Voluntary medical male circumcision (VMMC) programmes are
expanding in several African countries and in a couple of locations have almost
reached saturation point, with most of the eligible young male population
19th International AIDS Conference (AIDS 2012) in Washington DC heard
Presenter Jane Bertrand of Tulane University said that, in the Nyanza
Province of Kenya, which was home to the traditionally uncircumcised Luo people,
the target has almost been reached of 80% of the adolescent male population
(aged 15 to 24) being circumcised. Since 2008, 312,789 procedures have taken place
in a province with an uncircumcised male population in that age range of around 400,000, meaning that between 73 and 82% of initially uncircumcised
young men have now been circumcised.
The pace of circumcision programmes is such that a
significant proportion of staff performing the operations are experiencing
burn-out, presenter Dino Rech of the Centre for HIV and AIDS Prevention Studies
(CHAPS) in Johannesburg said. Burn-out was more likely if doctors continued to
do the operation rather than having VMMC ‘task-shifted’ so that nurses and medical
auxiliaries were trained to do it.
There were very different patterns of burn-out from the
four different countries surveyed (Kenya, South Africa, Tanzania and Zimbabwe).
A lot of practitioners in Kenya (71%) said they experienced burn-out and had
seen it in others (88%): these practitioners were providing the most circumcisions,
and there was a clear link with the number of operations performed. In Tanzania, most practitioners said they had not seen burn-out in
colleagues, but a high proportion admitted to it themselves. In South Africa
and Zimbabwe, moderate numbers (around 30%) admitted to burn-out, though South
Africa had the highest proportion of practitioners who said it was “very common”
Fully qualified doctors were more likely to report
burn-out than nurse or auxiliaries. This is a second strong argument (after
cost) for task-shifting, the training up of nurses and auxiliaries to perform
Zebedee Mwandi of the Centers for Disease Control (CDC) in Kenya reported that,
while in VMMC performed by doctors, the proportion of adverse events (AEs) has
declined from 1.4% to zero, AEs in procedures performed by nurses and clinical
officers had also declined, from 2 to 0.7% in three years. He said that VMMC
programmes were now taking off in other provinces, with coverage of the
eligible population in Kenya’s Western province now about 20% and Nairobi about
15%, though Nyanza had contained the vast majority of Kenya’s uncircumcised
The CHAPS clinic in Soweto has also almost achieved
saturation coverage amongst the local young male population, and is facing the
expense of having to move. This is an argument for mobile circumcision clinics,
and 12% of circumcisions are now being performed by mobile clinics in Kenya.
South Africa, Nikki Soboil runs a mobile clinic in KwaZulu Natal, on behalf of
the Southern African Clothing & Textile Workers’ Union, which funds HIV prevention
work. An analysis comparing the costs of running a permanent establishment like
CHAPS and a mobile clinic showed that, while training and transport cost more in
the mobile clinic, all other costs such as capital expenditure and wages were
less, meaning that the mobile clinic could perform each circumcision for 498 Rand (US$59), while in CHAPS each procedure cost 827 Rand.
In other countries, VMMC is still not receiving funding
for large rollover programmes, though a survey from Swaziland found that the
proportion of men in the population who were circumcised had more than doubled since
2008. This was even before a large media campaign encouraging circumcision started and in the absence of any national rollout
– which, given this country's adult HIV prevalence of 26%, was urgently needed, presenter Jason Bailey Reed of the US CDC said.