Updated 21 July 2014

SA needs a combination of measures to prevent HIV

No single measure currently available will eliminate HIV infections in South Africa, but a broad array of ‘combination-prevention’ measures is required.


The release this week of a report suggesting South Africa has the world’s highest rate of HIV infections highlights the urgent need for an array of measures to lower infection risk, including medical male circumcision (MMC).

Dr Don Pupuma, a CareWorks clinical consultant and family physician in private practice in Soweto says that no single measure currently available will eliminate HIV infections, but that a broad array of ‘combination-prevention’ measures is required.

“Combination-prevention includes a mixture of biomedical and behavioural-based approaches such as consistent condom usage, reduction in the number of sexual partners, medical male circumcision (MMC), increased access to anti-retrovirals and mother-to-child prevention, all of which lower the number of infections. The difference that makes at an individual level is important, but over time at a national level it will reduce the number of infections as well.”

Relatively simple procedure

Dr Pupuma says MMC is a relatively new addition to the prevention arsenal and a once-off, relatively simple procedure which reduces by 60% a man’s chances of being infected with HIV during heterosexual sex.

He notes the newly-released HSRC (Human Sciences Research Council) National HIV Prevalence, Incidence and Behaviour Survey, which suggests that proportion of South Africans infected with HIV has increased from 10.6% in 2008 to 12.2% in 2012. The survey estimates that 6.4m South Africans are now infected with HIV, 1.2m more than in 2008. 

Read: Circumcision vs. Aids?

“That’s a national tragedy, especially as it’s avoidable. That’s why it’s important, for example, that male-dominated industries facilitate MMC among their workforces. It’s an excellent opportunity to contribute to individual workers’ health, their corporate bottom-line and to community and national socioeconomic development.

“In the face of rising infection-rates, a quick, relatively simple procedure to lower in infection risk can make huge difference,” says Dr Pupuma. He adds that HIV prevention should be addressed, not just by the Health Department: “Civil society, churches, sports clubs, soccer supporters’ club, stokvels, unions, all have a role to play. Many are already doing so.”

Apart from the potent humanitarian benefits of helping reduce the risk of HIV/Aids, it’s been estimated that an effective combination prevention strategy that includes MMC would save our country R50 billion over the next 10 years, says Dr Pupuma.

Solid research

Promoting MMC is backed by solid research: a landmark study in Orange Farm in 2009 found that, apart lowering HIV-transmission risk during heterosexual sex, circumcision lowers the risk of other STIs as well as urinary-tract infection and the risk of penile cancer. It lowers the risk of cervical cancer in female sexual partners and makes male personal hygiene easier.

Dr Pupuma explains why widespread MMCs could alter SA’s socioeconomic outlook: “One model suggests that each person with HIV infects five people in their lifetime. On that assumption, each five infect five, by ‘level ten’ of this exponential model, there have been nearly ten million new infections.

“MMC and its 60% reduction in transmission rates more than halve that rate: one infected person now infects two others, who go on to infect another two and so on, and by ‘level ten’ we only have a thousand new infections.”

He concludes: “SA has had great success with the roll-out of ARVs and mother-to-child-prevention. Combination-prevention, with MMC as a major component, can help provide SA with an Aids-free generation in 20 years,” says Dr Pupuma.

About MMC

MMC is a relatively simple, safe procedure performed by a medically trained professional to remove the entire foreskin from a man’s penis.

  •              While men have been circumcised for various cultural and other reasons for centuries, today MMC is also accepted as a powerful health measure that reduces the risk of sexually transmitted infections, including HIV.
  •              In 2010, South Africa accepted MMC as an integral element of the combination HIV prevention effort and the national comprehensive HIV/Aids strategy.
  •              MMC is one of the safest, most hygienic ways to get circumcised and offers numerous health and hygiene benefits.
  •              The inner skin of the foreskin is more likely to absorb HIV than any other skin as it’s more prone to small tears during sex. Within the foreskin, there are cells called Langerhans and other receptor cells that attract the HI virus. The removal of the foreskin means that the warm, moist and dark area where germs usually thrive is also removed. Viruses therefore have less chance to infect the man.
  •              Of the population at risk of HIV, the group of “five Ms” can benefit the most from MMC: Men, Migrant, Mobile, Marginalised and with Money. These are men who travel for work and are often separated from their families, who earn decent money but don’t always readily seek medical services such as periodic HIV testing. These are men who generally face higher risk of being infected with HIV. Many of them are employed in the transport, mining and construction sector, so MMC programmes in these sectors can significantly lower infection rates. This provides employers in male-dominated industries with a good opportunity to strike a blow against HIV.
  •     MMC is an essential and proven product within the basket of HIV prevention tools but it is not a magic bullet. Despite its proven effectiveness in reducing the risk of HIV and other infections, MMC does not eliminate the possibility of infection. Thus men should continue to use condoms, and access other services including HIV testing, treatment of sexually transmitted infections and promotion of safe sexual practices.

Read more:
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Circumcision: when tradition kills


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Dr Sindisiwe van Zyl qualified at the University of Pretoria in 2005. She is a patients' rights activist and loves using social media to teach about HIV. She is in private practice in Johannesburg.

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