The case of voluntary male medical circumcision roll out in South Africa

A promising HIV prevention strategy aimed specifically at young men is voluntary medical male circumcision (VMMC), as men who have been medically circumcised are 60% less likely to contract HIV through male to female vaginal sex. The World Health Organization and the Joint United Nations Programme on HIV/AIDS have recommended that 80% of men, aged 15 to 49 years old undergo circumcision by the end of 2016. Should these targets be met, the VMMC intervention should avert more than 1 million new HIV infections by the year 2025. Furthering its appeal, VMMC is a once off procedure and is fairly cost effective from a health systems standpoint. The possibility of a seemingly simple and effective HIV prevention offered by VMMC has created a stir of optimism in the field of HIV prevention.

But how widespread has the uptake of VMMC been? More importantly, have the most at risk young men been reached? A large household study in KwaZulu-Natal revealed:

  • Only 32% of men had undergone VMMC by 2015 and half of them were younger than 22 years old.
  • These men came from households with higher incomes and have acquired higher levels of formal schooling than their uncircumcised counterparts.
  • Additionally, men who were circumcised engaged in fewer HIV risk behaviours than uncircumcised men; they also had fewer sexual partners over their lifetime.
  • They were more likely to use a condom after consuming alcohol, more likely to use a condom consistently at first sex, and more likely to use a condom with their most recent partner and in general in the previous year.

What this data points to is that the most economically and socially marginalised men who are also most at risk for contracting HIV have not become involved in the VMMC programme. This highlights the general failure of HIV prevention programmes to attract and reduce – risk of the men who are most at risk for contracting and transmitting HIV. This is not the first time biomedical HIV prevention programmes in South Africa have failed to impact key populations. Many types of microbicides targeting vulnerable women have failed to reduce HIV incidence. Other nonsuccesses include low levels of condom use and poor ART adherence. The failure of interventions and programmes that in strictly biomedical terms, should be highly effective can be attributed to the failure to consider the complex social processes that influence the public reception of such HIV prevention techniques.

It is critical that policy makers consider the impact of social processes on biomedical HIV prevention programmes. One such social issue, particularly pertinent to the VMMC programme, is traditional masculine identities. Traditional masculinities have been shown to hamper men’s access to HIV services, and may be one of the root causes of young men’s self-exclusion from VMMC uptake. In the simplest of terms many men perceive VMMC as a challenge to their masculinity.  To effectively reach young men HIV services need to be made more ‘male friendly’ and more responsive to men’s lack of efficacy in seeking health care.

The following recommendations have previously been put forward to increase men’s participation in HIV prevention and treatment services:

  • Language around HIV campaigns needs to be directed at the male gendered identities.
  • Safe social spaces should exist where men can collectively discuss the challenges they are facing in accessing HIV services.
  • HIV services should be decentralized and moved to spaces that are not predominantly viewed as female (such as hospitals and clinics).
  • Discussions should be held at community level about masculine identities and how these create opportunities and barriers to the men’s health seeking behaviour.
  • The final recommendation suggests that the partners of targeted men should be involved in encouraging men to undergo circumcision.

It must be reiterated that biomedical prevention programmes such as VMMC, will only be successful if the social processes around HIV are taken cognisant of when designing the roll out of HIV prevention programmes.

While VMMC is viewed as one of the most important methods to prevent HIV, its success will always be limited if those responsible for its roll out do not consider the social and contextual factors influencing the uptake of VMMC. Only then will we be able to rectify the current pitfalls that the VMMC campaign has encountered and thereby stand a better chance of reaching the targets set out by experts in the field.

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