Background on MC in Swaziland
In 2007, the World Health Organization and UNAIDS issued normative guidance recommending safe medical male circumcision for the purpose of HIV prevention in regions with high HIV prevalence and low male circumcision prevalence. These recommendations were based on three randomized clinical trials involving more than 10,000 men in sub-Saharan Africa. The trials demonstrated a 50-60% reduction in risk of female-to-male HIV transmission among men randomized to receive circumcision compared to uncircumcised controls. This evidence is supported by decades of ecologic and observational data. Additionally, observational studies and mathematical modeling indicate an indirect protective effect reducing HIV risk for women when MC is widespread in a community. The key recommendations of WHO/UNAIDS for MC are:
- MC should always be considered as part of a combination HIV prevention package, which includes the provision of HIV testing and counseling services; treatment for STI; the promotion of safer sex practices, such as abstinence from penetrative sex, reduction in the number of sexual partners, and delay in the onset of sexual relations; and the provision of male and female condoms, and promotion of their correct and consistent use;
- MC should be provided with full adherence to medical ethics and human rights principles, including informed consent, confidentiality, and absence of coercion;
- Countries with high prevalence, generalized heterosexual HIV epidemics and low rates of MC should consider urgently scaling up access to MC services and that additional resources be mobilized to support this; and
- Promoting circumcision for HIV-infected men is not recommended.
The Government of the Kingdom of Swaziland (GKOS) has demonstrated a high level of political commitment to fight HIV/AIDS since the start of the epidemic. As the impact of the epidemic became evident, it was clear that a more developmental approach with a multi-sectoral angle would be appropriate. Political commitment at the highest level to the fight against HIV was demonstrated in 1999 when His Majesty King Mswati III declared HIV as a national disaster and established an HIV/AIDS Cabinet Committee and a multi-sectoral HIV/AIDS Crisis Management and Technical Committee under the office of the Deputy Prime Minister.
In 2000, the GKOS issued its first National Strategic Framework (NSF) for HIV/AIDS for 2000–2005, followed by successive plans that expanded the Government’s comprehensive HIV/AIDS response. The current NSF, 2009-2014, aims to improve the Swaziland Human Development Index from 0.542 in 2008 to 0.55 in 2014. This is in recognition of the negative impact that HIV has made on labor productivity and national output. The NSF defines priority HIV/AIDS prevention programs, including social and behavior change communication, male circumcision, prevention of mother-to child transmission (PMTCT), and condom distribution.
Aligned to the NSF for 2009–2014, the GKOS launched the national male circumcision policy in August 2009 to provide guidance on implementation. The policy defines priority target audiences for maximum public health impact, cadres of healthcare workers to provide male circumcision services, the types of facilities for service provision, and the integration of male circumcision with other health services. Other issues addressed in the policy include costing, quality assurance, monitoring and evaluation (M&E), communications and advocacy surrounding male circumcision and HIV prevention, human rights, ethical and legal issues, and socio- cultural considerations. Additional supporting MC strategies and tools include the Male Circumcision Communication Strategy, 2009–2013, and UNICEF’s HIV Prevention Module for Male Circumcision, adapted for Swaziland.