Men have traditionally been disinclined to access health services via the South African state healthcare system while women find it simpler as they easily and more frequently engage with the system when attending ante-natal care once pregnant or taking sick children to health institutions.

Many groups in Africa circumcise men, usually in late childhood or early adolescence, and this is an important part of their cultural identity. In other ethnic groups, men are not circumcised. This is similar in South Africa where the isiXhosa circumcise as part of a coming of age initiation rite while the isiZulu do not participate.

By the late 1980s, researchers noticed that HIV infection rates were lower in those groups where men were circumcised. But it was not clear whether it was circumcision itself or some other difference in behaviour between the groups that gave some protection to the circumcised men against getting HIV.

Researchers in Orange Farm, Johannesburg wanted to find out whether circumcising men could reduce their chance of becoming infected by HIV. They offered young, sexually active, heterosexual, uncircumcised men the chance to have the operation. They explained that half of those who came forward would be circumcised right away (the ‘€œtreatment group’€) and the other half would be circumcised 21 months later (the ‘€œcontrol group’€).

Some 3 000 men joined the study. The group that each man was put into was decided at random. The plan was that all the men would visit the research clinic four times during this 21-month period, and that they would be tested for HIV each time. However, after 14 months, the number of new infections in the control group (49) was so much greater than the number in the treatment group (20) that it was considered unethical to continue the study as the result showed unequivocally that there was great benefit in being circumcised. The men in the control group were told they could be circumcised without any further delay.

Infections were 60% fewer in the treatment group, which seemed to indicate that circumcised men were much less likely to become infected with HIV when having sex with infected women. These findings have been confirmed by studies in Uganda and Kenya.

It is now widely accepted that in communities where HIV is common, circumcision may prove to be a valuable tool for reducing men’s risk of getting infected. It is important to note that circumcised men can still become infected, even though the risk might be lower and that they should still take other steps to prevent themselves from getting HIV.

South African stakeholders have been pushing since 2005 to have the government engage the issue of male circumcision, however the former health minister Dr Manto Tshabalala-Msimang was outspoken in her opposition to medical male circumcision and believed that it was best left in the hands of traditional leaders.

‘€œNothing happened until Barbara Hogan became the health minister (in 2008),’€ said Dr Dirk Taljaard, one of the lead researchers of the Orange Farm study. ‘€œSuddenly everything came to life and with the new health minister Dr Motsoaledi taking over things are carrying on,’€ he said.

Soul City’€™s Senior Executive Dr Sue Goldstein believes that other factors have also caused the delay. ‘€œThe scientific evidence is clear, but I believe many people don’€™t understand the science and their criticism is often not well informed,’€ she said.

Goldstein said the biggest opposition has been from the women and traditional leader section. The women’€™s sector has expressed concern that the introduction of medical male circumcision would impact on condom distribution and move resources away from interventions aimed at protecting women. She believes the traditional leader sector is worried about their area being sidelined by the medical intervention.

Taljaard believes the resistance from traditional leaders has been exaggerated: ‘€œI have spoken to a lot of these leaders and they have no real problem with us doing the cutting bit as long as they can continue with the other initiation rites. In Orange Farm they have shown that they are quite keen to work with us,’€ said Taljaard.

President of the Southern African HIV Clinicians Society, Dr Francois Venter cautions that medical male circumcision would not be simple to implement within South Africa’€™s buckling health system. ‘€œIt’€™s do-able, but quite difficult and would require dedicated human resources for a shattered health system. It is an amazing opportunity to get hold of men and get the relevant messaging in there. It would be a shame if it was only an HIV intervention,’€ he said.

Venter said he would like to see one country in Africa ‘€œgoing massive’€, spreading the intervention across multiple provinces and he believes South Africa has the potential to lead the way.

Responding to the concerns of the women sector that male circumcision would undermine efforts to protect women, Venter said there was no doubt that women would benefit from the circumcision intervention.

‘€œIf less men are infected, it means that less women would be infected. So, of course women would benefit. Perhaps it is time that these sectors make themselves more relevant and not try to hold up the one intervention that could really work at this stage to reduce the rate of infection. They need to climb in and rather make sure that issues such as the messaging around gender violence is included,’€ said Venter.

A key stakeholder driving South Africa’€™s formulation of a policy has been Professor Helen Rees of the Wits Reproductive Health and HIV Research Unit. Rees is also co-chair of the South African National AIDS Council’€™s Programme Implementation Committee and Chair of the Prevention Sector Research Sub-committee.

Rees revealed there would be a report back at the next SANAC plenary meeting in November. ‘€œAt the last SANAC plenary meeting there was an agreement to continue the engagement with the traditional leadership, and that the National Department of Health would undertake a feasibility and costing exercise on expanding medical male circumcision services within the public health system.’€ Medical male circumcision is already available within the public health system, but on a limited scale.

Rees said there was agreement that it needed to be part of the wider integrated package of male sexual and reproductive health care which could include STI treatment, HIV counseling and testing, condom distribution and alcohol and gender issues. Rees said research has also shown that the introduction of male circumcision would not undermine condom use thereby increasing the risk of infection.

‘€œSpeaking as a researcher and a clinician I believe that if we are successful in developing this intervention it would be a real triumph for SANAC. We would have succeeded in engaging a wide range of stakeholders and achieving a consensus viewpoint. If we manage to do this while taking into account all these different inputs we should see national buy-in to the programme,’€ said Rees.