This study assessed the impact of the COVID-19 pandemic on VMMC in Gauteng province and the district variations thereof. The results indicated that in 2020, the COVID-19 pandemic disrupted VMMC by 33.8% for ≥ 10 years old, 32.4% for 10–14 years old and 35.8% for ≥ 15 years. Although all the five districts in the province experienced a decline in VMMC in ≥ 15 years, exceptionally, the Tshwane Metropolitan district recorded an increase of 21.8% in overall VMMC (≥ 10 years) and this was due to the 36.0% decline in 10–14 years old age group, compared to the pre-COVID-19 period of 2019. The highest decline in VMMC (84.7% for ≥ 10 years, 90.0% for 10–14 years, and 76.5% for ≥ 15 years) occurred in the West Rand district.
Generally, the current study attributes the decline in VMMC in Gauteng province to the indirect disruptive effect of COVID-19 that involved mitigation strategies like lockdowns which involved movement restrictions and the reallocation of health resources to the pandemic which adversely impacted a wide range of routine health services including HIV/AIDS and VMMC as reported in earlier studies (9, 12, 13, 16, 17). For example, the 33.8% overall decline in VMMC in Gauteng province in 2020, due to the indirect effect of COVID-19 in the present study is consistent with a similar 31.8% decline in another study that involved 13 Eastern and Southern African countries in 2020 compared to the baseline period of 2019 (16).
The findings of the current study highlight mixed variations in the nature of COVID-19’s effect on VMMC. Although a majority of the districts in Gauteng were adversely affected with the West Rand district experiencing the worst decline of 84.7% in ≥ 10 years and 90.0% in 10–14 years in 2020 compared to the pre-COVID-19 period of 2019, its counterpart the Tshwane district had an overall increase of 21.8% in ≥ 10 years due to 36.0% increase in 10–14 years age category. Such a mixed variation of COVID-19’s effect on VMMC corroborates with Peck et al. (2022) (17) findings wherein, South Africa only achieved 30.7% (losing 69.3%) of her annual target of VMMC due to the COVID-19 pandemic whereas, Rwanda recorded an increase of 23% (123.0% national achievement) of VMMC during the same period 2020.
The current study shows that we should advocate for the scale-up of VMMC in Gauteng province, and for stakeholder engagements to map out a framework for tackling the disrupted pattern in the respective districts. Nonetheless, support for LMICs from institutions determined to end HIV/AIDS such as WHO, the President’s Emergency Plan for AIDS Relief (PEPFAR), and the African Center for Disease Control (CDC) and Local government endorsements by Ministries of Health is critical for UNAIDS deadlines like the 2025 target of creating access to VMMC for 90% of men between the ages of 15–59 years and for ending HIV/AIDS by 2030 (18), even if the objective is not attained at the designated timeframes.
Again, the current study emphasizes a resounding call to improve the demand and supply of VMMC to reduce the risk of horizontal transmission of HIV/AIDS particularly among MSM. Also, efforts must continue in fighting vertical transmission of HIV/AIDS, including the Prevention of Mother-to-Child Transmission (PMTCT) (19), to preserve and not undermine the pre-COVID-19 gains.
Barriers to VMMC
To improve VMMC, it is important to understand the factors hindering access to the intervention. Besides movement restriction and the reallocation of health resources to mitigate the spread of COVID-19 (9, 12), evidence from Kenya suggests that the lack of policies and support for early infant circumcision, service integration at facilities, community ownership of VMMC programs, domestic funding, and household financial constraints undermine VMMC (20). Moreover, some studies have highlighted counter perceptions acting as cognitive barriers to VMMC like perceived reduced sexual pleasure, sexual dysfunction, infertility and health workers' misconceptions amongst other factors (21, 22). Yet, evidence from married men and women has refuted these perceptions and this should be discussed during health promotion campaigns (21, 22), coupled with addressing concerns about safety and adverse events, specifically for 10-14-year-olds (7, 23).
Demand creation strategies for VMMC
The current levels of VMMC are not enough even before COVID-19. To potentially increase VMMC awareness should be created among men about contemporary alternative methods of VMMC, for instance, the application of devices like situ for foreskin removal and elastic collar compression, contrary to surgery (16). Such innovative strategies of demand creation to motivate sexually active men susceptible to HIV/AIDS had earlier been recommended in another South African study that involved the Gauteng province (24). Other VMMC demand creation strategies include firstly, the scheduling of VMMC at male-dominated sectors like mines, farms, military residences, and sports avenues (7). Secondly, the use of economic incentives like vouchers to compensate for transportation costs and income losses when men undergo VMMC (7). Thirdly, increase service delivery hours for VMMC and extend the services into communities, schools and higher education institutes (7). Fourthly, policy reviews address barriers hindering access to VMMC for adolescent boys and men (7). In countries like South Africa and Malawi where traditional and cultural practices play a crucial role in circumcision (20), both the biomedical and traditional stakeholders should collaborate and integrate.
Other interventions against HIV/AIDS
Besides VMMC, there are multiple interventions against HIV/AIDS. Firstly, there is sufficient evidence of the high effectiveness of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) against exposure to risky encounters such as unprotected sexual intercourse especially with or among MSM, sex workers and serodiscordant couples (25). Alongside VMMC, the efficacy and cost-effectiveness of condoms in preventing HIV/AIDS transmission in the South African context (26) should be exploited. In summary, the combination HIV prevention package is a more comprehensive approach to fighting the disease (7). Furthermore, the 90-90-90 objective of HIV testing, treatment and viral load suppression should be incorporated into the VMMC package (16, 27). Similarly, the integration of HIV services into mother and child health services will align with “The Global Alliance to End AIDS in Children by 2030”, by aiming to test, treat and care for HIV/AIDS cases among infants, children, pregnant women and breast-feeders, and tackling gender, social and structural barriers to accessing healthcare (19, 27) will assist in ending HIV/AIDS. Lastly, community engagement and the inclusion of vulnerable populations like MSM and adolescent girls and women, sustainable funding for HIV/AIDS interventions and promulgating the right to care for the marginalized, discriminated, stigmatized and criminalized will advance the end AIDS agenda (18, 27).