
Van der Heever says under normal circumstances the province was looking to reach this target but due to the restrictions due to COVID-19 they only achieved 13 796.
"All districts have relaunched VMMC activities with strict adherence to the necessary COVID-safety protocol. There is a national initiative to reposition VMMC as an opportunity where men can access a package of health screenings and not just VMMC. We are also hoping to leverage on the national MINA campaign that promotes men's health. MINA is a nationwide movement to reconstruct men's relationship with healthcare and to destigmatise HIV and aims to increase the number of men accessing and retained on life-saving treatment services," he says.
In Gauteng, Spokesperson for the provincial health department, Philani Mhlungu says that COVID-19 impacted VMMC programmes as services had to be suspended.
"Medical male circumcision services were suspended due to lockdown restrictions at Gauteng Department of Health from April to June 2020. Suspension was then [lifted] and MMC services were to commence from 1 July 2020, pending [a] site readiness assessment of all service points including all GPs/doctors [the province has] on contract," says Mhlungu.
In the Eastern Cape, according to the South African National AIDS Council's executive manager for the NSP, Coceka Nogoduka, VMMC procedures dropped from 3 444 between April and June last year to only 166 for the same period this year-roughly a 95% drop. Nogoduka was speaking on a webinar titled "Regaining lost ground on HIV due to COVID-19".
Attempts to get comment from the KwaZulu-Natal Department of Health on its VMMC programmes were unsuccessful.
Meanwhile, the Department of Co-operative Governance and Traditional Affairs (Cogta) has suspended this year's summer circumcision season due to a rise in COVID-19 cases. However, as reported by GroundUp News, some Eastern Cape clinics are still issuing documents to parents certifying that their sons are fit for initiation school.
Tsietsi Mbuso, a demand creation coordinator at the Centre for HIV/AIDS Prevention Studies (CHAPS - an NGO that conducts VMMC), tells Spotlight that the pandemic has had "negative impacts on all HIV/AIDS prevention programmes that were active before".
According to Mbuso, most men still hold the perception that circumcision is best done in winter. He says prior to the outbreak of COVID-19, CHAPS had a lot of bookings from interested male clients that were willing to come during the winter season. But the lockdown restrictions in the country during that time, he says, affected the uptake of the VMMC programme.
Mbuso says the greatest challenge to the programme is that men are still sceptical about coming to public health facilities to access services for fear of contracting COVID-19.
Besides running circumcision programmes, CHAPS has also played a critical role in HIV prevention research.
"We pride ourselves in being the team that conducted the randomised controlled trial in Orange Farm at the Bophelopele Male Circumcision Centre from 2002 to 2005, proving the efficacy of VMMC being an effective method of reducing HIV transmission from female to male," he says.
A decade of VMMC as HIV prevention
In the years since the landmark Orange Farm trial, the protective effect of VMMC has been confirmed in additional studies and is now seen as a standard part of HIV prevention efforts endorsed by the World Health Organization (WHO). The VMMC programme has also over the last decade become an integral part of South Africa's HIV prevention efforts.
According to the latest estimates from the Thembisa model, 57.5% of men aged 15 to 49 in South Africa were circumcised (including both traditional and medical circumcisions) as of mid-2019. This constitutes a 21 percentage point increase over 2010-roughly when the VMMC programme started in earnest.
With 85% of men between the ages 15 to 49 circumcised, Limpopo was far ahead of other provinces in 2019 - followed by a group of four provinces around the 60% mark - Eastern Cape 63.5%, Mpumalanga 63%, Free State 61.9%, and Gauteng 58.4%. The four provinces with the lowest circumcision numbers are KwaZulu-Natal at 51.8%, North West at 47.7%, Western Cape at 40.9%, and Northern Cape at 37%.
The VMMC programme has mostly been well received with 78% of women preferring their partner to be circumcised, according to the 2011 youth sex survey.
How VMMC is done
Mbuso explains VMMC is an elective procedure. "Meaning that it is not an emergency and allows the prospective client to be informed about its benefits and risks in order to make an informed decision before they can commit," he explains. "There is no need for interested clients to wait for extended periods of time to undergo the procedure if they have been informed about the risks and benefits and are ready to do it."
The process typically involves one-on-one counselling, offering of an HIV test, a pre-assessment (to check for any underlying medical issues that may hamper the client's ability to be circumcised), a procedure conducted by a well-trained and qualified practitioner, post-operative care, and follow-up visits after 48 hours, seven days and then 14 days.
Mbuso says there are different types of circumcision methods that are performed all over the world depending on the country guidelines and these include Forceps Guided, Sleeve Resection, Dorsal Slit, Tara KLamp and Prepex. The latter two are circumcision devices while the first three are surgical methods.
"Out of all the circumcision methods mentioned, PEPFAR (US President's Emergency Plan for AIDS Relief) in consultation with the Department of Health in South Africa have recommended and endorsed the Dorsal Slit as being the most effective and safest method to be used for all ages in the country," says Mbuso.
And the use of the Prepex device in South Africa?
Mbuso says CHAPS was part of a team that conducted a Prepex study in the North West province and Gauteng. While the device was generally well received in the study, it is not currently recommended for use in South Africa.
"The Prepex device was discontinued in countries like Zimbabwe, Malawi and Mozambique, based on the few reported cases of tetanus in those countries. South Africa also discontinued the use of the Prepex device [based on] recommendations by PEPFAR and the Department of Health for safety of clients. It was recommended that more Prepex studies be conducted with extra precautionary measures taken into consideration for safety of clients by providing [a] tetanus vaccine [shot] before the placement of the device," says Mbuso.
Many concerns have also been raised about the Tara KLamp. Mbuso tells Spotlight how the device was tested as part of circumcision trials conducted at Orange Farm but he says based on the reports from participants about how the device caused a lot of discomfort, and pain being unbearable, use of the device was discontinued to ensure participants' safety. A randomised controlled trial published in 2009, found that use of the Tara KLamp was associated with high rates of adverse events. The device was nevertheless used for some time thereafter by the KwaZulu-Natal Department of Health.
Questions of culture
Medical circumcision has been shown to generally provide greater protection against HIV infection than traditional circumcision. But there are cultural pressures on some young men to be circumcised in the traditional way rather than with VMMC.
In provinces such as Limpopo, Free State and the Eastern Cape, many young boys still undergo circumcision the traditional way. In these provinces, circumcision is often seen as one of the most important moments in the lives of young boys as they embark on the journey from boyhood to manhood.
But some of them, especially in the Eastern Cape, end up with botched operations or sometimes die while undergoing the ritual. Twenty-one initiates died in the Eastern Cape during the 2019 summer circumcision season, EyeWitness News quoted Minister of Health Dr Zweli Mkhize saying last December.
Spotlight reached out to the Congress of Traditional Leaders of South Africa's (Contralesa) general-secretary, Zolani Mkiva, to hear what the traditional body's view is on VMMC and whether it can be a solution to deaths of initiates. But, although acknowledging receipt of our questions, he had not responded by the time of writing.
What makes a man?
Fearing for the safety of his 18-year-old boy who is set to undergo circumcision, a Cape Town parent *Mzimasi Nkewu says he is considering VMMC for him.
He would have preferred his son to undergo the practice in the mountain, just like him, but after seeing boys dying in his village, he is sceptical.
"The sad thing is that boys who don't do the practice in the mountains get isolated and get called names. They are not considered real men. But which is better - being isolated [or] dying in the mountain? I want VMMC for him," says Nkewu.
Mbuso believes communities need to be educated about cultural tolerance and be made to understand that all cultures are unique in their own way and no one should impose their cultural belief systems on others.
"I think South Africa is blessed to be counted alongside other countries that have diverse cultures coexisting with one another, but also not forgetting the fact that every person sees his/her culture being [superior to] the other, because of the difference in language, geographical attachment and upbringing," he says. "And with that being said, not all South African cultures practice the passage to manhood (initiation) within their respective cultures, and we also need to be cognizant of the fact that male circumcision is a choice and not a classification of defining what a man is."