HIV/AIDS Program

Safe CircumcisionJune/July Circumcision Season Report

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Key Considerations

• ECDoH acknowledges that the tradition circumcision is the competency of the LG and HOTL.

• The ECDoH’s involvement and role is to support the circumcision practice by working with and through the established task team led by HOTL.

• DoH HIV Conditional Grant 2013/14 – does not have specific budget for traditional circumcision – but for MMC. MMC budget (R20m) extended to support traditional circumcision

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DoH Involvement and support

• The following objectives are the bases under which the DoH is actively supporting the practice: – Enhance and strengthen traditional circumcision to

support the HIV prevention through the circumcision strategy.

– Promotion of safety of initiates– Curb and manage circumcision related complications and

deaths. (Injuries and Deaths)

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DoH Involvement and support

• The EC Provincial CMT, comprised of representatives from the HOTL, LG, DoH and Local Circumcision Forums led by local chiefs was established for this season to ensure safe passage of young boys to manhood. – Role of the CMT is to visit all districts provide support and monitor

the progress and outcomes of circumcision seasons.

• CMT considered the 2013 Winter Season to be starting on 17 June 2013,– The CMT developed a program to visit all districts – started 17

June 2013 to 19 July 2013

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DoH Involvement and support• DoH supported the functioning of the CMT and Designated

Medical Officer (DMO),– Accommodation for the teams during outreach activities– Food parcels for the teams during daily outreach activities – Hiring of 37 double cabs used during the season. – Protective/identity clothing – delayed with procurement delivered

late…to be used during the next season (November/December)– Airtime for DMO– Overtime– Contracting of volunteers to assist DMO

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DoH Involvement and support

ITEMS/SERVICES QUANTITY DURATION COST IMPLICATION

Hired 7 vehicles 7 vehicles 20 days R135 934

Hired 30 vehicles 30 vehicles 60 days R1 678 320

Hired 10 vehicles 10 vehicles 15 days Incurred by National DOH

Accommodation of provincial officials and traditional leaders

31people 17th June 2013 and out 19th July 2013

R811 000

Provision of lunch packs to members of initiation forums

250 people 22nd June 2013 to 19th July 2013

R135 000

Total R2 760 254

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DoH Support- Cars• Cars – first group of 7 cars hired to up to 18 June 2013

– OR Tambo District x 4 – Joe Gqabi District x 2– Alfred Nzo (Bizana area) x 1

• The second group of 30 hired cars were handed over by the MEC for Health to Mr Bokwe, CEO of HOTL, on 10 June, in EL– HOTL allocated 6 cars– DMOs allocated 24 cars

• 10 additional cars provided by NDoH– OR Tambo – 6; Alfred Nzo – 4

• The cars were allocated to cover all districts but special consideration was paid to areas considered to be hotspots – OR Tambo and Alfred Nzo

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INITIATION STATS – 2006 to 2013 YEAR HOSPITAL

ADMISSIONS AMPUTATIONS INITIATEDEATHS

LEGALINITIATES

ILLEGALINITIATES ARREST

2006 JUNE 288 5 26 3470 285 02006 DECEMBER 512 7 32 11243 708 02007 JUNE 329 41 24 12563 1460 02007 DECEMBER 311 11 8 33005 1327 02008 MARCH 18 NIL 5 241 152 22008 JUNE 352 11 24 14741 1694 492008 DECEMBER 267 0 5 40290 553 232009 JUNE 461 47 55 17538 2470 292009 DECEMBER 252 2 36 39581 896 92010 JUNE 389 22 41 18450 1429 122010 DECEMBER 269 1 21 53128 1352 72011 JUNE 313 10 26 13886 2808 35

2011 DECEMBER 338 10 36 41903 937 24

2012 JUNE 358 17 49 15259 730 8

2012 DECEMBER 219 6 25 22654 367 13

2013 JUNE 359 24 40 12169 2314 19Total 5035 214 453 349785 19547 230

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INITIATION STATS – June/July 2013

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District Legal Schools

Legal initiates

Illegal Schools

Illegal initiates

No of Admissions

Amputations of penis

No of Deaths

O.R. Tambo 737 5120 224 1120 259 24 26

Chris Hani 174 1818 5 5 21 0 1

Alfred Nzo 125 2323 30 1174 41 0 9

Buffalo City 238 852 5 5 2 0 1

Cacadu 61 206 0 0 0 0 0

NMBM 468 501 0 0 0 0 0

Joe Gqabi 96 265 2 2 13 0 1

Amathole 222 1084 7 8 23 0 2

Total 2121 12169 273 2314 359 24 40

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Highlights on Injuries/Deaths• Major causes of injuries and deaths

– Beating/Sjamboking of initiates– Dehydration– Infection/sepsis– Gangrenes and mutilation

• Only three initiates died at hospital level – NMAH and St Barnabas. The rest are dead on arrival (DOA) and others taken directly from Ibhuma by police and Private Mortuaries.

• Reported police cases opened so far - 5

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Assault cases in hospitals

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Illegitimate tendencies• Boys are as young as 14 years of age• Excessive removal of the skin of the penis (removal from the shaft

of the penis to the glance)• Mutilation of the scrotum sack.• Tight dressing which result in poor blood supply (gangrene)• Deprivement of reasonable amount of water which results to

dehydration• Incomplete initiation, removal of only the bottom part of the

foreskin• Assaults took place in the dark to hide identity of culprits

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CRIMINAL ELEMENTS in THE CUSTOM

• The custom has been hijacked by criminals who have total disregard for human life. Only interested in money making– Charge rate would be as little as R2, chickens, cell phone or up to

R800. • Boys are circumcised using unsterile rusty instruments. • Boys are at risk of contracting HIV during the process. • Some so called traditional surgeons perform procedures

under influence of alcohol. • Boys walk long distances before and after circumcision

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CRIMINAL ELEMENTS in THE CUSTOM

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Health Response Action

• Additional bed space:– UGH identified a space at back of OPD area - The space

accommodated about 15 beds…full throughout. – St Barnabas for Nyandeni – The old mental hospital…

total of 40 initiates were admitted.– St Elizabeth for Qaukeni – working with hospitals closer

by to down transfer – Holy Cross and Bambisana. Total of 20 admissions.

– St Lucy’s hospital for Mhlontlo – total of 13 admissions

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Health Response Action

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Health Response Action

• Correct Clinical management:-– Protocol on management of circumcision complications developed by

Department of Urology, NMAH. – The protocol was availed for the district for distribution to all Regional

and District Hospitals with an accompanying memo from the DM to enforce management of these patients according to this protocol

• Resources mobilization:– Human resources – doctors and nurses diverted to these special

wards– Mthatha Depot for medical supplies – fluids, drugs, dressing packs – EMS to transport referred initiates.

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Challenges experienced by Facilities

• The mass casualties and admissions created chaos as hospitals were completely not prepared for the admissions.– Staffing – the hospital needed to spread thinly the existing staff

complement– Equipment – these special wards were not equipped. Equipment

had to be shared from other wards.– Food shortage – due to extra plates that are not budgeted for– Bed occupancy – those critical and admitted in the wards

occupied most of the beds – Mental unit in St Barnabas needed to be vacated for Contractors

to start with contraction in July.

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Of note and Recommendation • No clear and specific resource commitment shown by LG

and HOTL • OR Tambo/Alfred Nzo (Nyandeni, Qaukeni, Bizana)

circumcision practice is redefined – Circumcision Risk Areas– High level of criminal involvement and non accountability– Devise specific mechanism/strategies to curb and contain further

deaths – HOTL and LG to lead – DoH facilities readiness to manage complications

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Recommendations

• LG/Municipalities and HOTL take ownership of the practice– There should be a high level of accountability…one death is too many– Provision of resources – Year long structured, on-going prevention program – engage all sectors –

educational program to schools. – A continuous updated database of all Iingcibi and nurse. – Blacklisting of iingcibi who commit crimes and continue to disobey standing

orders and instructions.– Amakomkhulu must lead the program of initiation in their respective areas…

with high level of accountability• Review of policy and legislation regarding traditional male initiation;

implemented to the full extent of the law to ensure arrests/convictions.• All circumcision related deaths and assaults be investigated and arrest be made

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Enkosi

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