African low-income settings of high HIV incidence

Male Circumcision

A model for the roll-out of comprehensive adult male circumcision services in African low-income settings of high HIV incidence: the ANRS 12126 Bophelo Pele Project.

The World Health Organization (WHO)/Joint United Nations Programme on AIDS (UNAIDS) has recommended adult male circumcision for the prevention of heterosexually acquired HIV infection in men from communities where HIV is hyperendemic and adult male circumcision prevalence is low. The objective of this study was to investigate the feasibility of the roll-out of medicalized adult male circumcision according to UNAIDS/WHO operational guidelines in a targeted African setting. The ANRS 12126 "Bophelo Pele" project was implemented in 2008 in the township of Orange Farm (South Africa). It became functional in 5 months, once local and ethical authorizations were obtained. Project activities involved community mobilization and outreach, as well as communication approaches aimed at both men and women incorporating broader HIV prevention strategies and promoting sexual health. Free medicalized adult male circumcision was offered to male residents aged 15 years and over at the project's main centre, which had been designed for low-income settings. Through the establishment of an innovative surgical organization, up to 150 adult male circumcisions under local anaesthesia, with sterilized circumcision disposable kits and electrocautery, could be performed per day by three task-sharing teams of one medical circumciser and five nurses. Community support for the project was high. As of November 2009, 14,011 men had been circumcised, averaging 740 per month in the past 12 months, and 27.5% of project participants agreed to be tested for HIV. The rate of adverse events, none of which resulted in permanent damage or death, was 1.8%. Most of the men surveyed (92%) rated the services provided positively. An estimated 39.1% of adult uncircumcised male residents have undergone surgery and uptake is steadily increasing. This study demonstrates that a quality adult male circumcision roll-out adapted to African low-income settings is feasible and can be implemented quickly and safely according to international guidelines. The project can be a model for the scale-up of comprehensive adult male circumcision services, which could be tailored for other rural and urban communities of high HIV prevalence and low adult male circumcision rates in Eastern and Southern Africa.

The Orange farm community, about 45 km outside Johannesburg, is home to Sothos, Zulus, Tswana, and Xhosa ethnic groups. The overall pre-project self-reported male circumcision level was 22-30%. The Bophelo Pele (Health First) project, the first adult male circumcision community project to be initiated following the WHO/UNAIDS 2007 recommendations for scale-up, is designed as a catch-up programme. A saturation level will be reached when all willing, eligible men have been circumcised, after which an age-related strategy (e.g. newborns and/ or 15 year olds) will sustain circumcision prevalence. The strengths of Bophelo Pele are its successful community engagement, its outreach and communication strategies, and its innovative task shifting organisational model. The cost per male circumcision performed has fallen to 300 rand (about 40USD), adverse events are uncommon, and the project has already been successfully replicated at 3 sites in Botswana, Swaziland, and Zimbabwe. This is an excellent example of scientific knowledge translation from trial results to implementation.