Miss Dhirisha Naidoo - Clinical Manager of Male Medical Circumcision Programme at McCord Hospital spoke on the primary concepts related to prevention of infectious diseases, with a focus on Male Medical Circumcision (MMC). Based on the biological plausibility and epidemiological evidence, Miss Naidoo's presentation focused on the individual and public health benefits of Medical Male Circumcision (MMC). She also outlined the comprehensive programme based at McCord Hospital, and the challenges faced by the institution.

1. Dhirisha Naidoo
Peninah Thumbi

2.  Prevention Concepts
 The case for Medical Male Circumcision:
• Biological plausibility
• Epidemiologic evidence
 Current HIV prevention situation
• Biomedical
• Behavioural
 Adding MMC to the toolbox
• WHO / National
 National Strategic Plan (2012 -2016)
 Social Mobilisation
 Training
 Bioethics
 McCord Hospital and MMC

3.  Avoid contact with the source: Behavioural
change for HIV infection– abstain, use
condoms, reduce number of partners, know
your status etc
 Reduce the infectious load in the source –
Treatment of cases: e.g. HAART for
PMTCT, now „Treatment for Prevention‟
 Block Entry / Access to receptors in the host-
Condoms, Microbicides for HIV
infection, MMC
 Immunization – still evasive for HIV, very
effective for other diseases including
eradication possibility e.g. Small pox

4.  The shaft & outer foreskin- keratinized
epithelium (protects against HIV infection)
 Inner mucosal surface is not keratinized and is
rich in Langerhans‟ cells- particularly
susceptible to HIV infection
 During intercourse – foreskin pulled back over
the shaft of the penis exposing the whole of
its inner surface and thus a large surface area
where HIV transmission can take place
 Longer survival of organisms in the warm
moist sub-preputial space
 Indirectly; by protecting against other STDs

5.  1st suggestion of association as early as1986
 Ecological descriptions of areas with low MC
prevalence and high HIV prevalence late „80s
 Systematic reviews of observational studies
comparing HIV risk between circumcised and
uncircumcised men in the same populations-
consistent finding of lower HIV risk in circ men
 Meta- analysis of 15 studies that adjusted for
potential confounders – risk reduction large and
significant
 Evidence compelling, but causality difficult to
prove using observational data

6. 0
10
20
30
40
50
60
70
80
WC FS LP EC MP NC NW KZN GP
67.5
70.7
47.5
43.8
36.3
34.1 32.8
26.8
25.2
3.2
19.2
11.0
15.5
23.1
9.0
18.0
21.9
15.8
Circ
HIV
Data from: Shisana O; Rehle T, Simbayi LC, Parker W, Zuma K, Bhana A, Connolly C, Jooste S, Pillay V et al. (2005).
South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. Cape Town:
HSRC Press.

7.  Testing the observed concept: 3 RCT of
circumcision among consenting healthy adult
men – Uganda, Kenya, SA initiated 2002-3
 Each halted early by DSMBs due to significant
reduced risk of infection in the circumcised
men (2005-06)
◦ Kenya: RR 0.41 (95% CI, 0.24-0.70)
◦ Uganda: RR 0.43 (95% CI, 0.25-0.75)
◦ South Africa: RR 0.41 (95% CI, 0.24-0.69)
 Compared well to observational data:
◦ RR 0.42 (95% CI, 0.34-0.54)

9. Inclusion of all strategies known to work:
 the provision of HIV testing and counselling
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 “When
you teach people how to use condoms, give [them some] to take home, then the message
that male circumcision only works together with other HIV prevention strategies is better
reinforced.“ Clinical manager, Kenya
 Reduction of number of sexual partners
 Promotion and provision of proven biomedical HIV
prevention strategies – PMTCT,PEP, MMC, Prep, Rx
as they become available

10.  Medical male circumcision reduces the risk of
heterosexually acquired HIV infection in men by
approximately 60%
 It is safe if provided by well trained health
professionals in properly equipped settings
 WHO/UNAIDS recommendations (March 2007)-when it
hailed male circumcision as an important landmark in
the history of H.I.V. prevention emphasize that it
should be considered an efficacious Intervention for
HIV prevention in countries and regions with
heterosexual epidemics, high HIV and low male
circumcision prevalence- that‟s us.
 Male circumcision provides only partial protection, and
therefore should be only one element of a
comprehensive HIV prevention package

11. Health:
 A decrease in HSV2 infections
 A decrease in penile HPV infections
 Indirect female benefits in transmission of
bacterial vaginosis, trichomoniasis & HIV
 Reductions in UTIs, phimosis and balanitis

12. Scaling up MMC to reach 80 % of adult and
newborn males in 14 African
countries(including SA) by 2015 could:
Avert > 4 million adult HIV infections between
2009-2025, with 10 of the 14 countries averting
more than 19 % of new HIV infections by 2025
Yield an annual cost saving of US$ 1,4 -1,8 billion
after 2015, with a total net saving of US $20,2
billion between 2009 and 2025
Taken from USAID – Health Policy Initiative Sept 2009

13.  UNAIDS and WHO using SA data in a heterosexual
transmission model, estimate that one new HIV
infection can be avoided for every 5-15 circumcisions
done and this estimate takes into account possible
risk compensation across the entire population
(Kesinger & Millard, SAMJ NO:3 2012).
 Stepping up combination prevention is more cost
effective in SA than compared to other countries (US
Secretary of State of State Hillary Clinton) , as cost
saving in HIV prevention in high prevalence areas is
estimated at between US$150 and near $900 per
infection prevented over a 10 year time horizon
(Hankins/UNAIDS/WHO/SACEMA 2009).
 If 1000 adults circumcised in Gauteng alone, $2,4
million could potentially be saved on HIV treatment in
the next 20 years (Khan, Marseile, Auvert 2006)

14.  Recommended MMC in March 2007 for regions
with high HIV and low MC prevalence
 WHO is leading UN Agencies, UNAIDS etc, to set
norms and standards, develop policy and
programme guidance for safe male circumcision
services and support countries to develop male
circumcision policies and strategies within the
context of a comprehensive HIV prevention
strategy
 Manual for MMC under LA
 Operational guidance for scaling up male
circumcision services for HIV prevention e.g MOVE
method
 Has become DoH Policy; SA National Guidelines
for MMC under LA version 1, May 2010

15.  Target of 5,7 million men between the ages
of 15-49 years from 2010 – 2015
 Presently +- 500 sites offering MMC (incl.
High volume sites, district hospitals and
community health centres)
 2009 – 2011 – 140 000 men circumcised
 500 000 men circumcised to date
 Over 400 nurses and 150 doctors trained in
MMC thus far

16.  Strategic Objective 2 : Prevent new HIV,STI
and TB infections
 Package of combination prevention includes
MMC as part of an array of prevention
strategies that should be used in combination
with each other.
 Also mentions STRATEGIC ENABLER-
COMMUNICATION

17.  A Model for Optimizing Volume and Efficiency for MC (2010)
 Three recommended surgical MC methods (procedure time):
Forceps-guided (19 minutes 20 seconds),Dorsal slit (21
minutes 45 seconds) and Sleeve resection (27 minutes)
• Recommended use of the following techniques/concepts:
Hemostasis by diathermy machine, Task Sharing and/or Task
Shifting, Bundling of surgical items; use pre-assembled
surgical kits, Theatre layout for fast patient turnover and
Client scheduling (appointments)
• Staff ratios
1 physician/surgeon per 4 clients (1 surgeon per 4 surgical
bays*)
4 preparation/surgical assistants (e.g., nurse assistants) per
surgeon
1 anaesthesia/suture provider (e.g., surgical nurse) per
surgeon
1-2 counsellors per team + 1 site manager (if high volume
site)
Futures Group, Preliminary cost Analysis for NDOH, March 2011

18.  Staffing based on task-shifting from
physicians might lead to reduction in
personnel costs, especially in the High
Volume model
 However, this requires policy change and
extra up-front training costs for surgical
nurses

19.  The goal of the surgical procedure is the removal
of the foreskin in its entirety ; a variety of methods
 Paediatric surgical methods
◦ Dorsal slit method for children
◦ The Plastibell method
◦ Mogen clamp method
◦ Gomco clamp method
 Adult Surgical methods
◦ Forceps-guided method of circumcision
◦ Dorsal slit method of circumcision
◦ Sleeve resection method of circumcision
◦ Tara Klamp method -safety in question per study in
Orange farm (sample size very small- more data is
needed)

21.  Used in KZN only
 Tara Klamp, Shang Ring and Ipex still under investigation by
WHO
 In a statement by Dr Yogan Pillay (Deputy director General
Health) “We are not going to expand the use of Tara Klamp
beyond KZN, but we are likely to conduct a larger randomised
control trial with the WHO to test the three devices used in
circumcision, the Tara Klamp, Shang ring and Ipex, which
doesn‟t need anaesthetic.”
 Neither WHO or PEPFAR have indicated support for TK thus far
 WHO developed a Framework for Clinical Evaluation of
Devices for Adult Male Circumcision and this states that WHO
and other health authorities wish to identify 1 or more
devices that would make the MC procedure safer, easier and
quicker, more rapid healing than current methods and or
might entail less HIV risk transmission in the immediate post
operative period, easily performed safely by HC providers
with minimal level of training and would be cost effective
compared with standard surgical methods for MC scale up (
MILLARD, SAMJ March 2012)
Taken from www.health-e.org.za (Kerry Cullinan 10/06/2011)

22.  Primary Training in SA by CHAPS (Centre for
HIV/AIDS Prevention Studies) in association
with FPD (Foundation for Professional
Development)
 OAC (Operation Abraham Consortium)
 DOH
 Match ( Maternal, Adolescent and Child
Health)

23.  1ST type is that that needs to be strengthened
between the NATIONAL and PROVINCIAL efforts to
ensure that all efforts need to be coordinated and
focused on achieving the goals of the NSP
 2nd type of communication that is critical for the
implementation is that of communication with and
through the media about the NSP, its
goals, principles, interventions and successes and
challenges
 3rd is the social and behaviour change communication
which is critical to changing risk behaviours and
social conditions that drive the HIV and TB epidemics.
This encompasses the individual, community and
social political levels and includes
advocacy, media, social/community mobilisation and
campaigns

24.  Brothers for Life (JHHESA)
Launched last month:
• Campaign “Time is now” based on insights that MMC
should be done in winter as is with traditional
circumcision, but can be done through out the year
• MMC Database that uses GPS technology to enable
people to access their closest MMC site (SMS “MMC”
to 43740), they will receive a return sms with
prompts and receive details of their nearest MMC
service provider – FREE SERVICE
• HCT Database to follow the same route shortly
• Will be marketed using Television ads, outdoor media
campaign
• 2nd sms number created for men who have been
circumcised and can receive reminders about follow
up visits and care post operatively

25.  Soul City
• Television series Siyayinqoba-Beat it, on SABC
1 Thursdays @ 13h30
• Previous Soul City series 11 aired from Oct
2011(messages of MMC)
• Radio Talk shows since last year in all the
provinces (MMC )
 Sonke Gender Justice
 Various others partners involved in social
mobilisation

26.  Anticipated risk compensation among
circumcised men necessitates good
communication and the need to get the
messaging right about this intervention:
◦ highlight the partial effectiveness of male
circumcision and that it will not work in isolation
◦ need to abstain from sex for 6 weeks after the
procedure

27.  Consent: what information do you give?
• Currently available to 15- 49 year old (CDC awaiting
DOH official written stance on doing younger than 15
years before requesting their partners to do so)
◦ Voluntary
◦ Condom use- Emphasize partial protection
◦ Disposal of foreskin
 Does Testing have to take place before MMC?
◦ Does not have to, but it is part of the comprehensive
package that is being offered for HIV prevention. Men
will be encouraged to test- referring the positive ones
for care and offering MMC for prevention to negative
men
◦ Unintentional disclosure -

28. FREE MALE MEDICAL CIRCUMCISION

29.  PEPFAR funded through CDC
 Started February 2011 in McCord Hospital
 Moved off site to Brickfield Road on the 18th
July 2011
 4 Operating Theatres
 Using Move Method
 Thus far we have done over 3400
circumcisions
 6 moderate AE‟s and 1 severe AE
 Staff have been trained by OAC and CHAPS

30. We offer a Comprehensive Package of Care :
 HIV Counselling and Testing
 Screening for Sexually Transmitted Infections and
treatment
 General Health Assessment including a
symptomatic TB screen
 Risk Reduction Counselling
 Linkage to HIV care and Treatment for HIV positive
men
 This is a FREE SERVICE

31. About the Procedure :
 It is done under Local Anaesthetic (5ml Lignocaine
and 2ml Bipuvicaine)
 The Forceps guided method is used
 The procedure takes between 10- 20 minutes
 Clients are monitored for about 45 minutes to an
hour post procedure which includes Blood
Pressure, Pulse and operation site
 Clients are discharged with Pain Medication
 Clients are required to come in for a review on Day
2, 7 and 21
 Clients advised to ABSTAIN from Sexual Intercourse
and Masturbation for 6 weeks
 Clients educated on condom usage

32.  Pain
 Haemorrhage, Haematoma
 Injury to/amputation of the glans
 Redundant foreskin
 Infection
 Delayed wound healing etc.
 In the context of the 3 RCTs : Kenya- 1.7%, SA
3.6%, Higher in Uganda -7.6%.
 Overall the risk of moderate adverse events
related to surgery was 3% and 0.2% severe AEs –
all were successfully managed and resolved

35.  Low patient numbers  Funders Targets
 Marketing Initiatives
 Workplace Forums
 Partnerships with other Health Care Providers
 Partnership with Local Educational Facilities

36. Know Status Target Women Men
HIV Positive Reduce infection in source HIV Treatment HIV Treatment
STD Treatment STD Treatment
Condoms Condoms
HIV Negative Block entry / Avoid Contact Abstain Abstain
Be faithful (Avoid multiple
partners)
Be faithful (Avoid multiple
partners)
Condoms Condoms
Pre-exposure prophylaxis (e.g
PMTCT)
Pre-exposure prophylaxis ?
Post exposure prophylaxis Post exposure prophylaxis
Treatment of STIs Treatment of STIs
Microbicides – in studies MMC

37. Contact us :
155 Brickfield Road
Overport
Durban
031 2093295
circumcision@mccord.co.za
www.mccord.org.za
Dhirisha Naidoo
Dhirisha.naidoo@mccord.co.za
031 209 3297
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