'Swimming amongst crocodiles': How HIV services are provided in conflict zones across Africa

Lindsay Mgbor/Department for International Development. Image for illustrative purposes only. Creative Commons licence.

In Cape Town, South Africa, where gang violence is a serious problem with as many as 90 to 130 gangs, Jhpiego has been working with gang leaders who control different areas of the Cape Metro to provide voluntary medical male circumcision (VMMC) to prevent HIV, the 22nd International Conference on AIDS and STIs in Africa (ICASA 2023) held last week heard.

According to the presentation by Zolani Barnes, the 'collaboration' with gang leaders has led to the provision of over 40,000 circumcision services, with most gangs naming it a 'gateway to full manhood', thereby creating demand. The number of circumcisions performed in 2022 saw a 47% increase compared to the previous year (from 5,898 to 8,666). In 2023, the project has already performed 8,285 circumcisions.

"Because the country has failed to curb gang-related violence, it is necessary to find the best way to work around the gangs to ensure the continuance of VMMC services,” said the researchers from Jhpiego. "By viewing the gangs as partners, we have been able to use our VMMC services to circumcise gang members to enable them to be recognised as real men."


voluntary male medical circumcision (VMMC)

The surgical removal of the foreskin of the penis (the retractable fold of tissue that covers the head of the penis) to reduce the risk of HIV infection in men.


The surgical removal of the foreskin of the penis (the retractable fold of tissue that covers the head of the penis) to reduce the risk of HIV infection in men.

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

drug interaction

A risky combination of drugs, when drug A interferes with the functioning of drug B. Blood levels of the drug may be lowered or raised, potentially interfering with effectiveness or making side-effects worse. Also known as a drug-drug interaction.


A healthcare professional’s recommendation that a person sees another medical specialist or service.

Voluntary male medical circumcision is a strategy recommended globally since 2007 to prevent HIV, especially in African countries with low coverage of male circumcision and high HIV prevalence. Circumcision decreases the risk of HIV acquisition by about 60%. However, in Cape Town, frequent gang wars make it difficult to offer circumcision and other health services due to safety concerns.

To operate safely in these gang-controlled areas and provide services, Jhpiego uses various strategies while ensuring the safety of its employees.

The first strategy employed was using community mobilisers from the same local communities to approach the gang leaders and explain what they were doing and that they were not threatening the gangs. This approach was necessary because gangs are generally distrustful for fear of assassination by their opponents. The mobilisers also engaged the gang leaders to ensure their safety.

As a result, Jhpiego and gang leaders have developed a relationship of trust that has led to protection and service delivery. In addition, circumcising gang leaders have influenced their members to follow their examples.

By working closely with the gang leaders, the Jhpiego team has identified the boundaries of different gangs operating in the area. This has allowed them to ensure rival gang members do not mix while accessing their services. For instance, when transporting clients to the circumcision centre, they cannot transport a gang member across a rival gang territory.

Because borders can change anytime after a war, the team continually engages with gang leaders to know new territories. Understanding clothing, colours, jewellery, graffiti, tattoos and territories belonging to different gangs has also enabled them to avoid clashes when providing services.

Although the team has made progress, there are still challenges. For instance, when wars break out, service provision tends to drop, and it becomes harder to interact with gang leaders and members who are fully committed to their cause. Additionally, leadership changes are common due to deaths, so it is necessary to engage with the next leader.

In West Africa, a bigger war has been raging in Cameroon's northwest and southwest regions over the last seven years, resulting in the mass displacement of people and health personnel, as well as the destruction of health facilities. This armed conflict has greatly impacted the delivery and usage of HIV care services, with as many as 17% of patients lost to follow-up. Many individuals have been forced to move to safe but hard-to-reach areas with no operational health facilities.

Therefore, to track, reinitiate and retain people lost to follow-up in the southwest region, the Reach Out Mobile Clinic visits one health district every 21 days. The mobile clinic is staffed by a doctor, two nurses and a laboratory technician, who provide routine consultations, screening, and treatment for common health conditions and HIV testing. Clients are also tested for sexually transmitted infections based on their clinical presentations and symptoms. All HIV-positive cases are referred to the nearest HIV care and treatment centre. For clients who cannot go to the treatment centre, an individual treatment plan is created to ensure regular refills.

Between November 2022 and June 2023, the clinic provided 4130 consultations across four health districts. The majority of the clients (55%) were women, and 196 people were tested for HIV. Twenty four people (12%) had HIV, of which the majority (75%) were women. Out of the positive cases, 83% had dropped out of care, leaving 17% as newly diagnosed.

All clients received an initial two-month supply of antiretroviral treatment and were also connected to the nearest treatment centre.

As conflict increases vulnerability to diseases, including HIV, targeted interventions should be urgently implemented to facilitate access to healthcare.


Zolani B et al. Swimming amongst crocodiles: Rendering VMMC services amongst rival gangs in Cape Town, South Africa. 22nd International Conference on AIDS and STIs in Africa, Harare, abstract THPED038, 2023.

Achua K et al. The role of the mobile clinic in identification, re-initiation and retention of HIV treatment defaulters in an armed-conflict setting. 22nd International Conference on AIDS and STIs in Africa, Harare, abstract TUPEE013, 2023.

Full image credit: Tattoos mark moving up the ranks. Lindsay Mgbor/Department for International Development. Image is for illustrative purposes only. Available at www.flickr.com/photos/dfid/8517217425 under a Creative Commons licence CC BY 3.0 Deed.