Collaboration between the health sector and traditional leaders may have contributed to a higher uptake of voluntary male circumcision in Limpopo compared to other parts of the country. Such collaboration should be supported and expanded to further improve HIV prevention efforts in the province, delegates heard at a recent provincial dialogue in Limpopo. At this event, the HSRC released the regional results of its Sixth South African National HIV Prevalence, Incidence, Behaviour, and Communication Survey. By Jessie-Lee Smith
SABSSM VI fieldworkers during data collection visits in Limpopo in April 2022 Photo: HSRC
Collaboration between provincial government departments, implementation partners and the House of Traditional Leaders was key to an increase in voluntary male medical circumcisions (VMMC) in Limpopo.
Lindiwe Mothemane, a technical programme director from the global nonprofit Education Development Centre, spoke about the province’s VMMC success at a recent dialogue in Polokwane. At the event, members of government, implementation partner organisations and civil society discussed the Limpopo findings of the HSRC’s Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI).
In 2018, Ramphelane Morewane from the University of Cape Town documented how Limpopo’s government and traditional leaders collaborated to promote VMMC. This is a practice that the World Health Organization recommends, based on studies showing a 60% lower risk of men acquiring HIV infection during heterosexual exposure.
Aiming to improve engagement in efforts to protect people against HIV while respecting cultural sensitivities, Limpopo’s District Health Management Offices appointed traditional leaders as the primary stakeholders in implementing VMMC.
Traditional leaders introduced their districts to VMMC at mass meetings (imbizos) and encouraged boys to undergo screenings for HIV and sexually transmitted infections (STIs) before being circumcised. Leaders also allowed medical professionals into traditional settings to train traditional surgeons in VMMC and sterile health practices. In addition, in close collaboration with various partners, civil society played a crucial role in mobilising efforts, raising awareness, and monitoring the implementation of these initiatives within communities.
The SABSSM VI survey showed Limpopo had the highest percentage (87.7%) of males over 15 who self-reported being circumcised, followed by the Eastern Cape at 77.2%. However, unlike the Eastern Cape, where only 14.3% of these circumcisions were VMMC, 46% of males underwent VMMC in Limpopo.
Centre for Positive Care project manager Aphington Amukelani Mashele emphasised the importance of sustaining connections between stakeholder groups to ensure continuity in the provision of VMMC and other HIV services. This also could be an issue when funding – which often formed part of collaborative projects – run out.
Prevalence
Limpopo achieved one of the lowest HIV prevalence rates among provinces at 8.9% in 2022, down from 10.1% in 2017. This represents approximately 570,000 people living with HIV in 2022 – down from 580,000 in 2017. Figure 1 shows that HIV prevalence decreased in eight out of 10 age groups. Despite this, several challenges still remain.
Figure 1. Overall HIV prevalence by age group, Limpopo, 2022
Source: HSRC
Low testing uptake among men
HIV testing rates in the province were low among young men in the 2022 survey. Figure 2 shows that only 23.7% of males aged 15–24 were tested in the previous three years compared to 70.1% of females.
Mashele said that although men were willing to discuss HIV, many of them did not want to participate in testing services.
“We agree that men prefer services to come to them,” he said. “Collaboration between partners and the Department of Health to deliver services through mobile clinics is essential.”
Figure 2. HIV testing among people aged 15+ years, by age groups, Limpopo, 2022
Source: HSRC
Condom use remained inconsistent in Limpopo. Figure 3 shows that 53% of those 15 years and older reported never having used a condom with their most recent sexual partner.
Beyond Zero programme manager Sauwe Maditsi argued that distributing condoms should be done through a collaboration between the government, educational entities and service delivery organisations.
“We must not sit here as academics and decide that the people on the ground need pineapple condoms, vanilla condoms or female condoms. We have to supply by preference … People should distribute condoms face-to-face, as this will provide an opportunity to educate and review what works and what doesn’t,” she said.
Figure 3. Consistency of condom use with the last sexual partner among people aged 15+ years by province, South Africa, 2022
Source: HSRC
HIV messaging
SABSSM VI revealed several challenges in reaching the public with HIV messaging. A key finding was the low awareness and uptake of PrEP (pre-exposure prophylaxis). Of surveyed individuals, 24.5% had never heard of PrEP, 2.2% had used it before, and 0.8% were using it at the time of the survey.
“HIV education primarily comes from [the subject of] Life Orientation in schools,” said Emmanuel Malatji, a senior education specialist from the Limpopo Department of Education HIV and AIDS life skills programme. He explained that most Life Orientation teachers were not specialists in the subject, and many of the older teachers did not want to talk about issues related to sex and sexuality.
Another problem identified with school education was that children with disabilities were often excluded.
“They are kept out of school because of family attitudes, which stem from a lack of awareness and knowledge,” said Dr Disego Thobejane, a senior education specialist at the Limpopo Department of Education.
Mothemane argued that out-of-school messaging was essential and that it should accommodate various age groups and contexts.
“The misalignment of policies of the Department of Health, the Department of Social Development and the Department of Education makes it difficult to reach the youth,” she said.
The messengers
“Most young people are always on their phones. They are always checking what’s happening within their communities,” said Lesiba Ofentse Molopa, a young HSRC master’s research trainee.
He argued that influencers and advertisements on social media platforms could communicate essential messages to youth. He also suggested that influential leaders should tackle the spread of myths.
“Because churches are a place of gathering and healing, they are a great platform for church leaders to encourage health and spread HIV messaging,” said Molopa.
Malatji pointed out that because VMMC was high in the province, doctors had the opportunity and access to act as educators for young men. He said that doctors who visited initiation schools should collaborate with researchers and organisations that were up to date with pervasive behaviour, allowing them to provide relevant and statistically driven interventions and messaging.
Looking forward
The HSRC dialogue fostered mentorship and knowledge sharing among new and experienced stakeholders from Limpopo. Hoedspruit Training Trust nurse Ntanganedzeni Ntshauba said that she was grateful for the relationships she had built with prominent people in the field, which she would maintain for collaboration in the future.
Dr John Blandford, country director of the Centers for Disease Control and Prevention in South Africa, saw the dialogue as a platform for academics, civil society and government agencies to collaborate on the latest data, shaping Limpopo’s progress over the next five years. Hlahla Lekalakala, the provincial director of the South Africa National TB Association, referred to the event as a pivotal moment for regional cooperation and expressed optimism about the future of HIV initiatives in the province.
Research contacts
Yolande Shean for SABSSM research enquiries and Dr Lehlogonolo Makola, senior research specialist, in the HSRC’s Public Health, Societies and Belonging Division
If you enjoyed reading this article, please click here to subscribe to the HSRC Review quarterly magazine.
