1. Motivating for national circumcision policy

2. Global prevalence of MC

3. Background Male circumcision is traditionally practiced in many parts of sub-Saharan Africa MC offers other health benefits for men and women WHO recommends MC ‘as a new additional prevention strategy for HIV prevention in men’. Other high HIV prevalence African countries are developing and implementing MC policies Communities already aware of MC data and are already seeking safe, and unsafe, access to MC Impact takes years but the faster the rollout the quicker the impact

4. Supporting evidence that MC is protective against HIV in men. Strong supporting epidemiological evidence Strong and consistent evidence from three randomised controlled trials in South Africa, Tanzania and Uganda, all show MC to be highly efficacious (50-60%) in protecting men against HIV, sustained for 42 months (Tanzania), without behavioural disinhibition being shown

5. Importance of a RH package MC should be introduced to adolescents and young men as part of a comprehensive reproductive health package for men that could include: VCT, STI treatment, safer sex messaging and condoms, alcohol counselling etc HIV testing should be offered prior to MC but should not be a prerequisite for MC.

6. Communication strategy Community messaging is essential to ensure full understanding about what MC offers, and to discourage the use of unsafe MC services Messages must be clear –Partial efficacy –Sustaining safer Sexual practices –Delay sexual debut –Alcohol abuse –Changing gender norms –‘Male Morality’ e.g. respect of women Appropriate media for the disabled

7. Policy process Evidence to policy path Areas of contestation –Culture –Politics and history of HIV in SA –Public understanding/perceptions of science Key players SANAC and NSP Traditional leaders/healers Researchers Politicians and civil society Communities

8. Traditional MC should be included as part of the broader MC policy Standardisation of traditional practitioners training Regulation Monitoring and control of illegal initiation schools Demarcation of sacred spaces for initiation schools Consideration of surgical technique noting that only full removal of foreskin is efficacious for HIV prevention Expanding messaging to embrace broader sexual health and gender issues “Embrace traditional and western ways to stop people dying” “Reciprocal link between biomedical practitioners and traditional practitioners”

9. MC rollout in health services More than 3 million young men are uncircumcised in SA Design programmes with reference to demonstration projects already underway e.g. Orange Farm 5000 MCs in 11 months Provide an integrated package that embraces services and messages addressing men's sexual health, gender and substance abuse Beware of creating demand for MC without services being able to respond

10. Take home messages Speed in developing policy is essential as communities are already aware of the data and are seeking safe and unsafe access to MC services Develop urgent communication strategy informing communities of MC and HIV prevention data and discourage unsafe MC practices National policy should include both medical and traditional MC services and activities and should be part of broader integrated sexual health package