Human immunodeficiency virus (HIV) ranks as a top global cause of morbidity and mortality. Since the identification of the HIV epidemic, over 70 million individuals have acquired the virus, of whom 50% have died. At the end of 2018, global prevalence estimates suggest that 37.9 [32.7–44.0] million people were living with HIV with some geographical regions being more affected than others (1).
Sub-Saharan Africa still carries a disproportionate burden of HIV with an estimated one in every 25 adults (4.4%) living with HIV. This accounts for approximately 70% of global HIV infections. Out of the estimated 6,000 new infections that occur worldwide each day, two thirds occur in sub-Saharan Africa. As such, successful interventions for HIV prevention in this region could have a major impact on the overall burden of HIV worldwide (1).
According to 2019 UNAIDS estimates, South Africa has an overall HIV prevalence rate of 20,4% (7,7 million people living with HIV) (2). KwaZulu-Natal Province harbours an overall HIV prevalence of 27%, the highest among the nine provinces that constitutes the geopolitical structure of South Africans’ landscape (3). In this province, 12% of youth in the age category 15–24 years live with HIV infection, the highest compared to the other provinces (4). Interventions such as antiretroviral treatment (ART) have been widely rolled out due to their beneficial effect of improving the quality of life and reducing transmission and mortality (5). However, to achieve an AIDS free generation, there is need to enhance combination intervention strategies and expand access to VMMC (6, 7) as an additional preventive strategy targeted at reducing HIV acquisition among men.
Findings from randomised controlled trials done in three sub-Saharan African countries as well as data from mathematical modelling reaffirmed the evidence in support of the efficacy of VMMC for preventing men’s risk of heterosexual acquisition of HIV. This evidence reinforced WHO (8) to make the recommendation for a large scale roll-out of VMMC as an essential component of HIV preventive strategy that could effectively help reduce heterosexually acquired HIV (9–14). Further, a meta-analysis including 49 studies revealed that VMMC was protective against HIV infection for both homosexual and heterosexual men (15). With an 80% coverage of VMMC among HIV negative men in the countries with high prevalence of HIV and low VMMC uptake would provide a substantial threshold for sustained prevention of HIV transmission at population level. Since the prevention strategy was established in 2007, over 18 million men have been medically circumcised in sub Saharan Africa countries to date. Of these close to 5 million procedures were done in South Africa (16). VMMC uptake in these countries has ranged from 10–63% (16). This provides some light as to the acceptability of this strategy in countries where circumcision is not the traditional norm. VMMC has the potential to alter current HIV epidemic trajectory in sub Saharan Africa if effectively combined with other proven intervention mentioned earlier (17, 18).
From a public health perspective, strategies to optimize expansion of existing proven interventions as well as creating demand for uptake of such existing interventions within resource limited areas need to be enhanced (19, 20). In view of this there is need to reinforce improvement of the surgical procedures through use of novel surgical approaches so as to deliver safe and high quality VMMC services which minimise post-surgical complications and maximize public health benefits (8, 21). The PrePex® and ShangRing® foreskin crushing devices were approved by the WHO after a series of evidence generated from clinical trials conducted among adult males in 5 countries in sub Saharan Africa (22–24). However, the trials conducted on PrePex® and ShangRing® systematically excluded males with preputial / penile and preputial / penile scrotal abnormalities and diseases. These include phimosis, paraphimosis, warts or ulcers of the prepuce, active genital infection, hypospadias, torn or tight frenulum including anatomical abnormalities and any other preputial / penile pathological conditions that the opinion of the investigator would impede device placement for a thorough VMMC procedure. Evaluating the performance PrePex® and ShangRing® devices by the WHO technical committee found that among the study participants 7% among PrePex® and 1% of ShangRing® were not eligible for circumcision (22, 25). It is therefore essential to understand the burden of preputial / penile abnormalities identified pre-surgically as this has an impact on effective expansion of VMMC program but also need to be taken into account so that new devices that could be able to accommodate common abnormalities could be made available in the market for use. This study was therefore carried out to assess the prevalence and related factors of preoperative preputial / penile abnormalities during the VMMC among young and adult males in KwaZulu-Natal Province.