Voluntary medical male circumcision is one of the most important ways to reduce new HIV infections. The foreskin contains receptors that the HIV virus can attach to, and removing it reduces HIV transmission from women to men by about 60% .
But cost and access issues have been barriers for many men and boys in southern Africa. With US funding being cut for HIV programmes, it is increasingly important to scale up voluntary circumcision programmes using local resources.
Together with Bonginkosi Eugene Khumalo, head of circumcision programme at Northdale Hospital, KwaZulu-Natal, we did a study to evaluate the training of primary care providers to use Unicirc, a novel surgical instrument designed in South Africa according to World Health Organization (WHO) specifications.
Our new study describes an ongoing training programme being run by the Centre for Excellence (a long-standing circumcision training programme) at Northdale Hospital in KwaZulu-Natal, a province where traditional circumcision is not practised and which has the highest HIV prevalence in South Africa.
Unicirc is a simple, single-use circumcision tool made of metal and plastic. It’s pre-sterilised, disposable and designed for use by general healthcare workers not just specialists. This makes it safe and practical for use in local clinics.
The study demonstrated the practicality of training primary care doctors, nurses and clinical associates in Unicirc male circumcision.
Circumcision is an important HIV prevention method. It’s vital for countries to scale up services in a cost-effective way and to make them widely available in local areas.
How it’s done
Currently, almost all circumcisions are done by surgical cut and stitch techniques, where specially trained surgeons cut off the foreskin with scissors, then sew up the open wound. It can be done in a surgery under local anaesthesia, but men and boys need to be monitored closely afterwards to make sure all bleeding is stopped. It can cost anywhere between R1000 and R4000 in the private sector in South Africa.
Doctor Cyril and doctor Elisabeth Parker developed the method at their general practice in Cape Town in 2012. This new tool greatly simplifies circumcision so that it can be performed by medical personnel with basic training. It takes only 10 minutes, causes no bleeding, needs no injections or stitches. It results in a rapidly healing, cosmetically pleasing circumcision.
Thousands of these circumcisions have been performed at clinics in Cape Town and an area called Mitchell’s Plain, and nurses and clinical associates have been trained in the technique. Unicirc circumcisions are now being offered at nurse-run Unjani clinics in South Africa.
In the Northdale programme, Dr Cyril Parker and his colleagues trained 67 providers, the majority of whom were nurses and clinical associates. These are mid-level healthcare professionals who work under the supervision of a medical doctor to provide primary medical care. They performed these circumcisions on 1,240 men and boys with no serious complications. Trainees found it faster, simpler and with better results than other methods. The programme is ongoing, with trainees continuing to perform circumcisions safely.
Initially, none of the trainees had used Unicirc. Around 61% of trainees were men and 39% were women, showing a need to encourage more women to join. Nurses (46%) and doctors (45%) made up most trainees, and clinical associates the rest (9%). About 38% had no prior circumcision experience, while 33% were highly experienced in surgical circumcision. This shows the programme can train complete beginners as well as experienced providers.
Nurses and clinical associates are key to expanding cost-effective circumcision access, freeing up medical doctors for other tasks. A disposable, single-use tool reduces infection risks and is well-suited to clinics with limited resources.
What next?
The programme is moving into a phase focused on mentoring, quality checks and further expansion. If widely adopted, Unicirc could greatly improve access to safe, simple and rapid circumcision across resource-limited settings. It is simple enough to be used in traditional circumcision schools.
Along with effective treatment, prevention of mother-to-child transmission, and medication to prevent HIV infection, circumcision plays a critical role in HIV prevention efforts in Africa. Unlike traditional circumcision, voluntary medical circumcision is done under sterile conditions by trained providers with few complications and the ability to deal with any that do occur.
Several southern African countries started their national circumcisions programmes to prevent HIV in 2010. As of 2023, 37 million voluntary medical male circumcisions had been performed in 15 high priority African countries. Estimates are that one million HIV infections have been prevented, saving the cost of treating and monitoring those cases, and avoiding transmission to partners. Circumcision actually saves money in many countries.
Peter S Millard does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
High Woo
A British man on safari walks into a bar far out in the reaches of a game reserve in Southern Africa, he stays at the bar for a while shooting the shit with the bartender and drinking like a fish, he offer to buy the barkeep a round and since no one else is within 2km of their small oasis of liquor the barkeep obliges. The englishman goes off to the bathroom to have a good old go at the porcelain, he\’s back and ready for a few more whiskeys. He\’s just sat down when suddenly in the distance he hears a scream. He looks over his shoulder and dismisses it as nothing, he turns to the barkeep and orders a drink, takes a sip and hears the scream again. He looks at the barkeep who just shrugs it off. A minute or two later he and the barman hear it again and go outside to take a look. They see a lone figure running towards them screaming, he spots them and lets out a cry, RUN!!!!! HE\”S COMING!!!!!
The barkeep and the Englishman both look at the terrified bedraggled sight before them, and try to calm him down, but he\’s completely inconsolable. They give him water and finally manage to get a word out of him but he struggles free from their grasp and run away screaming.
A few minutes later the same thing happens with a whole group of men running in and screaming, he\’s coming, he\’s coming the barkeep grabs hold of one of the men as he tries to sprint past the bar and tries to get information out of him, again no response other than terrified gibberish.
The barkeep and his customer are starting to get worried, they start to pack up before another group of horrified natives run up to the bar most of them flee but one tries to hide behind the bar, the barkeep pulls out a shotgun and points it at the terrified man\’s face, finally managing to coax some words out of him. \”He\’s coming for us, Vernon Koekemoer is coming for us, we have to hide!!! We have to get out of here.\” He gets up and tries to run but the barkeep grabs him, feeling trapped in a panic he grabs the barkeeps shotgun and blows his own head off. The Englishman and the barkeep look at each other starting to really panic now.
They look out of the window and off in the distance they see a tornado coming towards the bar, at the bottom of the tornado they see the hugest beast of a man they have ever seen, as he gets closer they spot that he is riding a rhinocerous and using a crocodile as a riding whip, with each smack of the crocodile across the back of the rhino the louder is screams and the faster it runs, the tornado following it getting ever larger.
The 2 look at each other and start to fortify their position, they\’ve got a gun and they\’re waaay to drunk to run, so they start piling bar stool and tables and anything they can get their hands on to make sure they\’ll be safe when he arrives. They\’re not gonna make it, they can see the man slowing down his rhino, by now the crocodile is nothing but reptile paste on the bruised rump of the half dead rhino, the rhino drops down dead from exhaustion and crashes to the ground right outside the bar the tornado loses it\’s last breath in a cloud of dust as the huge man crashes his way through the make shift barricade and charges up towards the bar where the 2 men have taken shelter, he grabs a bottle of the hardest liquor on the shelf and down the entire litre in 1 gulp, he peers over the bar sobbing and sees the 2 defenders cowering down behind the crates of beer, they look up at the mans\’ face and he stares at them with a look of complete and utter hopelessness, he stares at them for a half second and half screams, half sobs, \”Oh my god what are you still doing here!!! WE HAVE TO GET OUT OF HERE NOW!!!! Vernon Koekemoer is coming!!!!\”
New York Winder
Fun South African Fact: South Africa has one of the world’s most luxurious trains.