PMR - Professional Management Review

Dr Francois Venter, President, the Southern African HIV Clinicians Society, Clinical Director of the University of Witwatersrand’s Reproductive Health and HIV Research Unit and Lecturer, Department of Medicine, Wits

Has government let go of its denial on the HIV/AIDS crisis in South Africa?

No. I think the Minister of Health is doing everything she can to stop the antiretroviral treatment programme. She has not taken responsibility for dealing with HIV seriously, and she’s not playing a leadership role.

Is the National Strategic Plan on HIV/Aids and STIs 2007-2011 (NSP) on track?

Of all the NSP’s targets, the only one which has definitely been reached is the number of adults who are on treatment. Some of the other targets are not easily measured, so we just don’t know. But in many, we are not succeeding. There are 400 000 adults on treatment in the public sector and 90 000 adults on treatment in the private sector. We need to really start evaluating why we aren’t reaching the NSP’s targets. We can’t congratulate ourselves on the NSP if it isn’t making a difference in the lives of people on the ground.

Why have HIV prevention efforts in South Africa been such a failure?

We haven’t been sophisticated enough about how we tackle HIV prevention. Our HIV prevention messaging isn’t targeted at specific groups. It’s the same for people in rural and urban areas and this one-size-fits-all approach doesn’t work. But HIV prevention is really hard. Throughout the world, people have failed in HIV prevention. Although there has been a decrease in infection rates in Zimbabwe and Kenya, we’re still not sure why this has happened.

Studies have found that circumcision reduces HIV transmission rates. Should South Africa introduce mass male circumcision as an HIV prevention intervention?

The reason why circumcision reduces HIV transmission rates is because the foreskin, which is removed during circumcision, has cells which make it very likely to contract HIV . Mass circumcision should only form part of a package of HIV prevention services which include HIV testing, HIV /Aids education, screening for TB, etc – it shouldn’t simply be rolled out on its own. I think circumcision-linked HIV prevention programmes would be a great opportunity to get large numbers of men together and provide them with HIV testing and education.

Throughout the world, men tend to test for HIV later and much less often than women. One of the reasons for this is that women are more used to using healthcare services, as they access these services for pregnancy care, and often have healthrelated childcare responsibilities.

Have the studies that show circumcision reduces HIV transmission rates caused an increase in men in Southern Africa getting circumcised?

Since the studies came out, there has been an increase in circumcision rates in Botswana and Swaziland, but not in South Africa. Certain southern African governments have started discussing mass circumcision programmes.

Health Minister Tshabalala-Msimang expressed doubts about the merits of male circumcision in preventing HIV transmission, saying that the procedure might make women more vulnerable to the disease.

In a situation where an HIV-positive man has just been circumcised and has unprotected sex with a woman who is HIV-negative, then the woman is more likely to contract HIV. But this is only in the first few weeks after circumcision because the circumcision process can cause some small sores on the penis. Issues like this really show the importance of circumcision being part of a proper health risk reduction programme which includes information about the importance of using condoms even if you’ve been circumcised.