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Circumcision for Prevention Against HIV: Marked Seasonal Variation in Demand and Potential Public Sector Readiness in Soweto, South Africa
Global Health Sciences Literature Digest
Published March 12, 2007
Journal Article

de Bruyn G, Smith MD, Gray GE, McIntyre JA, Wesson R, Passos GD, Martinson NA. Circumcision for Prevention Against HIV: Marked Seasonal Variation in Demand and Potential Public Sector Readiness in Soweto, South Africa. Implement Sci. 2007 Jan 25;2:2.

Objective

To assess the existing medical capacity of the only public sector hospital in Soweto, South Africa to undertake a large-scale male circumcision (MC) program for the prevention of HIV acquisition.

Study Design

Retrospective review of procedure logs of adult (93 months from 1998-2006) and pediatric (33 months from 2003-2006) surgical services from a large public hospital.

Setting

A large public sector hospital (Chris Hani Baragwanath Hospital) in Soweto, South Africa; the hospital has 3,000 beds and serves a community of 1.1 million.

Participants

Male adults and children.

Intervention

None. This was a retrospective chart review.

Primary Outcomes

Based on a review of operating room logs, the authors assessed the number of circumcision procedures performed per month on male adults and children during the study period.

Results

Chart review revealed that 2,786 circumcision procedures were performed on adult men during the study period (30/month); the mean age of patients was 22.6 years (SD 8.8 years). The number of procedures varied by season (Edwards test, p<0.0001), being greatest in the winter months, with marked peaks in July and August; rates were low early in the summer and in December and January. The median age of patients declined over the study period. The survey also found that 335 pediatric male circumcisions were performed over the study period (10.2/month). About half (46.3%) of pediatric circumcisions were performed on children between the age of one and five. In contrast to the adult patients, no seasonality in frequency of procedures was noted (Edwards test, p=0.355).

Conclusions

The authors concluded that public sector capacity in Soweto to perform circumcision would have to be substantially improved to deal with the caseload required for sufficient numbers to have a public health impact. Circumcision of 60% of the male birth cohort (estimated at 15,000/year) would require at least 8,000 procedures per year, not including expansion to other uncircumcised men. The reason for variation in adult procedures by season is not clear, but nevertheless poses a challenge for planning services.

Quality Rating

The quality of this study was not assessed, as it was a brief descriptive report.

In Context

A recent randomized controlled trial of MC for the prevention of HIV acquisition demonstrated that MC reduces the risk of HIV infection,(1) confirming similar findings from prior observational studies.(2) Two studies conducted in South Africa found that MC would be acceptable to the majority of uncircumcised men if it were to be proven beneficial in preventing HIV/AIDS.(3,4)

Programmatic Implications

Capacity in this setting, as well as other areas, would have to be substantially improved to deal with the additional caseload of circumcisions required for public health impact. Alternatives to the provision of services (such as general medical or nurse practitioners) may need to be explored, including whether acceptability would be reduced by using female providers.

References

  1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005 Nov;2(11):e298.
  2. Siegfried N, Muller M, Volmink J, Deeks J, Egger M, Low N, Weiss H, Walker S, Williamson P. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2003;(3):CD003362.
  3. Lagarde E, Dirk T, Puren A, Reathe RT, Bertran A. Acceptability of male circumcision as a tool for preventing HIV infection in a highly infected community in South Africa. AIDS. 2003 Jan 3;17(1):89-95.
  4. Rain-Taljaard RC, Lagarde E, Taljaard DJ, Campbell C, MacPhail C, Williams B, Auvert B. Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection. AIDS Care. 2003 Jun;15(3):315-27.