Durban – Last month, Statistician-General Pali Lehohla reported that HIV had moved from the sixth to the third leading cause of death in South Africa.

While this shift is thought to be due to improved reporting rather than increased infections, a significant reduction in HIV infection risk could help reduce the impact of other serious illnesses such as tuberculosis, pneumonia and influenza.

Being HIV-positive introduces the risk of developing Aids, and once that occurs, reduced immunity increases vulnerability to other infections such as South Africa’s leading killer, TB, and the second-deadliest illnesses, the combination of influenza and pneumonia.

South Africa already has 6.4 million HIV-infected people despite the remarkable success of the ARV roll out programme. However, only 35 percent of eligible men and 26 percent of eligible women are on ARVs. The untreated remainder risk developing Aids.

Drug-resistant TB is spreading at the rate of about 1 400 new infections. Nearly half of the patients won’t be treated and thus won’t survive, so the link between HIV and TB is as strong – and as lethal – as ever.

By reducing the number of new HIV infections we also reduce South Africans’ vulnerability to other potentially lethal infections. Crucially, we have an opportunity to break the link between TB and Aids, which both lead to, and capitalise on, compromised immunity.

That’s why medical male circumcision is so potent: it’s a routine, once-off procedure under local anaesthetic that permanently reduces by 60 percent a male’s risk of HIV infection during heterosexual sex.

Combined with other preventative measures, such as consistent condom use, regular HIV testing, delaying sexual debut and reduction in the number of sexual partners, circumcision is the closest intervention we have to an HIV vaccine for now.

If this were rolled out effectively, South Africa could have an Aids-free generation within 30 years.

Circumcision specifically presents a major opportunity for labour-intensive employers such as the mining, construction and transport sectors: besides high rates of absenteeism when workers get ill, the time and money invested in training is not realised, especially where skilled workers die or are no longer able to work.

The health of workers has a direct impact on overall business sustainability in the sector. It is also a given that wellness impacts on safety – another critical industry imperative. So lowering HIV infections is critical at a time when the sector has such an intense focus on productivity, competitiveness and cost-effectiveness.

South Africa is estimated to have lost about 1 percent of its GDP growth annually for the past decade because of HIV/TB. Lowering the national prevalence of HIV by 50 percent would also lower TB cases by about 25 percent, so an extensive roll out of medical male circumcision will contribute greatly to national health.

This country has just 0.7 percent of the world’s population but 16 percent of the global HIV burden. The new Stats SA figures cite TB as the country’s main killer, responsible for 8.8 percent of all lives, followed by influenza and pneumonia, at 5.2 percent, and HIV at 3.9 percent.

The Department of Health’s medical male circumcision programme aims to medically circumcise 4.3 million South African men by 2016. To date, 1.55 million South African men have been circumcised. This already will avert more than 220 000 new infections by 2050.

We need to understand just how important this opportunity is. As a medical professional and as a man with deep respect for tradition and science, I see circumcision as a crucial component in freeing our nation from the diseases that hamper our socio-economic development and robs families of loved ones and breadwinners.

We must accept that we won’t have a silver-bullet solution for HIV any time soon, and that delaying comprehensive action until a vaccine is developed costs lives. We must also accept that simply urging men to abstain or even to condomise doesn’t work.

A recent study in the impoverished township of Kayamandi outside Stellenbosch found that sexually active men are generally very reluctant to use condoms because of the fallacy that condoms lead to infertility. The HIV infection rate in Kayamandi is three times the national average. So we have a long way to go in Aids education.


But it’s also useful to examine modelling on infection rates to grasp the importance of medical male circumcision. The closer to their sexual debut that males are circumcised, the greater the benefit of the procedure.

Men circumcised in their thirties, for example, have an immediate impact on infection rates because they’re sexually active.

By that time they’ve already increased the number of new HIV cases by 10 percent. As their level of sexual activity plateaus, so does their impact on infections.

Men circumcised in their early twenties have an impact on the infection rate for longer, reducing it by 22 percent. But when teens have medical male circumcision – all protocols of parental consent and so on observed – they reduce new infections by 40 percent over 50 years.

Each infection averted constitutes a son, father or brother saved from a lifetime of taking ARVs, from possibly developing Aids and importantly, from infecting others. At an individual level there are clear humanitarian dividends. But at a broader, population level, scaling up medical male circumcision could help South Africa have an Aids-free generation within 20 years.

The health minister and his team should be commended for taking the lead on circumcision. I’m also encouraged that there’s a groundswell of support for medical male circumcision among my professional colleagues. They’ve eagerly embraced the upskilling programmes being offered to the extent that those programmes are oversubscribed.

That potential – to liberate a nation from an incurable disease and from the massive costs and tragic consequences of HIV – demands that we act and collaborate.

* Dr Don Pupuma is a family physician in private practice in Soweto.