Since the beginning of the epidemic, almost 70 million people have been infected with the Human Immunodeficiency Virus (HIV) and about 35 million people have died of AIDS related diseases. Globally, 34 million people were living with HIV at the end of 2011. It is estimated worldwide that 0.8% of adults aged 15-49 years are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions. Sub- Saharan Africa remains the most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV. South Africa has the highest global burden of HIV with 5.6 million people infected.
In Africa male medical circumcision (MMC) has been shown in a number of clinical trials to reduce HIV acquisition by up to 60%. WHO/UNAIDS recommendations emphasize that male circumcision should be considered an effective intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV and low male circumcision prevalence. Mathematical models based on the results of randomized controlled trials suggest that medical circumcision could avert two million HIV infections over the next 10 years; however it is unclear whether medical circumcision would decrease the overall prevalence of HIV infection when delivered outside the context of the controlled environment of a randomized trial.
Whizzkids United Health Academy is an adolescent friendly primary care clinic and recreation centre at Edendale Hospital. Amongst other activities, WKUHA offers HIV testing, MMC, antiretroviral treatment, sexual risk assessment, screening for sexually transmitted infections and other primary healthcare services (including contraception advice), support for orphans and vulnerable children, and career guidance. The facility and services represent a multi-stake partnership between WhizzKids United, Africaid, the KwaZulu-Natal Department of Health and Edendale Hospital.
The Football for Hope legacy established by the 2010 FIFA World Cup has funded an artificial turf football pitch and extension to the Health Academy. Currently more than 6,600 beneficiaries are registered at the WKUHA and more than 1,600 have been tested for HIV infection (with 4.1% testing HIV seropositive). More than 20,000 schoolchildren have interacted with the WhizzKids United team.
The MMC service facility at Edendale Hospital performs around 200 circumcisions a month. MMC camps take place in the Edendale Nursing Home Hall where about 150 boys and men are circumcised monthly. Whizzkids United has made the uptake of MMC services more accessible for adolescents.
Male circumcision provides only partial protection, and therefore should be only one element of a comprehensive HIV prevention package which includes: the provision of HIV testing and counseling services; treatment for sexually transmitted infections; the promotion of safer sex practices; the provision of male and female condoms and promotion of their correct and consistent use. Circumcised men may develop a false sense of security following their procedure and engage in riskier sexual behaviour, including lower condom-use and an increased number of sexual partners. This “risk compensation” (increase in risky sexual behavior), could possibly diminish or negate the protective effect of male medical circumcision.
An estimated 45% of new HIV infections in South Africa occur amongst 15-24 year olds, mainly via sexual transmission. Evidence suggests that in South Africa for 15–24 year old men, sexual debut is frequently prior to 15 years of age. Such early sexual debut is a determinant of HIV infection.
The potential exists to avert 22% of HIV infections between 2011-2025 among the 14 priority countries (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe), if 80% of males aged 15 - 49 years are circumcised by 2015 and that coverage is maintained. By the end of 2010, 555 202 MCs were reported to have been performed for HIV prevention. The largest numbers were done in 2010 when there was a fourfold increase from the number in 2009. Kenya has performed the most MCs (232 287), achieving nationally 27% of their target number of MCs needed by 2015 and 62% of their target in Nyanza Province, followed by South Africa (145 475) and Zambia (81 849).
In South Africa there is a diverse perspective on male circumcision. The scale-up of voluntary male medical circumcision has meant that the country, along with Kenya and Zambia, was ranked one of the highest globally, in terms of number of circumcisions performed in 2010. In 2009, 9168 men were circumcised and in 2010 this increased to 131,117. It is estimated that a programme of full coverage could prevent half a million infections and 100,000 deaths within a decade, with these figures rising in the future.
Each generation will perform, or not perform, certain cultural practices for reasons best known at that time. The practice of circumcision in the African context is performed by the traditional surgeon at the mountain side or in the bush as a secret ritual. We can only rely on verbal information as to how circumcision originated. It is written about in the Bible as a religious activity – a means to enhance adulthood, sexual lust and as a hygiene aid. However, there are arguments both for and against this- circumcision among Jewish people was praised for health reasons, whereas among Philippians, it was seen as mutilation.
A mix of delivery approaches has been used as MC services expand into all nine provinces in South Africa. Fixed sites (mainly district hospitals) were used with MC services integrated into these settings. During 2010 over 130 000 MCs were performed at 143 sites. South Africa is now moving towards scaling-up services, with all provinces now initiating the provision of services.
Contemporary society is in the age of daring, sexual freedom and talking openly about all manner of sexual matters. We are used to seeing many appropriate/ inappropriate things on TV, in magazines and newspapers, but not very often about the affairs of men and circumcision! Men are very private, both in pictures and talk. People do not talk about the penis and circumcision very often except in some religious and traditional groups. In one survey, some teachers reported feeling uncomfortable about teaching a curriculum that contradicted with their own values and beliefs. Another problem was believed to be the disadvantaged home life of the students, with some teachers believing poor role models at home did not help to reinforce HIV prevention messages received in the classroom.
The circumcision issue will remain a strangely conservative subject in this sexually enlightened age until such time the medical profession evidently finds out the relevant risk factors for uncircumcised men in terms of STIs, HIV/ AIDS, other viral/ bacterial diseases, penal cancer and cervical cancer etc. Previously circumcision was mostly done by people without proper medical/ surgical training and anatomical/ physiological knowledge; as a result there was a fatal outcome in a number of reported cases.