Abstract
BackgroundEpidemiological data from South Africa demonstrate that risk of human immunodeficiency virus (HIV) infection in males increases dramatically after adolescence. Targeting adolescent HIV-negative males may be an efficient and cost-effective means of maximising the established HIV prevention benefits of voluntary medical male circumcision (VMMC) in high HIV prevalence–, low circumcision practice–settings. This study assessed the feasibility of recruiting male high school students for VMMC in such a setting in rural KwaZulu-Natal.Methods and FindingsFollowing community and key stakeholder consultations on the acceptability of VMMC recruitment through schools, information and awareness raising sessions were held in 42 high schools in Vulindlela. A three-phase VMMC demand-creation strategy was implemented in partnership with a local non-governmental organization, ZimnadiZonke, that involved: (i) community consultation and engagement; (ii) in-school VMMC awareness sessions and centralized HIV counselling and testing (HCT) service access; and (iii) peer recruitment and decentralized HCT service access. Transport was provided for volunteers to the Centre for the AIDS Programme of Research in South Africa (CAPRISA) clinic where the forceps-guided VMMC procedure was performed on consenting HIV-negative males. HIV infected volunteers were referred to further care either at the CAPRISA clinic or at public sector clinics. Between March 2011 and February 2013, a total of 5165 circumcisions were performed, the majority (71%) in males aged between 15 and 19 years. Demand-creation strategies were associated with an over five-fold increase in VMMC uptake from an average of 58 procedures/month in initial community engagement phases, to an average of 308 procedures/month on initiation of the peer recruitment–decentralized service phase. Post-operative adverse events were rare (1.2%), mostly minor and self-resolving.ConclusionsOptimizing a high volume, adolescent-targeted VMMC program was feasible, acceptable and safe in this setting. Adaptive demand-creation strategies are required to sustain high uptake.
Highlights
KwaZulu-Natal in South Africa is at the epicentre of the global human immunodeficiency virus (HIV) epidemic with an estimated 24.7% infection prevalence in the general population in 2011 [1]
Ethics statement voluntary medical male circumcision (VMMC) is part of routine service provision in South Africa and implementation is in accordance with World Health Organization (WHO) guidelines [20,21]
In the first two months of the clinic opening, only phase one of the demand creation strategy was implemented, and early adopters contributed an average of 58 procedures/ month
Summary
KwaZulu-Natal in South Africa is at the epicentre of the global human immunodeficiency virus (HIV) epidemic with an estimated 24.7% infection prevalence in the general population in 2011 [1]. Surveillance data in the district and elsewhere consistently demonstrate that in males HIV infection risk increases dramatically following adolescence, with prevalence in boys aged 15–19 estimated at 2–3%, compared to 11–12% in those aged 23–24 years [4,5]. Targeting VMMC at young males as part of such a combination prevention program in schools before entry into the high risk period could represent a directed and cost-effective means of altering current epidemic trajectories for HIV. Epidemiological data from South Africa demonstrate that risk of human immunodeficiency virus (HIV) infection in males increases dramatically after adolescence. This study assessed the feasibility of recruiting male high school students for VMMC in such a setting in rural KwaZulu-Natal
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