ZIMBABWE: Rate of male circumcision speeds up

HARARE, 4 July 2011 (PlusNews) - Zimbabwe has set a goal of circumcising 1.2 million men by 2015 - a bold target for a country that has been slow to get its circumcision programme off the ground but is now rapidly making up for lost time.

When the national circumcision policy was launched two years ago there was widespread scepticism as to whether the country had the capacity to provide mass male circumcision, in view of a health system that had been starved of resources, drugs and equipment for years.

Tinashe Damba, 29, is one of almost 30,000 men who have taken advantage of the free circumcision scheme offered by the ministry of health in conjunction with Population Services International (PSI), an NGO, and other partners.

"I thought the circumcision procedure was going to be very painful but I did not feel a thing," said a relieved Damba after leaving the operating room at a clinic in the capital, Harare. The only pain he felt was when his penis was injected with the anaesthetic that made it numb during the procedure.

"I heard that if you get circumcised you have a better chance of not contracting the deadly HIV. It's not 100 percent prevention, but you reduce the chances of contracting that disease."

A large study in Kenya, South Africa and Uganda in 2006 found that the procedure could reduce a man's risk of contracting HIV through vaginal intercourse by as much as 60 percent.

Before Zimbabwe launched its campaign, male circumcision had only been available at private health institutions and mostly for reasons other than as an HIV intervention measure.

"Blessing in disguise"

Zimbabwe is not the only country that has been slow to introduce free male circumcision in state facilities. In neighbouring Malawi, the government has yet to implement mass male circumcision, while South Africa has been criticized for moving too slowly in developing a national circumcision strategy.

"I do not think we were too far behind other countries," said Minister of Health and Child Welfare Dr Henry Madzorera, "but then we were going through a rough patch politically and economically, and the public health system was close to collapse."

A health worker strike that began in November 2008 shut down public health services for several months. The loss of qualified nurses and doctors who left to work in other countries made it even more difficult to deliver the service.

The delay was, according to PSI circumcision programme manager Roy Dhlamini, a blessing in disguise. "Only very small pockets of the Zimbabwean population practice circumcision [as a cultural rite]. People needed to be educated on the benefits, so a nationwide campaign to sell male circumcision was launched."

The findings of research in Zimbabwe’s rural areas, published in the May issue of the Tropical Medicine & International Health journal, show that 52 percent of the men surveyed were prepared to undergo the procedure.

Dhlamini said Zimbabwe was also benefiting from the success and challenges of those who had started earlier, resulting in the lowest rate of "complications" - less than 1 percent - compared to a regional average of more than 3 percent.

Two years ago, the programme had the capacity to circumcise only eight people per day at its flagship facility, the Spilhaus Family Planning Centre in Harare. From the time a client walked into the centre included up to two hours of mandatory counselling and an HIV test, with another half hour for the procedure, to when he walked out without his foreskin.

Staff shortages were another major problem. "We only had eight doctors and 18 nurses, now we have 40 doctors and 160 nurses and training is ongoing," Dhlamini said. The ideal is to have at least a doctor and eight nurses at a health centre in each of Zimbabwe's 62 districts.

The programme currently has five stationary and two mobile centres. "People have been travelling from as far as 500 kilometres to the few centres available. We want to make it more accessible for them by establishing the district centres and taking the service to them, using the mobile centres."

The process also had to be speeded up. "We devised the Model of Optimising Volumes and Efficiency (MOVE), whereby doctors now work in teams of three - one anaesthetizes, the other carries out the procedure, and the third one bandages the penis," Dhlamini said.

This has reduced the operation to fifteen minutes and counselling now takes one and a half hours.

The campaign was largely financed by external donors but the cash-strapped government has also contributed. "This programme is part of the health delivery system. It is carried out primarily in already established government health facilities, and we provide the staff," Health Minister Madzorera said. The government will also pay allowances to those involved in field work.

Earlier in 2011, PSI and the ministry of education targeted adolescents older than 13 during school holidays, resulting in a 200 percent jump in the number of circumcisions. "We plan to repeat the exercise in the next school holidays," PSI’s Dhlamini said.

Nevertheless, some are still sceptical about whether circumcision will bring down the incidence of HIV. Mary Sandasi, Executive Director of the Women's AIDS Support Network (WASN), feels that male circumcision does not protect women and may lead some men, especially younger ones, to believe it is the silver bullet against HIV.

"Thirty years after the first AIDS case was identified we are still getting infections, even in countries where men are circumcised as infants, so this may not be the answer," she said, adding that the only solution for sexually active people is the correct and consistent use of condoms. "They need to remind men after the operation."

Health minister Madzorera said Sandasi's concerns would be valid in the absence of pre-circumcision counselling, which makes it clear that the procedure has to be used with other HIV prevention interventions.

"The message is repeated during the obligatory visits to a medical centre after the procedure. After these visits we keep on reminding those circumcised through multi-media campaigns, so there is no let-up."

Madzorera is confident the target can be reached. "The success to date of this programme is due to the fact that Zimbabweans are quick to adapt to new ideas. We have rural chiefs encouraging their people to get circumcised - that is a good sign."

Risk factors for HIV vary between African cities, need tailored responses

A comparative study in three large cities in southern Africa has found big differences in risk factors for acquisition of HIV infection, emphasising the importance of locally tailored HIV prevention strategies and up-to-date information on local risk factors.

The study looked at behavioural risk factors associated with acquiring HIV infection in 5000 sexually active women in Harare, Durban and Johannesburg who took part in a large trial of an HIV prevention method based on use of the diaphgram.

Sue Napierala Mavedsnege and colleagues report the findings of their prospective cohort analysis in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes. 

A total of 309 incident HIV infections were identified. Durban reported the highest incidence rate, followed by Johannesburg and then Harare (6.75 per 100 person years, 95% CI: 5.74-7.93; 3.33 per 100 person years, 95% CI: 2.51-4.44; 2.72 per 100 person years CI: 2.26-3.26, respectively).

Having more than one partner in the last three months was the only common factor associated with HIV incidence.

The majority of the estimated 35 million people living with HIV live in sub-Saharan Africa where 70% of all new infections occur. Women represent over 60% of all infections. Southern Africa, with the highest regional prevalence, reflects different phases of the epidemic.

In Zimbabwe, with an estimated prevalence of 14.3%, the epidemic began early, peaked in 1998 with a subsequent decline in incidence and prevalence.

From 1990-1998 South Africa had an exponential increase followed by a moderate increase until 2004 when apparent stabilisation began. In 2008 estimated provincial prevalence rates ranged from 5.3% to 25.8%.

In Gauteng province, with Johannesburg its largest city, prevalence appears to have peaked in 2002 at 20.3% and declined to 15.2% in 2008. In contrast, Kwa Zulu Natal province where Durban is the largest city, estimated prevalence rose from 15.7% in 2002 to 25.8% in 2008.

While cross-sectional studies looking at risk factors associated with HIV have taken place in Zimbabwe and South Africa, few have looked at risk factors for HIV incidence in women.  A better understanding of these factors within local contexts will help develop targeted interventions so reducing transmission.

The authors looked at factors associated with differences of HIV incidence among women in Harare, Johannesburg and Durban enrolled between September 2003 and September 2005 in the Methods for Improvement of Reproductive Health (MIRA) study, a randomised clinical trial to look at the effect of the diaphragm plus lubricant gel for the prevention of HIV. The intervention did not reduce HIV incidence.

The authors undertook a prospective cohort analysis of trial participants who were followed for a median of 21 months (12-24 months).

Socio-demographic, biological and behavioural data were collected at baseline and at quarterly visits. Testing for HIV and STIs were conducted at each quarterly visit.

Each location had distinct characteristics as well as different patterns of individual risk factors.

In Harare women were more likely to live with their partner, be employed and not use alcohol or drugs but more likely to wipe inside their vagina. While they had a later sexual debut and fewer partners than in Durban or Johannesburg there was more transactional sex (for money, food, drugs or shelter) within the last three months.

Early sexual debut was more common in Durban, while in Johannesburg consumption of alcohol within the last three months, multiple sexual partners and sex under the influence of drugs or alcohol were more likely.

Sexually transmitted infections (STIs) were important risk factors in Harare and Durban (prevalent herpes simplex virus AHR=2.56, 95% C: 1.61-4.06; incident herpes simplex virus AHR= 12.6, 95% CI: 2.13-21.87; gonorrhoea AHR=6.82, 95% CI: 2.13-21.87 and prevalent herpes simplex AHR=1.64, 95% CI: 1.07-2.52; gonorrhoea AHR=4.40, 95% I: 2.07-9.39, respectively.

Multiple partners and sex with a partner under the influence of alcohol or drugs significant increased the risk in Durban (AOR=1.78, 95% CI: 1.11-2.85 and AOR= 1.51, 95% CI: 1.05-2.16, respectively, whereas in Johannesburg early sexual debut was a strong predictors of getting HIV(AOR= 2.60, 95% CI: 1.30-5.17).

In Harare and Johannesburg 20.2 % and 22.3% of HIV infections, respectively, were attributable to wiping inside the vagina. Wiping inside the vagina has been independently associated with decreased condom use

In Harare over 96% of women were living with their partner; the median number of lifetime partners was 1.3. This implies, note the authors, most HIV infection was acquired from their live-in partner, yet 25% did not know their partner’s status.

The authors note the strengths of the study include its longitudinal study design and large sample size.

A limitation is that the study was conducted among clinical trial participants with strict eligibility criteria.

The authors suggest “as an epidemic matures more transmission occurs within stable partnerships, and we may see South Africa. As the epidemic wanes, as… in Zimbabwe, we may begin to see…HIV transmission among young people and high risk core groups become increasingly important drivers of the epidemic.”

The significant differences in drivers of HIV incidence in the three locations support targeted HIV programming based on the local situation and epidemiology as the most effective approach to reduce HIV incidence among women, the authors conclude.


Napierala Mavedzenge S et al. Determinants of differential HIV incidence among women in three southern African locations. JAIDS advance online edition, doi: 10.1097/QAI.0b013e3182254038, 2011.

Scant regard for HIV care workers in SADC

Cape Town - A call has been made for explicit and, ideally, government-backed policies to support countless people providing care to people living with HIV and AIDS amid reports that many care givers are neither officially known nor rewarded for their work in Southern Africa.

'Very often when people talk about care workers in the SADC region they talk about nurses, doctors and other people employed at health facilities.

'They do not talk about people providing care in the shadows: home-based caregivers like mothers, wives, sisters, grandmothers, grand children and others looking after people living with HIV,' Ms Loga Virahsawmy, GEMSA regional chairperson, said in a recent interview.

With approximately two in five of all people infected with HIV globally in the past few years, Southern Africa is now regarded the epicenter of the global HIV pandemic.

Experts say HIV and AIDS disproportionately affects women and girls, who also form the overwhelming majority of people providing care and support to people infected and affected by the pandemic.

Loosely defined, care workers are people who help the sick or infirm.

The majority of care workers in Southern Africa provide home-based care for people living with HIV, often without being paid.

Virahsawmy explained that caregivers may be close family members such as children, wives or sisters socially or culturally expected to nurse the sick, or may be associated with organizations (such as NGOs) or linked to government-run health facilities.

She said recently the Gender and Media Southern Africa (GEMSA) Network audited care work policies in 12 countries that are members of the Southern African Development Community to establish the extent to which care work was recognized in those countries.

She was optimistic that the study would deepen and broaden the understanding of the challenges and needs of care givers all over the region.

The Southern Times has obtained a copy of the audit, which shows a serious dearth of laws and policies with respect to care work in six of the audited countries.

The audit was conducted in Botswana, the Democratic Republic of Congo, Lesotho, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe.

The audit says Namibia has an 'excellent community home-based care policy'.

'The new CHBC policy calls for a monthly incentive of N$250 – N$500 (roughly US$31-62). Under the new policy, all caregivers will require an identity card; T-shirt; shoes; umbrella; a home-based care kit; some form of transport; communication funds; and a monthly monetary incentive…the government will re-train all care givers using a standardized manual.

'Government will accredit those who pass the training through the Namibian Qualifications Authority,' says the audit of Namibia.

It adds that the new policy would address the psychological needs of care givers and encourage men to get involved in care work.

In Botswana, no clear policy on care work exists and the government is not keen on paying caregivers, arguing that incentivizing care work would compromise the spirit of volunteerism.

That being the case, only donor organizations provide financial incentives while the government provides volunteers with transportation allowances of P151 (about US$22) per month and clinical supplies.

At the time of the audit there was no stipulated minimum training for volunteer caregivers.

Training provided to them by nurses lasted about a week followed by refresher courses should new issues have arisen.

In Tanzania care work was not recognized as a profession and there was no policy with respect to payment of caregivers.

Gender equality also appears not to be a prime issue in the sector.

The Zimbabwe audit found that the government also had no policy on gender policy and payment of caregivers.

However, new guidelines recommended incentives that included uniforms, bicycles, food packs, monetary allowances, free medical treatment, support for income generating projects, part-time jobs in hospitals and funeral assistance.

The guidelines also espouse training on basic care.

Mr. Mike Podmore, who is based at the Voluntary Services Overseas headquarters in London where he works as an HIV policy and advocacy advisor said women and girls remained the unsung heroines in the response to HIV.

'Home-based care is one of the great, invisible and forgotten responses to the HIV and AIDS pandemic across the world but especially so in Southern Africa where the pandemic is generalized.

'The region is the epicenter of the HIV pandemic. Home-based care is the care and support mostly provided by women and girls in the community; either by family or loved ones or within community-based organizations by community volunteers,' Podmore said.

He said most caregivers – whether in the home or working for community organizations – worked each and every day of the week, looking after between 10 to 20 people each.

'They walk long distances between their clients. They provide care for them in their homes, often with little or no training and with very little equipment.

'For example, only a few of the home-based carers have access to home-based kits or equipment like gloves or simple things like soap.

'If they want those things they have to pay for them out of their pockets. An awful lot of carers are doing this. Most carers are made poorer by what they do.'

He said research on home-based care is still very limited and stressed the need for a deeper and broader l understanding of the lives of volunteers and the level to which they receive remuneration for what they do or what it costs them to deliver.

However, Podmore said there are some studies that are beginning to give a better understanding of home-based care.

One of them was done by Voluntary Services Overseas-RAISA and the World Health Organization's Africa office.
That research was conducted across six Southern African countries and included interviews with the caregivers and other key stakeholders.

The study came up with several recommendations targeted at governments and civil society.

'The idea is to make home-based care visible, properly supported and resourced. The second study was conducted by the Huwai Commission with funding from the United Nations Development Programme.

'This is a network of women's organizations globally. They interviewed nearly 2 000 carers across six southern and eastern Africa in 2009.'

On the key findings of that research, Podmore said: ' They asked the care givers if they had received any training.

'Only two-thirds had received any training at all and half of those had received once-off training. Only seven percent of all those interviewed were receiving any form of stipend or monetary recompense for the work they did.

'The interviews covered a whole range of issues including access to training, equipment and it gave us a good insight into what the issues were.'

Podmore said policies need to be improved so that more resources are made available to community and home-based programmes; both funding the formal health sector and providing the resources and support to people who have been providing home-based care on their own for such a long time.

'There is need to re-look at human resources for health; ensure that men are getting involved in care work and challenging gender norms in that respect; creating a link between nurses and doctors as well as community and home-based carers on the ground so that support is given to those carers.

'Nurses and doctors can hopefully pass on less complex duties to the care givers.'

Indications are that the involvement of men in care work has been very minimal, with some reports suggesting the few that get involved prefer clerical or administrative roles.

While conceding that bringing more men on board is not easy, Pomore was optimistic that it could be done.

'There are short-term and long-term approaches. Short-term approaches entail engaging men very specifically; perhaps by identifying tasks related to home-based care that they might feel comfortable doing given the traditional roles for men and women.'

He suggested this might involve some lifting, fetching or cutting of firewood and opined that giving men some sort of stipend might draw them into the sector.

A long term approach would entail redefining or understanding what it means to be a man or a woman.

'It involves talking to men and young boys about their conception of being male while showing them that it is important for them to get involved in care work.'

Podmore said schools and other agents of socialization would have to be roped in. 'This is challenging gender norms. It has to begin at school. By the age of 19 or 20 men have already formed a lot of their understanding of who they are, what they should or should not be like.

'This is not to suggest that men at that age are unreachable. I am just saying at that age there is a lot of dismantling to be done before one can rebuild new attitudes. Schools are the best place to start.'

Virahsawmy and Podmore spoke as 20 parliamentarians from Angola, Malawi, Mozambique, Botswana, Namibia, South Africa, Swaziland and Zimbabwe, as well as representatives from seven NGOs met in Cape Town to discuss the burden of care work on women and girls.The SADC Parliamentary Forum organized the one-day workshop in collaboration with VSO-RAISA. The workshop called for more research into the contribution and plight of caregivers and for policies and laws to support care work and care givers.

Reproductive services could open door to HIV prevention

JOHANNESBURG, 27 June 2011 (PlusNews) -  In theory, it should go something like this: pregnant woman tests HIV-positive as part of prevention of mother-to-child HIV transmission (PMTCT) services at her antenatal clinic, and tells dad-to-be; dad tests for HIV and they support each other, start treatment if need be, and prevent HIV transmission to baby or dad.

It seldom turns out that way. In a small, qualitative study of about 60 women in two clinics in the Durban area, Tamaryn Crankshaw, a PMTCT programme manager at McCord hospital in Durban, South Africa found that while two-thirds of the women did tell their partners they were HIV positive, only half of them reported that their partner had been tested for HIV as a result.

"There were some positive outcomes but mostly there was a lot of blame, recrimination, and silences,"Crankshaw told IRIN/PlusNews. "HIV was never raised again within the context of the relationship, and in a lot of cases it was actively discouraged."

As in previous studies, the women also reported being physically, verbally and emotionally abused after disclosing their HIV-positive status.

Surprisingly, the women's disclosure sometimes prompted men to disclose that they were also HIV-positive, or to consider their partner’s HIV-positive diagnosis as a proxy for their own HIV status.

In two cases, women reported that their disclosure had prompted unprotected sex as their partners, who purported to be HIV-negative, intentionally exposed themselves to HIV infection to show their commitment to the relationship and to starting a family, said Crankshaw, who presented her findings at the recent 1st International HIV Social Sciences and Humanities Conference in Durban.

"In South Africa, HIV disclosure is a very prominent component of HIV prevention and treatment because it’s assumed to mediate sexual risk behaviour, and is widely regarded as important to... supporting [adherence to] antiretrovirals," she told IRIN/PlusNews.

"In the PMTCT setting, HIV disclosure receives particular emphasis because of [HIV] prevention aims however... very little attention has been paid to the success of these strategies, and whether they do reduce risks or change behaviour."

What's love got to do with it?

About 30 percent of women choose to keep silent about their HIV-positive diagnosis. New research shows how a lack of trust between partners in some communities may be interfering with the expected HIV prevention benefits of HIV disclosure. This may merit a new take on HIV counselling and testing for couples.

For most women, multiple concurrent partnerships are a relationship reality. There is also mutual suspicion, a very low expectation of permanency, and their own emotional baggage, like being unwilling to trust. This may affect a partner’s willingness to disclose his HIV status, Crankshaw said.

"The thing is, we also have our ups and downs," said one 29-year-old mum. "I am not sure about our future... so I don't see the need to tell him something so confidential [like my HIV-positive status]."

Multiple concurrent partnerships, in which men and women have more than one sexual partner at the same time, are thought to be one of the main drivers of HIV in southern Africa.

Data from a larger sample of 656 men and women in rural KwaZulu-Natal, analysed by researcher Deborah Mindry of the University of California, Los Angeles, reinforced many of Crankshaw's observations about relationships.

Mindry found that awareness of the HIV risks associated with multiple concurrent partnerships and fear of contracting HIV led many men to monitor their partner's behaviour in order to assess their own HIV risk. This included, for example, asking a girlfriend's family to confirm her whereabouts over a weekend, or sending male friends to ask their girlfriends out as a test of the woman's fidelity.

"Sometimes men… end up controlling a person... this is what I feel when it comes to using condoms," said one HIV-positive new mum, who spoke to Crankshaw about the guilt she felt after not being able to negotiate safe sex with her partner. "I felt I was not in control of the situation but… I was counselled here and I knew everything."

Crankshaw said the reality that disclosure by HIV-positive mums did not always spark partner testing or risk reduction should lead to a rethink of PMTCT programme design:

"We forget to look at the fact that what drove prior risky behaviour will continue to drive future risky behaviour. Disclosure is not going to change that," she told IRIN/PlusNews. "We have to stop accessing only the pregnant woman because she's the easy one to access, because she's already in care."

What's best for baby

Crankshaw suggested that couples counselling might help share the burden of behaviour change between new mums and dads. Couples counselling has gained popularity in recent years, but it is still not easy to get couples, especially with complicated relationship dynamics, to test together in large numbers.

Mindry found that many couples were grappling with major issues and were reluctant to address HIV, but many were better able to talk about HIV and risky behaviours within discussions about existing or future children.

Crankshaw said Mindry's findings are part of a growing body of research showing that voluntary HIV testing and counselling - and subsequent behaviour change - may be more palatable to couples when presented in the context of reproductive services. As a result, McCord Hospital will begin offering reproductive services to people living with HIV.

"People have very serious issues in their relationships already, and HIV just adds another dimension," she told IRIN/PlusNews. "We have to start addressing these lived realities, and see how we might address broader issues in their lives and... how this can help us address HIV."

Older ARVs associated with premature ageing

NAIROBI, 27 June 2011 (PlusNews) - Certain antiretroviral (ARV) drugs commonly used in the developing world may be responsible for premature ageing, according to the authors of a new study published in the journal, Nature Genetics. Newer, less toxic but more expensive ARVs are more commonly used in the Western world.

Nucleoside analogue reverse-transcriptase inhibitors (NRTIs) - including Zidovudine, Lamivudine and Abacavir - have enabled millions of people living with HIV to prolong their lives. The UN World Health Organization has recommended that countries phase out Stavudine, an NRTI commonly used in Africa, due to long-term, irreversible side effects.

"We noticed that people in their 40s who had been on NRTIs for the past several years had signatures of ageing in their muscles commonly found in healthy people in their 70s and 80s," said Prof Patrick Chinnery of the University of Newcastle in the UK, one of the study's lead authors.

The researchers studied skeletal muscle from 33 HIV-infected adults, all aged 50 years or under, and 10 uninfected control subjects of comparable age. They found that in patients on NRTI treatment there was an expansion in mutations of mitochondrial DNA - the energy-producing part of the cell - similar to the mutations found in healthy older individuals.

"What we saw in our study is similar to patterns described by people who have been on ART [antiretroviral therapy] for a long time," said Chinnery.

Studies have found that despite a significant drop in mortality, people living with HIV are often affected by an increased risk of non-AIDS complications, including osteoporosis and heart attacks, which undermine their life-expectancy.

"The findings suggest that we need to look carefully at the effects of these drugs because some of the diseases caused by the abnormalities - diabetes, heart failure and so on - are serious and can cause progressive disability," Chinnery noted.

"But at the same time, clearly the patients need their drugs in order to keep them alive... but our study suggests that it may be beneficial to move to newer classes of drugs."

Chinnery said there was a need to conduct prospective studies on the likely effects of long-term use of different ARVs in order to catch and address potentially harmful side effects.

My fertility was stolen from me

Series Name: 
Nursing Update
Published by: 
Democratic Nursing Organisation of South Africa

In Namibia, HIV-positive women are being tricked into sterilisation. Is this a country desperate to curb Aids, or just a blatant human rights violation? Marion Stevens of the Women and HIV/AIDS Gauge, Health Systems Trust, came across this recent article, which exposes the reality of what’s happening in Namibia’s state hospitals.

Mpilonhle Project

Mpilonhle Project is the community component for the HIV/AIDS anti-retroviral rollout (ARV) at Ladysmith Provincial Hospital in partnership with the Communicable Disease Clinic (CDC).The joint partnership is called Augmented Community HIV Action Project (ACHIVA), and is funded by Bristol-Myers Squibb (BMS) Secure the Future (STF) Program. Mpilonhle works to assist orphans and vulnerable children and people living with HIV and AIDS.