INTEGRATED ACTIVITY FLAG:

This activity is conducted in coordination with the Perinatal HIV Research Unit (#7881) and Health Policy Initiative (#7606).

SUMMARY:

The Human Sciences Research Council (HSRC) will use PEPFAR funds to hold stakeholder meetings with traditional healers and traditional leaders to receive input on what should be included in messages for delivering circumcision as a part of a comprehensive traditional healers HIV prevention program. Based on the policies and guidelines, HSRC will work with traditional healers to develop medically and culturally appropriate messages for traditional male circumcision. This is one of three interrelated activities focusing on articulating a framework for male circumcision that meets international standards and reflects the local cultural context. The other two activities are (1) support to PHRU for a workshop and a report on the feasibility of alternative models of male circumcision and (2) support to HPI to conduct a policy analysis of the impact of pending South African legislation restricting male circumcision to medically defined conditions and for cultural practices. In all three cases the activities will concentrate on policy issues surrounding circumcision within the South African context rather than on actual service delivery. The major emphasis area addressed for circumcision is policy and guidelines. Doctors, nurses, traditional healers and community healthcare workers are the target groups for this activity.

BACKGROUND:

Although not widespread, prevalence rates for male circumcision in South Africa ranges from 20% to nearly universal among some ethnic groups. Male circumcision is a procedure that is usually done for cultural or religious reasons rather than for health benefits. This is seen among certain ethnic groups such as the Xhosa who routinely practice male circumcision as part of initiation to transition boys to manhood. In such cases the circumcision is done by traditional healers rather than by medically trained in a health facility. However, since it is a surgical procedure, there are risks involved in traditional male circumcision. Complication rates vary depending on the study but range from 1.7% to 12%. In a study of adverse effects (AE) of male circumcision by facility type, it was found that traditional circumcision carried a 34.3% rate of AE versus 11.1% at public facilities and 22.5% at private facilities. There are many anecdotal reports in South Africa highlighting problems of bleeding, infection, mutilation and death associated with traditional circumcision practices.

In the past, one reason that HIV infection has been acquired during traditional circumcision ceremonies is because one instrument has been used to circumcise large numbers of initiates, one after the other, without taking any infection control precautions. Further, most traditional surgeons are not trained in proper health standards and procedures; therefore, there is a high risk of transmission of HIV and other infections such as Hepatitis B and HIV during circumcision, as well as other complications. Trained medical staff has not been available in order to intervene in the case of complications. Conversely, if male circumcision is performed correctly, there may be significant benefits. Results from the Orange Farm study in South Africa in 2005 indicated that circumcised males were 60% less likely to acquire HIV after a mean 18-month follow-up.

With this in mind, HSRC will use FY 2007 PEPFAR funding to 1) perform desk-top review of "best-practices" in traditional male circumcision; 2) hold stakeholder meetings with traditional healers who perform traditional male circumcision; and 3) begin the development of messaging, communication and prevention particularly around safe male circumcision among traditional healers.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Development of Messages

Following on a one-day colloquium on male circumcision hosted by the Perinatal HIV Research Unit in South Africa in 2006, HSRC will focus of the development of messages

and communication for the development of safe male circumcision practices by traditional healers.

Initially, HSRC will conduct a desk-top review of best practices in male circumcision by traditional healers. The review will be followed by a series of workshops and focus groups in the Eastern Cape between and among traditional healers, traditional surgeons and traditional nurses, as well as with medical doctors and nurses. This background work will take into consideration the South African social and cultural context in order to formulate the basis on which messages for male circumcision by traditional healers can be developed. These messages will build on and be adapted from existing UNAIDS/WHO surgical training with the primary focus of ensuring safety and prevention of HIV by traditional healers. Once messages on safety and HIV prevention have been developed, these will be piloted with same groups that took part in the series of workshops and focus groups to ensure that the messaging is appropriate and culturally appropriate. Thereafter, HSRC will ensure that the messaging is distributed appropriately.

This activity will contribute to the PEPFAR goal of preventing 7 million new infections.