FAQs

  • 1. What Is Medical Male Circumcision (MMC)?

    Medical male circumcision (MMC) is the surgical removal (cutting away) of the foreskin, which is the thin layer of skin that extends over the tip of the penis. MMC may be offered to men who elect (wish) to undergo the procedure after they have been informed of the health benefits and risks associated with the procedure.

  • 2. How does MMC protect men against HIV infection?

    People are exposed to HIV when they have sex with someone who is infected. Specifically, men who have vaginal intercourse with HIV-infected women are exposed to HIV through their penis. Uncircumcised men who are exposed to HIV are more likely to become infected due to characteristics of the foreskin tissue. Removing the foreskin through MMC reduces the likelihood of HIV infection. For men whose primary HIV exposure risk is through their penis in heterosexual intercourse, MMC provides life-long partial protection against HIV infection.

  • 3. Is MMC recommended for HIV-infected men?

    MMC protects men from acquiring (becoming infected with) HIV. If an uncircumcised man is already infected with HIV, becoming circumcised can no longer protect him from acquiring HIV. Furthermore, there is no scientific proof that a circumcised man living with HIV, is less likely to transmit HIV to others. Thus, for uncircumcised men who are HIV Positive, MMC is not recommended for HIV prevention purposes though HIV Positive men can derive other MMC benefits and can be safely medically circumcised.

    All MMC clients are strongly encouraged to get tested for HIV, and clients who test HIV Positive at MMC sites are referred to care and treatment services. They are also encouraged to bring their partner for testing, in case the partner is unaware of their own status. Clients who test positive are informed that there is no HIV prevention benefit of MMC for HIV Positive men and are given the opportunity to reconsider the procedure. If they still wish to be circumcised for reasons other than HIV prevention, and are healthy enough to undergo the procedure, they (as with all MMC clients) are counselled very strongly to abstain from sex during wound healing.

    All clients, regardless of HIV status, are also counselled to reduce their high-risk sexual behaviours indefinitely following MMC. Clients also receive condoms and education about correct and consistent use of condoms.

  • 4. Aren’t HIV Positive men who undergo circumcision at increased risk of transmitting HIV to their sex partner(s)?

    Following a MMC procedure, the risk of HIV transmission from an HIV Positive man to an HIV Negative woman may be increased if they have sex before the surgical wound has healed.

    Reference:

    • Gray RH et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 369(9562): 657–666.

    Some couples have reported early resumption of sex after surgery.

    References:

    • Herman-Roloff A, Bailey RC and Agot K. 2012. Factors associated with the early resumption of sexual activity following medical male circumcision in Nyanza province, Kenya. AIDS Behavior 16(5): 1173–1181.
    • Hewett PC et al. 2012. Sex with stitches: The resumption of sexual activity during the post-circumcision wound healing period in Zambia. (abstract). AIDS 26(6): 749–756.

    It is therefore essential to emphasise the importance of waiting to resume sex until after the wound is healed. The World Health Organization (WHO) and UNAIDS recommend that men who have been circumcised wait at least six weeks before having sex to allow time for the wound to heal completely. In addition to receiving counselling about the importance of sexual abstinence during wound healing, all men who undergo circumcision should receive education and counselling about the importance of reducing their high risk sexual behaviour, such as having sex with multiple partners, indefinitely after MMC, and correct and consistent condom use.

  • 5. Is MMC recommended for Men who have Sex with Men?

    Findings from research studies are inconclusive. For men who have sex with men, circumcision may provide the insertive partner with some level of protection against acquiring HIV during anal sex, because the insertive partner’s exposure risk includes the skin of the penis. The receptive partner in anal sex, however, is not protected from acquiring HIV, because the receptive partner’s primary exposure to HIV is through the rectal tissue and not the tissue of the penis. Thus, for the receptive partner, removing the foreskin does not reduce his risk of acquiring HIV.

  • 6. How painful is the MMC procedure?

    The perception of pain varies by individual. Local anaesthesia controls pain during the surgical procedure, but the anaesthesia is injected through a needle, which itself causes brief discomfort.
    Men often report minor discomfort in the first days following circumcision. This discomfort is sufficiently managed with over-the-counter pain relief.

  • 7. Won’t women with a newly circumcised male partner have greater difficulty negotiating condom use?

    Three research studies suggest that circumcision does not significantly change patterns of condom use.

    References:

    • Gray RH et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 369(9562): 657–666.
    • Auvert BE et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2(11): e298.
    • Bailey RC et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 369(9562): 643–656.

    In fact, some men have suggested that putting on a condom is easier after circumcision.

    Reference:

    • Krieger JJN. 2008. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. Journal of Sexual Medicine 5(11): 2610–2622.

    All MMC clients are counselled that circumcision is only partially protective—not completely protective—and that they still need to take other measures to prevent HIV infection. Condom promotion is part of the WHO’s recommended minimum package of services that MMC programmes should provide, along with HIV testing and counselling, risk reduction counselling, screening and treatment for sexually transmitted infections, and the MMC procedure.

  • 8. Does circumcision make sex less enjoyable for men?

    Studies that evaluated sexual satisfaction among African men who had undergone MMC indicated that MMC does not have any effect on sexual desire or satisfaction, erectile function, or ability to achieve penetration; nor does it cause pain with intercourse.

    Reference:

    • Kigozi G et al. 2008. The effect of male circumcision on sexual satisfaction and function: Results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda. BJU International 101(1): 65–70.

    A study that compared men who had undergone MMC to a control group showed that 98% of the men in both the intervention group and the uncircumcised control group rated their sexual satisfaction as “satisfied” or “very satisfied” six to 24 months after enrolling in the trial.

    Reference:

    • Krieger JJN. 2008. Adult male circumcision: Effects on sexual function and sexual satisfaction in Kisumu, Kenya. Journal of Sexual Medicine 5(11): 2610–2622.

  • 9. Is PEPFAR’s support of MMC an imposition of Western culture and policy on Africa?

    Male circumcision is widely practiced in diverse cultures around the world, for a variety of reasons that encompass cultural norms, religious beliefs, appearance preferences, and health concerns. Male circumcision is traditionally practiced in Africa, and MMC is an African solution to an African public health threat. An estimated two-thirds of African men are already circumcised for cultural or religious reasons. The non-circumcising communities in Southern Africa and parts of East Africa have the highest HIV prevalence.

    PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) does not define HIV prevention strategies for countries in Africa; rather, PEPFAR supports African governments in their fight against the HIV/AIDS epidemic. Most ministries of health in Africa follow international guidance from WHO and UNAIDS, and that guidance recommends MMC as an important HIV prevention intervention in countries with high HIV prevalence, low male circumcision prevalence, and a generalised (heterosexual) HIV epidemic.

    All individuals have the right to know the proven benefits and potential risks of MMC and to decide for themselves whether they wish to be circumcised (or have their new-born or adolescent son circumcised).

  • 10. Are men, boys, and infants given a choice about undergoing MMC?

    Informed consent is a critical component of MMC service delivery. All men (and/or the parents/guardians of minors) seeking MMC services are counselled about the risks and benefits of MMC, and they must provide their informed consent before the procedure is performed. MMC for adolescents requires both the consent of the parent/guardian and the assent (agreement) of the adolescent himself.

    The position that most ministries of health in the Eastern and Southern Africa region take is that parents have the right to give consent for circumcision on behalf of their infant sons, just as they have the right to consent to other preventive services such as immunisation. This standard is in place for responsible, ethical infant care throughout the world and is supported by WHO and UNAIDS.

    PEPFAR’s implementing partners adhere to a stringent policy of avoiding coercion or pressuring of males to receive MMC services.

  • 11. Does MMC benefit women?

    One of the primary benefits of MMC is that it is also associated with a reduction in penile human papillomavirus (HPV).

    References:

    • Hernandez BY et al. 2008. Circumcision and human papillomavirus infection in men: A site-specific comparison. J Infect Dis 197(6): 787–794.
    • Castellsagué X et al. X et al. 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 346: 1105–1112.

    Women with circumcised male sex partners also have reduced HPV and cervical cancer rates.

    As more men are circumcised, fewer men in the community will become infected with HIV, in turn decreasing the chances that a woman will encounter an HIV Positive partner. Mathematical models suggest that by 2025, MMC may avert nearly as many new HIV infections annually in women as in men, due to this indirect protective effect.

    MMC provides a great opportunity to engage and educate men about HIV prevention and sexual and reproductive health issues, which may have benefits for their female partners. In virtually every African country, more women than men know their HIV status (partly because women are tested during pregnancy). MMC presents a unique opportunity to encourage male interaction with the health system, test men for HIV, and get previously undiagnosed HIV Positive men linked to care and treatment services. Those care and treatment services can then reduce men’s viral load and reduce their risk of transmitting HIV to their sex partners. Men seeking MMC are educated about safer sex practices and their role in protecting their health and that of their partners.

  • 12. Doesn’t scaling up MMC services waste scarce resources that could be better spent on researching or implementing other prevention measures, including female-initiated prevention strategies (female condoms and microbicides)?

    MMC is not only cost-effective but cost saving. It is a brief, one-time medical procedure that provides a man with a lifetime of partial protection. Because repeated treatments are not necessary, services can be provided at a limited cost to health care systems. In some high prevalence settings, if scale-up is rapid, every dollar spent on MMC has the potential to save $14 in care and treatment costs, according to mathematical models.

    By averting new HIV infections in men and women (as fewer men acquire HIV, fewer women will encounter HIV Positive partners), MMC will save a substantial amount of money, which can then be used to accelerate progress in researching and implementing other prevention strategies.

    References:

    • Njeuhmeli E et al. 2011. Voluntary medical male circumcision: Modeling the impact and cost of expanding male circumcision for HIV prevention in Eastern and Southern Africa. PLoS Medicine 8(11): e1001132.
    • Hankins CA, Njeuhmeli E and Forsythe S. 2011. Cost, impact, and challenges of scaling up voluntary medical male circumcision. PLoS Med 8(11): e1001127. doi:10.1371/journal.pmed.1001127

    There have been concerns that MMC stresses scarce resources and adds to already overburdened health care systems. It is important to remember that although adult MMC services do require short-term support from health care systems, they promise substantial long-term relief by sharply reducing the number of HIV Positive individuals needing care and treatment. The opportunity cost of not scaling up MMC now will be the cost of providing care and treatment to an additional 3.4 million men and women in the future, individuals who likely would not have been infected had MMC scale-up occurred.

  • 13. Do men who are circumcised practice riskier sex behaviours because they have a false sense of security?

    This phenomenon is called risk compensation, and it is a valid concern with any partially protective intervention against HIV, including MMC. The available data suggest that men do not significantly change their behaviour after circumcision. Risk-taking levels remain relatively fixed over time among circumcised and uncircumcised men, even among recently circumcised men.

    Reference:

    • Gray RH et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 369(9562): 657–666.

    A study in Kenya found that men who underwent MMC as part of a randomised controlled trial (RCT) did not increase their risk-taking behaviour compared to their uncircumcised counterparts. There were no statistically significant differences in risk-taking behaviours (or incidence of gonorrhoea, chlamydia, or trichomoniasis) between circumcised and uncircumcised men, which further supported the self-reported evidence that risk compensation did not occur among men circumcised in the RCT.

    Reference:

    • Auvert BE et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2(11): e298.

    In slight contrast, a study in South Africa found that men enrolled in an RCT in the intervention group (circumcised men) reported an average of approximately one more sexual contact in the prior eight months compared to men in the control group (uncircumcised men).

    Reference:

    • Bailey RC et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 369(9562): 643–656.

    As more research and programmes address the risk compensation issue, risk compensation among MMC clients may be better understood and subsequently reduced.

    All MMC clients receive extensive safer sex counselling and are advised that MMC is only partially protective. In print media, circumcision is often described as the “goalkeeper” on a football field, analogous to the last line of defence against HIV, if other “defenders,” such as condom use and reducing the number of sexual partners, fail. Men are counselled to take additional steps to reduce their HIV risk, such as reducing their number of partners and using condoms correctly and consistently. In addition, all MMC clients are provided with a supply of condoms.

  • 14. Doesn’t medical circumcision ruin the cultural initiation process for populations that practice traditional circumcision of males?

    Many tribal chiefs and custodians of traditional culture disagree with the view that MMC ruins the cultural initiation process. Some elders have expressed the belief that for cultures to survive, they must evolve. Many elders understand that cutting the foreskin of all initiates with the same blade is not a safe practice, especially with the increased risk of transmitting HIV.

    Reference:

    The public health community respects tradition and is grateful for those custodians of tradition who recognise the capacity for science and culture to combine with a unified goal of protecting health, manhood, and tradition.

    There are examples of communities where medical circumcision services have been successfully linked with traditional initiation ceremonies. In the Northwest Province of Zambia, for example, an all-male, all-circumcised team (traditional initiation practices generally require that the one performing the circumcision be a circumcised male) provided MMC in a clinic close to the initiation school. Following circumcision, the initiates went to the traditional initiation school for the cultural portion of their initiation. The medical follow-up exams were conducted by health care providers at the camp. The linkage between medical circumcision and cultural practices ensures that the initiates have access to safe MMC procedures and that cultural practices are respected.

  • 15. Some surveys have shown that HIV prevalence is higher among circumcised men than uncircumcised men in some populations. Why? Does this mean that circumcision won’t protect heterosexual men in these populations?

    In populations in which men’s HIV risk is primarily due to injection drug use (exposure to HIV is intravenous) or through receptive anal sex with other men (exposure to HIV is rectal), male circumcision is not expected to be protective because removing the foreskin does not change infection risks that are intravenous or rectal. However, in generalised (heterosexual) epidemics, male circumcision does biologically protect men from acquiring HIV from women through sex.

    In countries with generalised HIV epidemics, there are infrequent cross-sectional surveys (surveys that enrol people to participate at only one point in time) that reveal high HIV prevalence in populations that practice male circumcision. These data may imply that male circumcision is not effectively protecting men against HIV in such areas. However, there are reasons why cross-sectional data do not discredit the scientific evidence that male circumcision partially protects men from acquiring HIV through heterosexual sex.
    Before reviewing the reasons that cross-sectional data do not always align with the highly publicised results of the three male circumcision RCTs that took place in Uganda, Kenya, and South Africa, it is important to look at how hypotheses are scientifically tested. When researchers first suspect a cause-and-effect relationship between two things (in this case male circumcision and HIV), they look to see whether there are existing correlations that support their hypothesis.

    Scientists looked at levels of HIV and male circumcision across different populations and found a strong correlation: HIV prevalence was often higher in countries where male circumcision was uncommon (and lower in countries or areas where male circumcision was common).

    References:

    • Bongaarts J et al. 1989. The relationship between male circumcision and HIV infection in African populations. AIDS 3: 373–377.
    • Moses S et al. 1990. Geographical patterns of male circumcision practices in Africa: Association with HIV seroprevalence. Int J Epidemiol 19: 693–697.
    • Halperin DT and Bailey RC. 1999. Male circumcision and HIV infection: Ten years and counting. Lancet 354: 1813–1815.

    This is particularly true in Africa, although not for all countries/areas. If the association had been found across all populations worldwide, then further studies and clinical trials might not have been necessary to prove the cause-and-effect relationship.
    There are a number of reasons, in addition to biological reasons, why HIV prevalence may be lower among some circumcised men. Some religions customarily circumcise males, while others do not, and there may be other differences among men in these religions that are associated with behaviours that put them at greater (or lesser) risk of HIV infection. For instance, if men from a specific religion are commonly circumcised, and they also engage in sexual behaviours that are less risky, then their lower HIV prevalence could be explained by their safer sexual behaviours rather than circumcision.

    Therefore, to further test the hypothesis that male circumcision provides biological protection against HIV acquisition, observational studies (the next higher level of scientific investigation) were performed. The observational studies followed HIV negative men over time to see if they developed HIV infection. The infection rates among the circumcised men in the studies were then compared to the rates among the men who were not circumcised. Because men were being followed over time, they could also be asked about their sexual behaviours.

    In this way, the statistical analyses could control for any differences in sexual behaviours, and the level of protection against HIV resulting from circumcision could be separated from the level of protection resulting from differences in behaviours. The data from the observational studies also supported the hypothesis that male circumcision biologically protects men against acquiring HIV.

    References:

    • Cameron DW et al. 1989. Female to male transmission of human immunodeficiency virus type 1: Risk factors for seroconversion in men. Lancet 2: 403–407.
    • Weiss HA, Quigley MA and Hayes RJ. 2000. Male circumcision and risk of HIV infection in sub-Saharan Africa: A systematic review and meta-analysis. AIDS 14: 2361–2370.
    • Quinn TC et al. 2000. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Eng J Med 342: 921–929.

    Despite the ecological and observational evidence, some scepticism remained about whether unmeasured differences between circumcised and uncircumcised men were resulting in lower HIV in circumcised men. To conclusively test the hypothesis that male circumcision biologically protects men against acquiring HIV, randomised control trials (RCTs) were needed. The ecological and observational studies provided the ethical justification needed to randomly assign study participants either to undergo male circumcision or to remain uncircumcised. Because the process of randomisation is entirely one of chance, it ensures that men in the circumcised and uncircumcised study arms are/will be different in only one way: the presence or absence of their foreskins. Thus, if the risk of HIV is different between the two groups of men over time, the difference is attributable to circumcision.

    As with the observational studies, men were also asked about risk behaviours while in the study, in case men randomised to undergo circumcision behaved differently than those randomised to remain uncircumcised. The results of three RCTs revealed that the circumcised men experienced an HIV infection rate that was 60% lower than the infection rate of uncircumcised men.

    References:

    • Gray RH et al. 2007. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet 369(9562): 657–666.
    • Bailey RC et al. 2007. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 369(9562): 643–656.
    • Auvert BE et al. 2005. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Medicine 2(11): e298.

    It was at this point that WHO and UNAIDS issued recommendations for male circumcision and gave priority to countries with generalised (heterosexual) epidemics, high HIV prevalence and low male circumcision prevalence.

    Reference:

    • World Health Organization. 2007. New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. WHO: Geneva.

    Although the scientific evidence that male circumcision provides partial biological protection against HIV acquisition is irrefutable, some researchers still question whether the men who enrolled in the RCTs were similar enough to men in the general population. It stands to reason that if the men in the trials were very different from men in the general population, then scaling up MMC in the general population might not result in the same reductions in HIV infection that were as seen in the RCTs. However, community-level studies from Uganda and South Africa have since demonstrated that the rate of HIV infection is lower among circumcised men compared to uncircumcised men.

    References:

    • Kong G et al. 2012. Longer-Term Effects of Male Circumcision on HIV Incidence and Risk Behaviors during Post-Trial Surveillance in Rakai, Uganda. Paper #36. 18th Conference on Retroviruses and Opportunistic Infections, February 27–March 2, Boston, Mass.
    • Auvert BH et al. 2012. Decrease of HIV Prevalence over Time among the Male Population of Orange Farm, South Africa, following a Circumcision Roll-out (ANRS-12126). Presentation at the 2012 International AIDS Conference, July 22–27. Washington, DC. Abstract TUAC0403.

    In these studies, men who received circumcision did so as part of routine health services and not as part of an RCT. Therefore, it is clear that when men in the general population receive circumcision as a routine service (instead of as a research intervention), their risk of HIV is reduced—a finding that is consistent with the RCT findings.

  • 16. The WHO prioritised expansion of MMC in 14 countries with generalised (heterosexual) epidemics, high HIV prevalence, and low male circumcision prevalence. What about areas within these countries where HIV is more prevalent among circumcised men than uncircumcised men?

    These data, which seem contradictory to the RCT findings, are from cross-sectional surveys, meaning that the data were collected at a single point in time. It is not possible to know whether men in these populations were circumcised before becoming infected with HIV, or after. Men may have been infected with HIV when they were uncircumcised and later decided to become circumcised for clinical or other reasons.

    Also, cross-sectional data about circumcision status are based on self-reporting. Studies have revealed that many men report being circumcised when actually they either are not circumcised at all or are only partially circumcised.

    References:

    • Thomas AG et al. 2011. Voluntary medical male circumcision: A cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho. PLoS ONE 6(11): e27561. doi:10.1371/journal.pone.0027561
    • Hewett PC et al. 2012. The (mis)reporting of male circumcision status among men and women in Zambia and Swaziland: A randomized evaluation of interview methods. PLoS ONE 7(5): e36251. doi:10.1371/journal.pone.0036251

    For these reasons and others, cross-sectional data cannot be used to prove a causal relationship. Nevertheless, sceptics often refer to cross-sectional data to refute the gold standard scientific evidence provided by the RCTs.

    Reference:

    • Thomas AG et al. 2011. Voluntary medical male circumcision: A cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho. PLoS ONE 6(11): e27561. doi:10.1371/journal.pone.0027561

    There will always be extraordinary examples of people who seem to defy science. For instance, most of us know people who have smoked cigarettes throughout their adult lives but have not developed lung cancer. Some exceptionally health-conscious athletes have heart attacks at an early age. The international recommendations for MMC are based on overwhelming evidence provided through the scientific process. Cross-sectional data provided clues about hypotheses that warranted further and more rigorous investigation. These investigations have been completed and the findings are conclusive. Using cross-sectional data now to refute the conclusive findings demonstrates a lack of understanding of the limits of cross-sectional data and the overall scientific process for testing hypotheses.

  • 17. What if the foreskin is found to be protective against another disease? What will we do then?

    It is extremely unlikely that the recommendation to circumcise will change. Male circumcision has been widely practiced around the world for thousands of years. There is no evidence that it poses risks to health. On the contrary, there is much evidence in support of the health benefits of MMC.
    Male circumcision reduces the acquisition and transmission of a number of other diseases, including HPV (which causes cervical and penile cancers) and herpes.

    References:

    • Auvert BE et al. 2009. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: Results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis 199:14–19.
    • Castellsagué X et al. X et al. 2002. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med 346: 1105–1112.

    Furthermore, male circumcision prevents infections and other problems with the foreskin and reduces the rates of urinary tract infections in infants and young boys.

    Reference:

    • Wiswell TE and Hachey WE. 1993. Urinary tract infections and the uncircumcised state. Clin Pediatr 32: 130–134.

  • 18. Why are people so excited about male circumcision medical devices?

    Any medical device that is developed for adult male circumcision must first be shown to be safe and effective at removing the foreskin. In addition, a device-based procedure would ideally be quicker than the surgical methods, inexpensive, highly acceptable to the male population, and usable by trained nurses and other non-physicians.

    The goal of 80% male circumcision coverage by 2016 (20 million male circumcision procedures) is daunting, particularly since it took five years to complete the first one million procedures. A medical male circumcision device with many or all of the ideal characteristics could greatly assist in the scale-up of MMC.

    As with any medical device or service, the cost of a male circumcision medical device must be considered in the context of human lives saved and illness averted. If one or more devices are found to be safe and effective, and WHO recommends them for use in adults, organisations such as PEPFAR and other donors will begin purchasing them for countries who wish to make MMC devices available. PEPFAR and donors such as the Global Fund have a long history of using their significant purchasing power to negotiate reasonable prices for HIV-related products and pharmaceuticals. For example, thanks to donors, millions of people now have access to antiretroviral therapy at a reasonable price.

  • 19. Why is the goal for MMC set at 80%?

    Our ultimate target is to achieve an AIDS free generation. In 2012 there were 370 000 new HIV infections in South Africa alone. MMC has been recognised by the WHO as an effective HIV prevention intervention in settings with a generalised HIV epidemic, and it forms an integral part of the Combination Prevention strategy. A coverage of 80% is required for herd immunity.

    Herd immunity is a form of immunity that occurs when the vaccination of a significant portion of a population (or herd) provides a measure of protection for individuals who have not developed immunity.
    It arises when a high percentage of the population is protected through vaccination against a virus or bacteria, making it difficult for a disease to spread because there are so few susceptible people left to infect.
    This can effectively stop the spread of disease in the community. It is particularly crucial for protecting people who cannot be vaccinated. These include children who are too young to be vaccinated, people with immune system problems, and those who are too ill to receive vaccines (such as some cancer patients).
    The proportion of the population which must be immunised in order to achieve herd immunity varies for each disease but the underlying idea is simple: once enough people are protected, they help to protect vulnerable members of their communities by reducing the spread of the disease.

    Source: www.vaccinestoday.eu/vaccines/what-is-herd-immunity/

    Mathematical modelling suggests reaching 80% of the 15 – 49 age group in the nine African countries with the highest HIV burden would require 20.3 million circumcisions by 2015. These would avert approximately 3.4 million HIV infections through 2025 and result in US$16.5 billion in net savings from averted HIV health care and treatment costs.
    In South Africa, our target is 4.3 million circumcisions between 2012 and 2016 (resulting in an 80% coverage of sexually active men). Primary focus is on reaching 15 – 49 year old uncircumcised, heterosexual men.

    This target was identified as follows:

    • There are 16.2 million males between 15 and 65 years old in South Africa
    • Each of the five categories (15 – 25; 26 – 35; 36 – 45; 46 – 55; 56 – 65) contains approximately 3.24 million men
    • The 15- 45 age group (made up of three categories ) has approximately 9.72 million men
    • If approximately 55% (5.34 million) of these men are already circumcised; then 4.3 million remain
    • By targeting these 4.3 million men, the ultimate goal of 80% of sexually active men being circumcised by 2016 is achieved.
    • Men aged 25 – 35 are having transactional sex with women aged 15 – 20. The highest HIV prevalence amongst heterosexual males is found in the 30 – 35 year age group. For females, it is around 17 years. Most young females are infected with HIV between 15 and 20 years of age, and are six times more likely to be HIV Positive than their male counterparts. Thus the importance of MMC in protecting our young women cannot be overstated.

    South African population statistics (from Stats SA)

    Population 52 981 991 (July 2013, est.)
    Growth rate 1.34%
    Birth rate 19.61 births / 1 000 population (2010 est.)
    Death rate 16.99 deaths / 1 000 population (2010 est.)
    Life expectancy 49.2 years (2010 est.)
    Male 50.08 years (2010 est.)
    Female 48.29 years (2010 est.)
    Fertility rate 2.33 children born / woman (2010 est.)
    Infant mortality rate 43.78 deaths per 1 000
    Age structure
    0 – 14 years 28.9% (male: 7 093 328 / female: 7 061 579)
    15 – 64 years 65.8% (male: 16 275 424 / female: 15 984 181)
    65 and over 5.4% (male: 1 075 117 / female: 1 562 860) (2010 est.)
    Sex ratio
    Total 0.99 male(s) / female (2010est.)
    At birth 1.02 male(s) / female
    Under 15 1 male(s) / female
    15 – 64 years 1.02 male(s) / female
    65 and over 0.68 male(s) / female