HIVAIDS Program Safe Circumcision JuneJuly Circumcision Season Report

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HIV/AIDS Program Safe Circumcision June/July Circumcision Season Report 1

HIV/AIDS Program Safe Circumcision June/July Circumcision Season Report 1

Key Considerations • ECDo. H acknowledges that the tradition circumcision is the competency of

Key Considerations • ECDo. H acknowledges that the tradition circumcision is the competency of the LG and HOTL. • The ECDo. H’s involvement and role is to support the circumcision practice by working with and through the established task team led by HOTL. • Do. H HIV Conditional Grant 2013/14 – does not have specific budget for traditional circumcision – but for MMC budget (R 20 m) extended to support traditional circumcision 2

Do. H Involvement and support • The following objectives are the bases under which

Do. H Involvement and support • The following objectives are the bases under which the Do. H 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) 3

Do. H Involvement and support • The EC Provincial CMT, comprised of representatives from

Do. H Involvement and support • The EC Provincial CMT, comprised of representatives from the HOTL, LG, Do. H 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 4

Do. H Involvement and support • Do. H supported the functioning of the CMT

Do. H Involvement and support • Do. H 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 – – 5

Do. H Involvement and support ITEMS/SERVICES QUANTITY DURATION COST IMPLICATION Hired 7 vehicles 20

Do. H Involvement and support ITEMS/SERVICES QUANTITY DURATION COST IMPLICATION Hired 7 vehicles 20 days R 135 934 Hired 30 vehicles 60 days Hired 10 vehicles 15 days Accommodation of provincial officials and traditional leaders 31 people Provision of lunch packs to members of initiation forums Total 250 people 22 nd June 2013 to 19 th July 2013 R 135 000 R 2 760 254 R 1 678 320 Incurred by National DOH 17 th June 2013 and R 811 000 out 19 th July 2013 6

Do. H Support- Cars • Cars – first group of 7 cars hired to

Do. H 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 NDo. H – 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 7

INITIATION STATS – 2006 to 2013 YEAR 2006 JUNE 2006 DECEMBER 2007 JUNE 2007

INITIATION STATS – 2006 to 2013 YEAR 2006 JUNE 2006 DECEMBER 2007 JUNE 2007 DECEMBER 2008 MARCH 2008 JUNE 2008 DECEMBER 2009 JUNE 2009 DECEMBER 2010 JUNE 2010 DECEMBER 2011 JUNE 2011 DECEMBER 2012 JUNE 2012 DECEMBER 2013 JUNE Total HOSPITAL AMPUTATIONS ADMISSIONS 288 5 512 7 329 41 311 11 18 NIL 352 11 267 0 461 47 252 2 389 22 269 1 313 10 338 10 INITIATE DEATHS 26 32 24 8 5 24 5 55 36 41 21 26 36 LEGAL INITIATES 3470 11243 12563 33005 241 14741 40290 17538 39581 18450 53128 13886 41903 ILLEGAL INITIATES 285 708 1460 1327 152 1694 553 2470 896 1429 1352 2808 937 ARREST 0 0 2 49 23 29 9 12 7 35 24 358 17 49 15259 730 8 219 6 25 22654 367 13 359 5035 24 214 40 453 12169 349785 2314 19 230 19547 8

INITIATION STATS – June/July 2013 District Legal Schools initiates Illegal Schools Illegal initiates No

INITIATION STATS – June/July 2013 District Legal Schools 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 NMBM 468 501 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 9

Alfred Nzo Amathole Buffalo City Cacadu Chris Hani Joe Gqabi Deaths Across the Province

Alfred Nzo Amathole Buffalo City Cacadu Chris Hani Joe Gqabi Deaths Across the Province NMBM O. R. Tambo 26 9 2 Alfred Nzo Amathole 1 Buffalo City 0 Cacadu 1 1 Chris Hani Joe Gqabi 0 NMBM O. R. Tambo 10

12 Distribution of Deaths Between Illegal and Legal School OR Tambo and Alfred Nzo

12 Distribution of Deaths Between Illegal and Legal School OR Tambo and Alfred Nzo Illegal 4 Legal 4 3 3 3 2 1 Mzimvubu Maluti 1 Nyandeni 1 Mhlontlo 1 KSD Qaukeni 11

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

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 12

Assault cases in hospitals 13

Assault cases in hospitals 13

Illegitimate tendencies • Boys are as young as 14 years of age • Excessive

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 14

CRIMINAL ELEMENTS in THE CUSTOM • The custom has been hijacked by criminals who

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 R 2, chickens, cell phone or up to R 800. • 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 15

CRIMINAL ELEMENTS in THE CUSTOM 16

CRIMINAL ELEMENTS in THE CUSTOM 16

Health Response Action • Additional bed space: – UGH identified a space at back

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 17

Health Response Action 18

Health Response Action 18

Health Response Action • Correct Clinical management: – Protocol on management of circumcision complications

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. 19

Challenges experienced by Facilities • The mass casualties and admissions created chaos as hospitals

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. 20

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

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 – Do. H facilities readiness to manage complications 21

Recommendations • LG/Municipalities and HOTL take ownership of the practice – There should be

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 22

Enkosi 23

Enkosi 23