MMC Programme in South Africa
- 1. Background
- 2. The National Department of Health
- 3. National Progress
- 4. Stepping up the pace of medical male circumcision
B. AN INTRODUCTION TO IMPLEMENTING PARTNERS
- The National Strategic Plan (NSP)
- 1. Government
- 2. International Organisations
- 3. PEPFAR Medical Male Circumcision (MMC) Partners in South Africa
In November 2011, the World Health Organisation (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) launched the Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, 2012–2016. The joint framework outlined key strategic pillars and activities for the expansion of medical male circumcision (MMC) to contribute towards the global goal of “getting to zero” new HIV infections.
The framework outlines activities for (1) accelerating the “catch-up” phase and (2) initiating the “sustainability” phase of the MMC programme. The former focuses on efforts to provide MMC services to uncircumcised adult men, while the latter are activities to implement the routine offer of MMC for infants and/or adolescents. The term “scale-up” is intended to encompass both the catch-up and sustainability phases.
The aim of the immediate catch-up phase is to rapidly achieve optimal coverage among adult men in age groups that are most likely to be, or soon become, sexually active. The sustainability phase will focus on efforts to reach adolescents and introducing MMC for neonates. The immediate priority is reaching men aged 15-49, who are currently most at risk of HIV exposure during heterosexual intercourse; while initiating services for adolescents, and taking steps towards integrating the routine offer of MMC into infant health programmes.
The Strategic Plan for the Scale up of Medical Male Circumcision in South Africa, 2012-2016, attempts to bring together several documents and guides to form a comprehensive strategy for MMC. South Africa began providing MMC as an HIV prevention strategy in 2010, and great advances have been made in the programme to date. With the largest number of men to circumcise in the world (4.3 million), the MMC programme in South Africa has tremendous potential to make a significant public health impact by preventing large numbers of new HIV infections and saving countless lives. A well-coordinated and strategic approach is needed that brings together the various stakeholders involved in the MMC programme. This plan aims to bring these various approaches together to accelerate the scale up of MMC, including developing plans for a sustainable approach to MMC. Sustainability requires the initiation of discussions about the process for long-term maintenance of male circumcision coverage, including health system integration of early infant and adolescent male circumcision, and sustainable country financing, to ensure the health impact and economic gains of this intervention become a permanent fixture in South Africa.
2. The National Department of Health
The National Department of Health’s mission is “to improve health status through the prevention of illnesses and the promotion of healthy lifestyles and to consistently improve the healthcare delivery system by focusing on access, equity, efficiency, quality and sustainability” (www.health.gov.za). The NDoH is therefore responsible for policy development, oversight and implementation of the MMC programme in South Africa. The South African National Strategic Plan for HIV, STIs and Tuberculosis (NSP) outlines South Africa’s national strategy for responding to HIV, STIs and Tuberculosis over the next five years. The NSP calls for the implementation of medical male circumcision (MMC) as part of a comprehensive package of sexual and reproductive health services that have the potential to greatly reduce the number of new HIV infections.
In response to the call for the implementation of MMC put forth by the NSP, the NDoH has developed the Strategic Plan for the Scale up of Medical Male Circumcision in South Africa, 2012-2016. The strategic plan provides a framework for the scale up of the current MMC programme in South Africa and sets a target of 4.3 million circumcisions by the end of 2016. The plan reflects a multi-sectoral approach, which supports the vision of the NDoH to work in partnership with stakeholders to scale up the provision and uptake of MMC in South Africa.
The NDoH leads the programme with strong coordination, financial and technical support from PEPFAR and the Global Fund. Organisations such as WHO, UNAIDS, the Bill & Melinda Gates Foundation, CDC and USAID provide ongoing technical input, especially in the areas of policy and operations. A number of implementing non-governmental organisations are also intricately involved in the programme and provide not only MMC services but also technical input into training, service delivery, research, evaluation, and innovation. As part of this plan, cooperating partners such as the South African National AIDS Council (SANAC) and the South African Military Health Service (SAMHS) are increasing their support, especially around programme coordination. This coordinated response can best leverage our national resources and fulfils the multi-sectoral mandate to involve various sectors in the national HIV response.
3. National Progress
By reducing the number of men who are living with HIV, scaled-up MMC should have significant health benefits not only for men but also for women in South Africa. In line with the goals of the NSP, the MMC programme aims to contribute to halving the number of new HIV infections in South Africa.
By the end of 2013, the South African MMC programme had achieved approximately 1.3 million male circumcisions since it started in 2010. While programme growth to date has been robust, this figure represents only 31% of current the 4.3 million target – which, according to the National MMC strategic plan, is expected to be completed by 2015/2016 (Figure 1 on Page 4). Approximately 53 000 of the 1.3 million circumcisions came from NDoH-led sites, while approximately 455 000 and 37 000 came from PEPFAR- and Global Fund-supported sites respectively.
4. Stepping up the pace of medical male circumcision
Countries must close a resource gap
Achieving 80% coverage of voluntary medical male circumcision in South Africa means reaching a total of 3 million more men, or approximately two and a half times more than the number currently reached. However, a working group of international partners warns of a major funding shortfall: through 2016, an estimated US$790 million is presumed to be available for voluntary medical male circumcision in the 14 priority countries yet $1.5 billion is needed to achieve 80% coverage – a resource gap of $710 million.
Medical Male Circumcision resource needs (by 14 priority countries)
Additional investment needed by 2016 for 80% coverage in 14 priority countries
Source: Global VMMC resource Group
Service innovations hold promise to accelerate scale-up
- Introducing new technologies: non-surgical devices could make circumcision easier to perform and offer men a choice of procedures. For example, PrePex was prequalified by the WHO in 2013 as a device for adult medical male circumcision that eliminates the need for anaesthesia and suturing. For new devices to have impact, their costs will need to be affordable.
- Expanding provider capacity: countries with shortages of doctors are expanding the number of other health care workers trained to perform MMC according to the highest standards.
- Meeting community needs: culturally sensitive approaches are needed to build community support for MMC. Diverse values and other factors shape the decision to be medically circumcised.
- Reaching those at highest risk: while striving to make voluntary MMC broadly accessible, countries should take special steps to reach men and boys at highest risk of HIV exposure. This will ensure efficient and effective use of resources.
New study: men reduce HIV risk behaviours after choosing medical circumcision
With the introduction and scale-up of any biomedical HIV prevention option, a valid question is whether its uptake will lead users to adopt riskier behaviours, thereby offsetting the HIV prevention benefits. This question has been raised for medical male circumcision.
A new long-term study in Kenya adds to the body of evidence suggesting that medical male circumcision does not lead men to adopt riskier behaviours. In fact, the study – which was conducted among more than 3 000 men over two years – found that men reduce their HIV risk behaviours after choosing medical circumcision. The results are forthcoming in the journal AIDS and Behaviour:
- Increased condom use: in the study, newly circumcised men reported increased condom use up to two years following the procedure. This is consistent with previous research that found circumcised men consider condoms more comfortable and easier to use.
- Declines in casual sex, partners: newly circumcised men also reported declines in other HIV risk behaviours, including less frequent casual sex, less frequent transactional (paid) sex and fewer sexual partners.
MMCs performed in the public sector from April 2010 to December 2013 vs.2015/2016 targets
B. AN INTRODUCTION TO IMPLEMENTING PARTNERS
The National Strategic Plan (NSP)
The National Strategic Plan (NSP) under the auspices of the National Department of Health (NDoH) was developed through a collaborative process that brought together government, international partners, and civil society. The Minister of Health has a critical role to play.
The NDoH continue to lead coordination efforts, to ensure participation by cooperating partners involved in the MMC programme.
Cooperating partners include other government structures involved in MMC (e.g. SANAC, SAMHS), provincial and district departments of health, non-governmental organisations, funding and technical agencies (e.g. USAID and CDC) and international organisations (e.g. WHO and UNAIDS).
National Department of Health: www.health.gov.za; www.healthsites.org.za
h3 The South African National Department of Health (NDoH) has implemented the MMC programme acknowledging the partial prevention value of MMC but recognising it as a key HIV combination prevention component. In response to the call for the implementation of MMC put forth by the NSP, the NDoH has developed the Strategic Plan for the Scale up of Medical Male Circumcision in South Africa, 2012-2016. The strategic plan provides a framework for the scale up of the current MMC programme in South Africa and sets a target of 4.3 million circumcisions by the end 2016. The plan is reflective of a multi-sectoral approach, which supports the vision of the NDoH to work in partnership with stakeholders to scale up the provision and uptake of MMC in South Africa.
Key NDoH personnel responsible for the National MMC Programme are:
- Dr Aaron Motsoaledi (Minister of Health)
- Ms Malebona Matsoso (Director General of Health)
- Dr Yogan Pillay (Deputy Director General of HIV, TB and Women and Child Health)
- Mr Collen Bonnecwe (Department of Health: Director: HAST)
- Mr Dayanund Loykissoonlal (Department of Health: Manager: MMC Programme)
Provincial Department of Health web sites
Limited information is available on the Provincial Department of Health websites:
Eastern Cape – www.ecdoh.gov.za
Free State – www.fshealth.gov.za
Gauteng – www.health.gpg.gov.za
Kwazulu-Natal – www.kznhealth.gov.za
Limpopo – www.dhsd.limpopo.gov.za
Mpumalanga – www.mpumalanga.gov.za
Northern Cape – www.govpage.co.za
North West – health.nwpg.gov.za
Western Cape – www.westerncape.gov.za
The South African National AIDS Council (SANAC) is a voluntary association of institutions established by the national cabinet of the South African Government to build consensus across government, civil society and all other stakeholders to drive an enhanced country response to the scourges of HIV, TB and STIs. The Council is not a juristic person. Under the direction of SANAC, the government of South Africa created the South African National AIDS Council Trust as the legal entity that is charged with achieving its aims. The SANAC Secretariat exists to implement the objects of the SANAC Trust established in terms of the Trust Property Control Act.
Through the rollout of the National Strategic Plan (NSP) for HIV and AIDS, TB and STIs (2012 – 2016), SANAC has the duty to support and to promote the goals of the NSP.
For media-related queries, contact:
Tel: 012 395 9675
South African Military health Service (SAMHS): www.mhs.mil.za
The vision of SAMHS is to establish a healthy military community. To ensure a healthy military community a comprehensive, excellent and self-supporting multidisciplinary military health service is required. Internationally it is standard principle that members of a defence force can depend on a dedicated health service that is guaranteed, comprehensive and supportive.
Tel: 012 367 9000 (National)
2. International Organisations
The World Health Organisation (WHO) www.who.int
The WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. In the 21st century, health is a shared responsibility, involving equitable access to essential care and collective defence against transnational threats.
The mission of the WHO South Africa Country Office is to promote the attainment of the highest sustainable level of health by all people living in South Africa through collaboration with the government and other partners in health development and the provision of technical and logistic support to country programmes.
Phone: 012 305 7700
UNAIDS aims to advance global progress in achieving country set targets for universal access to HIV prevention, treatment, care and support and to halt and reverse the spread of HIV and contribute to the achievement of the Millennium Development goals by 2015. The strategy works to position the HIV response in the new global environment. The AIDS response is a long term investment and the intent of the strategy is to revolutionise HIV prevention, catalyse the next phase of treatment, care and support, and advance human rights and gender equality. The UNAIDS strategy is a roadmap for the Joint Programme with concrete goals marking milestones on the path to achieving UNAIDS’ vision of “Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths.”
In 2007, the Joint United Nations Programme on HIV/AIDS (UNAIDS) recognised and recommended MMC as an additional and important strategy for the prevention of heterosexually acquired HIV infection in men in countries with a high prevalence of heterosexually transmitted HIV infection (generalised epidemic) and low levels of male circumcision.
Fritz Lherisson (UNAIDS Country Director-SA)
Telephone: +250570403 / +27718566072
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) www.pepfar.gov
PEPFAR is the U.S. Government initiative to help save the lives of those suffering from HIV/AIDS around the world. Created by President George W. Bush in 2003, this historic commitment is the largest by any nation to combat a single disease internationally. PEPFAR investments also help alleviate suffering from other diseases across the globe. PEPFAR is driven by a shared responsibility among donor and partner nations and others to make smart investments to save lives. PEPFAR has several implementing partners in South Africa: while the CDC and USAID are the largest, the Department of Defence, Peace Corps and HRSA also have programmes in South Africa.
Telephone: 012 431 4706
The Centers for Disease Control and Prevention (CDC) www.cdc.gov
The Centers for Disease Control and Prevention (CDC) is the national public health institute of the United States. Its main goal is to protect public health and safety through the control and prevention of disease, injury, and disability. CDC is partnering in South Africa with government, private institutions, universities, and non-governmental organisations to improve the country’s public health foundation, prevent transmission of HIV, provide care and treatment for those already infected with HIV, and strengthen laboratory capacity.
Telephone: 082 524 3334
USAID is the lead U.S. Government agency that works to end extreme global poverty and enable resilient, democratic societies to realise their potential. Created by President John. F. Kennedy in 1961, USAID has always had the twofold purpose of furthering America’s interests while improving lives in the developing world. USAID carries out U.S. foreign policy by promoting broad-scale human progress at the same time it expands stable, free societies, creates markets and trade partners for the United States, and fosters good will abroad.
Telephone: 012 452 2004
3. PEPFAR Medical Male Circumcision (MMC) Partners in South Africa
PEPFAR works through partnerships with national governments, non-governmental organisations (NGOs), civil society and other organisations to provide, among other things, life-saving HIV and TB medication and improved overall health systems. PEPFAR’s focus in South Africa is transitioning to prevention and Health Systems Strengthening and technical assistance.
PEPFAR has direct funding agreements with more than 120 prime implementing partners in South Africa, including SAG, parastatals, non-governmental organisations, unions, private entities, and universities. Approximately 10% of PEPFAR’s budget directly funds and provides technical assistance to several national departments and parastatals.
Anova Health Institute www.anovahealth.co.za
The Anova Health Institute is committed to improving the quality of public health services, with a special focus on HIV.
Anova is a leading partner in capacity building and the provision of technical support to the Department of Health, with a reputation for innovative responses and ground-breaking research in HIV. Anova is primarily funded by the President’s Emergency Fund for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID).
With its extensive experience in the implementation of HIV programmes, Anova is well known for its flagship efforts in the prevention of mother-to-child transmission (PMTCT) as well as its work in TB and HIV care and treatment including paediatric, adolescent and adult care. Anova’s ability to tailor innovative HIV responses is exemplified by its pioneering work in the fields of men who have sex with men (MSM), mental health, medical male circumcision (MMC) and working with the media.
The Anova Institute is based in Parktown, Johannesburg. For media queries, please contact:
Name: Cephas Chikanda
Tel: 011 581 5000/1
Email: firstname.lastname@example.org / email@example.com
Aurum Institute www.auruminstitute.org
We are a proudly South African, public-benefit organisation with over 17 years’ experience in leading the response, treatment and research efforts to eradicate TB and HIV. We have been working quietly alongside government, the mining industry, among NGOs and in communities to better understand the epidemics to provide real solutions.
Our remit is to improve the health of people and communities through innovation in TB and HIV integration.
With our knowledge and skills, we are best suited to achieve this by:
- Strengthening existing health care systems
- Constantly innovating to improve the way things are done; and
- Doing research to determine the best ways and means of eliminating TB and HIV.
We do this with one aim – to make a differential impact – underpinned by an evidence-based track record of excellence in delivery against programme objectives which have a transformational impact on health in the communities in which we work.
The Aurum Institute is based in Parktown, Johannesburg. For media queries, please contact:
Tel: 010 590 1300
CareWorks is a South African healthcare company formed in 2004 as a social enterprise. They focus on HIV prevention and disease management as well as some other key areas of employee wellness. Although CareWorks works across a broad spectrum of sectors, they have created a niche in working with mobile males, specifically in the mining, construction, farming and road freight industries. From this base, they are able to widen their focus to partners and communities. They combine a well-established presence of field mobilisers throughout the country with smart technology and systems. This allows them to accurately measure and manage many of their processes, including state-of-the-art antiretroviral treatment management centrally, through what they call their “virtual clinic”.
CareWorks’ long-term vision is to make a tangible impact on the degenerative effects that both HIV/AIDS and TB have on individuals, organisations and our country. Since 2012, with support from the U.S. President’s Emergency Plan for AIDS Relief, through the US Centers for Disease Control and Prevention, CareWorks has implemented the following HIV Prevention Programmes:
- HIV Combination Prevention in the mining communities of Mpumalanga, Limpopo and North West provinces;
- Mobilisation and demand creation for Medical Male Circumcision (MMC) nationally.
CareWorks is based in Newlands, Cape Town. For media queries, please contact:
Name: Gavin Walton
Tel: 021 673 5300
Centre for Communications Impact (previously trading as JHHESA) www.jhhesa.org
Centre for Communications Impact (CCI) is a non-profit organisation that designs and implements evidence-based mass media and community health and development focused communication campaigns and behaviour change programmes. The organisation is currently implementing two USAID funded awards, Strategic Communications and Community Responses, focused on HIV and gender-based violence prevention. Campaigns are run under the banner of either Brothers for Life, a men’s health and well being brand, or Zazi (know your strength), aimed at young women.
CCI is affiliated to the internationally acclaimed Johns Hopkins University, Bloomberg School of Public Health’s Centre for Communication Programs, based in Baltimore (U.S.A), which is a globally respected public health communication organisation.
CCI is based in Brooklyn, Pretoria. For media queries, please contact:
Name: Brenda Goldblatt
Tel: 012 366 9300
Centre for HIV and AIDS Prevention Studies (CHAPS) www.chaps.org.za
CHAPS is one of the largest South African non-governmental organisations (NGO) focused on voluntary medical male circumcision as HIV prevention on the African continent. Through its pioneering work in the research and promotion of voluntary medical male circumcision scale-up activities, CHAPS has successfully implemented and disseminated sustainable evidence-based health solutions throughout South Africa and the region.
CHAPS was founded in May 2010 by Dr Dirk Taljaard and Dr Dino Rech. The organisation evolved from the Orange Farm research programme and team that, in the five years prior to 2010, had researched and published extensively around the topic of medical male circumcision. This research and the publications of the Orange Farm team, most notably the randomised controlled trial which demonstrated the 60% protective benefit of medical male circumcision, contributed to the World Health Organisation (WHO) recommendations in 2007.
CHAPS is based in Houghton Estate, Johannesburg. For media queries, please contact:
Name: Ms Charmaine Mohale
Tel: 011 484 8086/011 648 9036
Community Media Trust (CMT) www.cmt.org.za
Community Media Trust is a not-for-profit organisation that has produced media content in the fields of health, HIV/AIDS, education, gender-based violence, human rights as well as social development. The organisation has been in existence since 1998 and continues to play a role in promoting knowledge, transparency, accountability and democracy to all areas affecting the quality of life of communities in South and Southern Africa.
CMT’s flagship brand is Siyayinqoba Beat It! which aims to illustrate both the application of medical protocol as well as to promote health seeking behaviour through biographies and the personal experiences of people living in South Africa. The television show aims to motivate the viewers to reflect on their own lives by showcasing personal stories and role models that speak to wide health issues in South Africa. CMT also has an outreach programme, taking health information to communities through training, a community health worker programme, door to door campaigns and community awareness events to drive demand for and uptake of health services. The outreach work is supported by community media on community radio stations and in community newspapers.
CMT is based in Rondebosch, Cape Town. For media queries:
Name: Debbie Van Zyl
Tel: 021 788 9163
An affiliate of John Hopkins University, Jhpiego has worked in South Africa since 1995. Jhpiego has a portfolio of programmes funded by the U.S. Agency for International Development (USAID), the U.S. Centers for Disease Control and Prevention (CDC) and, more recently, the United Nations Population Fund (UNFPA). Jhpiego works in partnership with Jhpiego South Africa, a registered Section 21 non-profit company in South Africa.
Jhpiego South Africa’s vision is to improve the health and life quality for men, women and children across Southern Africa. Its mission is to empower health professionals and communities to build and sustain quality healthcare services in low-resource settings through innovative research and policy and cutting-edge programmers. We do this in collaboration with our partners. Jhpiego South Africa currently supports a range of reproductive health and HIV prevention, care and treatment programmes including MMC.
JHPIEGO is based in Brooklyn, Pretoria. For media queries, please contact:
Name: Ida Asia
Tel: 012 346 4522
Maternal, Adolescent and Child Health (MatCH) www.match.org.za
MatCH was established in 2010 as a division of the Wits Health Consortium (Pty) Ltd, and is affiliated to the School of Public Health at the University of the Witwatersrand. MatCH is based in Durban and supports MMC services in eThekwini, Ugu, Zululand and uMkhanyakude districts in KwaZulu-Natal.
MatCH is based in Overport, Durban. For media queries, please contact:
Name: Arthi Ramkissoon
Tel: 031 275 1540
Right to Care www.righttocare.org
Right to Care is a South African non-profit organisation (Section 21) that supports and delivers prevention, care, and treatment services for HIV and associated diseases. Right to Care is helping the Department of Health with its efforts to scale up circumcision countrywide, through funding from USAID’s PEPFAR fund. Circumcision services are offered in Free State, Gauteng, KwaZulu Natal, Limpopo and Mpumalanga. Right to Care’s circumcision programme targets men aged 15 and upwards, who are HIV-negative. Medical male circumcision is a cost-efficient HIV prevention strategy that has been tested extensively and is effective.
Right to Care is based in Westdene, Johannesburg and in Centurion, Tshwane. For media queries, please contact:
Tel: 011 276 8850
SACTWU Worker Health Program (SWHP) www.sactwuworkerhealthprogram.org.za
The SACTWU Worker Health Program (SWHP) was started in 1998 as a worker education programme and has become the largest labour based HIV prevention programme in South Africa. As part of these prevention activities SWHP initiated a voluntary medical male circumcision (VMMC) programme in 2011. Using a roving model SWHP takes VMMC services to clients and conducts procedures at medical and non-medical sites situated within close proximity to communities. Working in close collaboration with the Department of Health (DOH) SWHP’s model has proved to be a great success and SWHP become one of the leading providers of VMMC in South Africa.
For media queries, please contact:
Name: Ms Colleen Khumalo
Tel: 031 305 5581
Address: 124 Magwaza Maphalala Street, Durban
Society for Family Health (SFH) www.sfh.co.za
SFH is one of South Africa’s leading non-profit, non-governmental provider of health products, services and communications and South Africa’s leading social marketing organisation. Social marketing is the non-profit use of commercial marketing techniques to address public health issues. SFH was founded in 1993 as a condom social marketing organisation and since that date has distributed over 1 billion condoms.
Also since that time, SFH has greatly expanded the portfolio of products and services it provides to include male condoms, female condoms, lubricant, HIV counselling and testing, CD4 counts, TB diagnosis and medical male circumcision. All of these programmes are supported by SFH behaviour change communications, marketing and training. SFH is the South African affiliate of Population Services International, the world’s leading network of social marketing organisations, with affiliates in 69 countries around the world.
SFH is based in Parktown, Johannesburg. For media queries, please contact:
SFH Communications Department
Tel: 011 484 5320
TB/HIV Care www.tbhivcare.org
TB/HIV Care Association is a registered non-profit organisation that puts integrated care at the heart of responding to TB and HIV. Their aim is to improve TB and HIV management by increasing access to TB and HIV diagnosis, care, treatment and community-based treatment adherence support. TB/HIV Care’s integrated approach to addressing both TB and HIV issues has made the organisation a pioneer in implementing a comprehensive system of support for TB and HIV clients.
TB/HIV Care is based in St George’s Mall, Cape Town. For media queries, please contact:
Name: Zolani Barnes
Tel: 021 425 0050