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Interim study results show ‘concerning’ levels of hepatitis C among groups most at risk

Friday the 28th July will mark World Hepatitis Day. Hepatitis B is endemic in South Africa, but up until now, little has been known about the local prevalence of hepatitis C, especially in high-risk populations such as men who have sex with men, sex workers and people who use drugs. Today an ongoing study has released preliminary results. These raise concerns over hepatitis C prevalence among certain groups.

High prevalence makes affordable treatment an urgent priority

“I don’t think anyone was expecting to see the kind of prevalence we’ve seen so far with 54% of people who use drugs testing positive for hepatitis C, and in some areas, up to 77% testing positive. This underscores the urgency for us to explore affordable treatment options as soon as possible,’ says Dr Andrew Scheibe, one of the researchers working with TB/HIV Care Association (TB/HIV Care) on this project.

Although hepatitis C is curable, the cost of current treatment puts it out of reach for many. There is a vaccine for hepatitis B, but it is not readily available for adults through the public health system.

Viral hepatitis is a public health threat worldwide, but a particular danger in South Africa because of the high prevalence of HIV.

Hepatitis B and hepatitis C are infectious diseases that affect the liver. Those who are infected can silently develop progressive liver damage and can unknowingly be infectious.

A life-threatening disease, viral hepatitis is a particular concern in regions with a high HIV prevalence regions, such as South Africa, because co-infection can result in more rapid progression of both diseases.

The World Health Organization (WHO) estimates that globally 150 million people are infected with hepatitis C and that the disease causes half a million deaths a year. Last year the WHO released the first Global Strategy for Viral Hepatitis. This aims to eliminate viral hepatitis as a public health threat by 2030. South Africa has adopted the same vision.

The early findings of the South African study conducted in seven cities (in Cape Town, Johannesburg, Pretoria, Mthatha, Pietermaritzburg, Port Elizabeth and Durban), put the overall prevalence of hepatitis C among the populations under study (sex workers, men who have sex with men and people who use drugs) at 13%, with the prevalence of hepatitis B at 4%. The study is being implemented by TB/HIV Care, the University of Cape Town, Anova Health Institute, OUT LGBT Wellbeing and the National Institute for Communicable Diseases with funding from the Bristol-Myers Squibb Foundation.

Difficulties in accessing treatment go beyond access to medication

The study has also unearthed disturbing trends relating to treatment. It seems that the difficulties in providing hepatitis C treatment and hepatitis B vaccination may go beyond access to medication alone. Clients who were diagnosed with hepatitis by the study were all referred on for specialist care, but many did not appear for subsequent appointments. The reasons for this are still under study, but early reports suggest that other experiences of discrimination and stigma in the health care system, confusing systems in facilities, the possibilities of a long wait for service and the costs associated with travelling to a different site may all play a role in discouraging clients from continuing care.

Prof. Harry Hausler, the CEO of TB/HIV Care, explains, “Research such as this is critical to understanding the viral hepatitis burden among vulnerable people. Next we will have to work with partners to develop cost-effective ways to provide prevention, screening, diagnosis and treatment services to those who need them, where they need them, and in appropriate ways.”

Medical male circumcision: Your questions answered

Is medical male circumcision safe?

Any surgical procedure carries risks, and medical male circumcision is a minor surgical procedure. However, because the procedure is conducted with sterile equipment by qualified personnel and follow up care is provided, the risk of any adverse event (or complication) is extremely low. If you experience excessive bleeding or pain or are concerned in any way, you should contact your service provider, or a clinic or doctor immediately.

Is medical male circumcision painful?

The surgical procedure is done under a local anesthetic so you will not feel it. After the procedure, when the anesthetic wears off, you may experience some pain, but the nurse or doctor who performs the procedure will provide you with painkillers to help you deal with this.

When the PrePex (device) is fitted, an anesthetic cream is used to avoid any discomfort. You will be given painkillers to take if necessary while the device is in place, but many clients do not experience much discomfort. During the removal of the PrePex device, there can be some brief pain, but this differs between clients.

How is medical male circumcision different to other kinds of circumcision, like traditional or religious circumcision?

MMC is different to other kinds of circumcision in three main ways.

Firstly, because of the way in which MMC is performed, you can be sure that you will receive the benefits of a reduced risk of HIV. The way other kinds of circumcisions are performed varies quite a lot, which means that you MAY be left with part of your foreskin and in that case, would not receive the benefits in terms of HIV and STI risk reduction.

Secondly, medical male circumcisions are always performed with sterile equipment by qualified medical personnel.

Thirdly, in general MMC does not have the cultural traditions attached to it, which some other kinds of circumcisions do. Some kinds of circumcision are linked with tradition or religion and have great social significance to those who undergo them. We respect this and people’s right to choose how they wish to honour their tradition.

Who does the procedure?

All of our staff who perform the procedure are qualified medical personnel who have undergone standardized, specialised training in medical male circumcision. Both male and female staff are employed to do the procedure. If you have a preference for a particular gender to perform the procedure, this can be accommodated, but it is best to make your preference known as early as possible so that arrangements can be made.

What are the benefits of medical male circumcision? Why should I have this done?

• An MMC reduces the risk of an HIV negative male contracting HIV by 60%
• reduced risk of cervical cancer for female partner
• reduced risk of sexually-transmitted infections
• makes the penis easier to clean

Will a medical male circumcision improve my sex life?

Sexual experience is subjective, meaning that different people experience sex differently. There is no scientific evidence to suggest that medical male circumcision will improve your sex life.

Will a medical male circumcision increase the size of my penis?

No, the size of your penis will not change. The appearance will be different – there will be no skin around the tip of the penis anymore, but the size will be the same.

When do they take out the stitches after my medical male circumcision?

For the surgical medical male circumcision, self-absorbing stitches are used so you will not have to have them removed.

No stitches are needed for the PrePex device circumcision method.

How long before I can have sex again after a medical male circumcision?

For the surgical procedure you must wait six weeks from the time of the procedure before having sex or masturbating.

For the PrePex device procedure, you must wait 7 weeks from the time the device is removed, NOT placed.

Who can have medical male circumcision?

Age:
The age of males targeted by this national campaign is 15-49, however, under the Children’s Act 2005 no 38, section 12(8), males under 18 can be circumcised with the consent of a parent, guardian or caregiver and children under 16 can be circumcised for a medical reason (such as HIV prevention) with the consent of a parent, guardian or caregiver.

In the Cape Metro, we cannot circumcise anyone under 15.

Medical conditions:
Certain medical conditions may also mean that we are not able to provide you with a medical male circumcision immediately until the condition has been addressed. For example, anyone with symptoms of a sexually-transmitted infection would need to be treated before they can be offered the service, and anyone with hypertension (high blood pressure) would need that condition to be brought under control before the procedure can be performed.

How much does medical male circumcision cost?

The procedure is free. All procedures are done in a safe, clinical environment.

How long does medical male circumcision take?

This depends slightly on the procedure you choose.

The surgical procedure takes 30 minutes or less.

Then you would need to come in for follow up visits 48 hours afterwards and 7 days afterwards. The healing time for the surgical procedure is 6 weeks from the procedure.

The PrePex device takes 5 to 10 minutes to place.

Afterwards you would need to come in 48 hours afterwards and on day 7 to have the device removed. Thereafter you would need to come in 48 hours after that and on day 21. The device wound takes 7 weeks to heal from the time of its removal.

Is there privacy during the medical male circumcision?

Our staff respect the privacy of the clients. The only people that are around the procedure room are the medical team.

What do I do if I get an erection after my medical male circumcision?

If you get an erection in the healing period just after your procedure it will be painful. It is therefore better if you avoid anything that might lead to an erection. You can put something cold, like an icepack, on your groin to help the erection go away.

Will a medical male circumcision protect my partner from HIV?

No, if you become infected with HIV, you will pass it on to your partner unless you use a condom.

Do I still need to use a condom if I’ve had a medical male circumcision?

Yes! Whether you have had an MMC or not, you need to wear a condom when you have sex. The MMC will reduce your risk of contracting HIV, but it will not eliminate it. You are still at risk if you do not wear a condom.

Study on ‘Test and Treat’ for Inmates Takes Flight

Inmates around the world are at higher risk for both TB and HIV. This week in Brandvlei correctional centre, TB/HIV Care will launch the local arm of a new Southern African study to help HIV positive inmates stay healthy.

In May 2016, the South African Government announced it will be adopting the World Health Organisation’s (WHO) new “test and treat” guidelines for HIV infected people, enabling immediate anti-retroviral (ARV) treatment upon HIV diagnosis. These guidelines will help place South Africa in the position to address at least one of the UNAIDS ’90-90-90′ treatment targets; that 90% of people who test HIV positive are initiated onto treatment. This policy was adopted after the seminal ‘START’ study showed that starting people on ARVs early helped to keep them healthy. If people stay adherent to treatment once started, their viral load drops and it also becomes much more difficult to transmit the virus.

The Department of Correctional Services, has been successful in screening high numbers of inmates for HIV, but treatment thus far has only been offered to inmates with CD4 counts of <500. The Treatment as Prevention (TasP) project supported by Evidence for HIV Prevention in Southern Africa (EHPSA) is designed to offer universal test and treat (UTT) as a feasibility pilot study within a correctional centre environment. EHPSA is funded by UK Aid from the Department for International Development (DFID) and Sweden and managed by Mott MacDonald. EHPSA so far has three research arms working with adolescents, prisoners and LGBTI communities. (http://www.ehpsa.org/).

The TasP study has three sites within Southern Africa; Lusaka, Johannesburg and Worcester with two local correctional facilities on board, Brandvlei and Worcester. TB/HIV Care Association (THCA) will be responsible for the Western Cape sites and THCA’s partners on this study, the Centre for Infectious Diseases Research in Zambia (CIDRZ) and the Aurum Institute will run the study from Lusaka and Johannesburg respectively. Although there have been significant delays in study initiation, ethics approval from the Department of Correctional Services (DCS) as well as the University of Witwatersrand has been granted for South African sites.

THCA will commence the study this week from an office set up at Brandvlei training centre. This will also provide a home base for the study team working at both Brandvlei and Worcester correctional facilities. The study team consists of Phunyezwa Langa (Professional Nurse Counsellor), Earl Titus (Data Monitor), Irene Mokwena and Mzi Fosi (Research Assistants) and three HAST counsellors, Angie Solomons, Vanessa Solomons and Juliana Baadjies. THCA are in the process of procuring additional staff members for the Worcester site. THCA believes in expanding staff skillsets and in this spirit, most of the study team have attended workshops and training courses aimed at providing additional training.

The specific study objectives are to (1) describe the continuum of THCA under TasP/UTT by using several key indicators; (2) identify health-system, socio-cultural and inmate barriers and/or facilitators of TasP/UTT to refine TasP implementation; (3) characterize the resources needed and steps taken to achieve a functioning TasP/UTT program within the correctional environment; and (4) identify key policy stakeholder concerns and questions to facilitate TasP/UTT scale-up within correctional facilities in Southern Africa.

To assist study teams recruiting inmates at the various sites, consent and case report forms (CRFs) have been designed to accurately record data for capturing on an electronic database. Currently, CIDRZ has started recruiting inmates onto the study and the THCA team is receiving training on the finalised CRFs and electronic database the will be used to garner data from consented inmates. The THCA study team has started a support group for inmates that are infected/affected by HIV/TB and they have meetings once a week. A novel way to reach more inmates about the study and the work that THCA is doing within correctional facilities, was to use the local radio station at Brandvlei. Angie and Vanessa were invited to give a brief introduction of TasP on air and subsequently THCA has been invited back to give health and wellness talks in scheduled regular slots.